Archives of Surgery最新文献

Hypothesis: The use of preoperative magnetic resonance (MR) imaging may have an effect on the reoperation rate in women with operable breast cancer.

Design: Retrospective cohort study.

Setting: University medical center.

Patients: Women with operable breast cancer treated by a single surgeon between January 1, 2006, and December 31, 2010.

Intervention: Selective preoperative MR imaging based on breast density and histologic findings.

Main outcome measures: Reoperation rate and pathologically avoidable mastectomy at initial operation.

Results: Of 313 patients in the study, 120 underwent preoperative MR imaging. Patients undergoing MR imaging were younger (mean age, 53.6 vs 59.5 years; P < .001), were more often of non-Hispanic white race/ethnicity (61.7% vs 52.3%, P < .05), and more likely had heterogeneously dense or very dense breasts (68.4% vs 22.3%, P < .001). The incidence of lobular carcinoma (8.3% in the MR imaging group vs 5.2% in the no MR imaging group, P = .27) and the type of surgery performed (mastectomy vs partial mastectomy, P = .67) were similar in both groups. The mean pathological size of the index tumor in the MR imaging group was larger than that in the no MR imaging group (2.02 vs 1.72 cm, P = .009), but the extent of disease was comparable (75.8% in the MR imaging group vs 82.9% in the no MR imaging group had pathologically localized disease, P = .26). The reoperation rate was similar between the 2 groups (19.1% in the MR imaging group vs 17.6% in the no MR imaging group, P = .91) even when stratified by breast density (P = .76), pT2 tumor size (P = .35), or lobular carcinoma histologic findings (P = .26). Pathologically avoidable mastectomy (multifocal or multicentric MR imaging and unifocal histopathological findings) was observed in 12 of 47 patients (25.5%) with preoperative MR imaging who underwent mastectomy.

Conclusion: The selective use of preoperative MR imaging to decrease reoperation in women with breast cancer is not supported by these data. In a considerable number of patients, MR imaging overestimates the extent of disease.

Objectives: To compare the outcomes of umbilical hernia repair in patients with and without signs of portal hypertension, such as esophageal varices or ascites; to assess the effect of emergency surgery on complication rates; and to identify predictors of postoperative mortality.

Design: Database search from January 1, 2005, through December 31, 2009.

Setting: North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program initiative.

Patients: We studied patients who underwent umbilical hernia repair. Those with congestive heart failure, disseminated malignant tumor, or chronic renal failure while undergoing dialysis were excluded.

Main outcome measures: Preoperative variables and perioperative course were analyzed. Main outcome