Efficacy and Safety of Accelerated Partial Breast Irradiation after Breast‐conserving Surgery: A Meta‐analysis of Published Comparative Studies

To compare the treatment outcomes between accelerated partial breast irradiation (APBI) and conventional whole‐breast irradiation (WBI) and to explore the efficacy and safety of APBI as an adjuvant treatment for early‐stage breast cancer who received breast‐conserving therapy. Eligible studies were identified on Medline, Embase, and the Cochrane Library updated to July 10, 2012. Comparative studies were considered for inclusion. Analyses were carried out using Stata software. Eleven comparative studies with a total of 7,097 patients were included. The meta‐analysis showed that there were no statistically significant differences between group APBI and group WBI associated with the supraclavicular failure, distant metastasis, overall survival, and disease‐free survival, while local recurrence (LR) and axillary failure (AF) increased in group APBI. The sensitivity analysis indicated that both the LR and AF were not statistically significant difference between the two groups. In the subgroup analysis, LR was statistically significantly higher in group APBI for patients with the age <60, large tumor size, and unknown margin status. APBI is a safe treatment modality and could become a potential option for the delivery of adjuvant radiation therapy in patients receiving breast‐conserving therapy, especially for the suitable group that was classified by the American Society of Radiation Oncology Consensus Panel.     

No difference in postoperative complications,pain, and functional outcomes up to 2 years after incidental durotomy in lumbar spinal fusion: a prospective,multi-institutional,propensity-matched analysis of 1,741 patients

BackgroundIncidental durotomies occur in up to 17% of spinal operations. Controversy exists regarding the short- and long-term consequences of durotomies.PurposeThe primary aim of this study was to assess the effect of incidental durotomies on the immediate postoperative complications and patient-reported outcome measures.Study designProspective study.Patient sampleA total of 1,741 patients undergoing index lumbar spine fusion were selected from a multi-institutional prospective data registry.Outcome measuresPatient-reported outcome measures used in this study included back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), and Oswestry Disability Index.MethodsA total of 1,741 patients were selected from a multi-institutional prospective data registry, who underwent primary lumbar fusion for low back pain and/or radiculopathy between January 2003 and December 2010. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years, with risk-adjusted propensity score modeling.ResultsIncidental durotomies occurred in 70 patients (4%). Compared with the control group (n=1,671), there was no significant difference in postoperative infection (p=.32), need for reoperation (p=.85), or symptomatic neurologic damage (p=.66). At 1- and 2-year follow-up, there was no difference in patient-reported outcomes of back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), or functional disability (Oswestry Disability Index) (p>.3), with results remaining consistent in the propensity-matched cohort analysis (p>.4).ConclusionWithin the context of an on-going debate on the consequences of incidental durotomy, we found no difference in neurologic symptoms, infection, reoperation, back pain, leg pain, or functional disability over a 2-year follow-up period.     

The Role of Laparoscopy-assisted Renal Autotransplantation in the Treatment of Primary Ureteral Tumor

Background

To evaluate the effect and safety of laparoscopy-assisted renal autotransplantation treatment for primary ureteral cancer (PUC).

Methods

Medical records of patients undergoing hand-assisted retroperitoneoscopic nephroureterectomy–extracorporeal total ureterectomy–renal autotransplantation–pyelocystostomy (Lap AutoTx) were analyzed. Demographic, intraoperative, and postoperative data were assessed.

Results

Fifteen patients diagnosed with PUC underwent this novel approach. Three kidneys were abandoned owing to the detection of residual cancer on the renal pelvic junction, surgeon’s judgment on three severe atherosclerotic arteries, and palpable pelvic lymph nodes proven to be evidence of metastatic disease by frozen section analysis. Twelve patients (mean ± SD age 67.5 ± 7.5 years) were treated with Lap AutoTx for PUC successfully. No perioperative mortality occurred. One patient with solitary kidney experienced delayed graft function that required short-term hemodialysis. Three recurrent superficial diseases in three patients were treated with transurethral resection. The mean ± SD follow-up duration was 12.1 ± 6.7 months (range 3–24 months). The renal pelvicaliceal system was easily examined by flexible cystoscopy.

Conclusions

Lap AutoTx is less invasive compared with the traditional two-incisional manner and can be performed safely even among elderly patients. Compared with other currently used therapies, this novel treatment can be used to successfully treat PUC with the added advantages of total resection of the ureteral lesion, preservation of the renal function, and simplification of follow-up procedures.     

Long-Term Outcomes of Laparoscopic Splenectomy Versus Open Splenectomy for Idiopathic Thrombocytopenic Purpura

The long-term outcomes of laparoscopic splenectomy (LS) versus open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP) are not known. A retrospective analysis of 73 patients who underwent splenectomy (32 LS and 41 OS) for refractory ITP between April 2003 and June 2012 was conducted. LS was associated with shorter hospital stay (P = 0.01), less blood loss and blood transfusion during surgery, quicker resumption of oral diet (P < 0.0001), and earlier drain removal (P < 0.01). Conversion to OS was required in 4 patients (12.5%). Operation time was significantly longer in LS (P < 0.0001). Deep venous thrombosis (DVT) was observed in 1 patient after LS and in 4 patients after OS (P = 0.52). One patient died from intraperitoneal bleeding after OS, another patient developed pulmonary embolism. Median follow-up of 36 months was performed in LS group (29 of 32, 91%) and of 46 months in OS group (35 of 41, 85%), 25 patients (86%) in LS group and 32 (91%) in OS group reached sustained complete response (P = 0.792). Kaplan-Meier analysis showed that there was no significant difference in the relapse-free survival rate between the groups (P = 0.777). In conclusion, the long-term outcome of laparoscopic splenectomy is not different from that of open splenectomy for patients with ITP.Key words: Idiopathic thrombocytopenic purpura, Splenectomy, Laparoscopy, Postsplenic complications, Relapse-free survival rateIdiopathic thrombocytopenic purpura (ITP) is related to increased platelet destruction along with reduced platelet production via the specific autoantibodies and may cause a potentially life-threatening hemorrhage. Most ITP can be managed medically, yet some patients are refractory to medical agents such as prednisone, or anti-D globulin therapy,¹ and require splenectomy. Splenectomy can be performed as open splenectomy (OS) or laparoscopic splenectomy (LS).^1,2In the past decade, LS has rapidly become recognized as the gold standard for the management of nontraumatic splenic disorders, such as ITP, thrombotic thrombocytopenic purpura, and hemolytic anemia purpuras.^1–3 Systematic review studies have demonstrated a complete response or durable remission following splenectomy in 66% of adult patients with ITP.⁴ Several retrospective studies have compared the outcomes of OS and LS^1,5–7 and have shown comparable perioperative results, and the recent guidelines of the American Society of Hematology for ITP suggested that a similar efficacy is achieved with both LS and OS, the long-term efficacy of LS for this disorder is uncertain. Therefore, we have retrospectively studied 32 consecutive LS (LS group) and compared them with a historical control group of 41 consecutive OS (OS group) performed for ITP in order to compare the outcomes of LS with OS for ITP.     

Hepatobiliary physiological changes after Roux-en-Y cholecysto-colonic diversion

Background

We speculated that Roux-en-Y cholecysto-colonic diversion was as effective for treating children with progressive familial intrahepatic cholestasis (PFIC) as partial biliary diversion. The feasibility of the novel approach in bypassing bile was investigated in rabbits.

Methods

Twenty-four rabbits were randomly divided into three groups: sham operated group (Group1), 30 cm limb group (Group 2), and 10 cm limb group (Group 3). Group 2 or 3 underwent a Roux-en-Y cholecystocolonic anastomoses with a 30- or 10-cm-long Roux limb. ^99mTcEHIDA dynamic biligraphy was used to detect alterations of bile flow among the three groups at 1 year postoperatively. TBA levels and histological changes were also evaluated.

Results

All animals survived and developed normally without clinical symptoms during 1 year follow-up. Bile was diverted into colon directly after cholecystocolonic anastomosis. In group 3, E20 and E35 values were (77.27 ± 6.15%) and (90.39 ± 1.49%) respectively. Gallbladder emptying was accelerated in 10 cm short limb group than in 30 cm long limb group. The ratio of bile shunt was (0.547 ± 0.182), which was also more than that in group 2 (p < 0.05). The activity-time curve for the gallbladder area in group 2 looks like a wave. A significant reduction in TBA level was observed in group 2 and 3 (p < 0.05).

Conclusions

Roux-en-Y cholecystocolonic bypass was safe and feasible. Its effectiveness is related to the length of Roux loop. Cholecystocolonic bypass led to a significant loss of bile acids in healthy rabbits and might be considered for bile diversion in pediatric patients with selected cholestatic diseases.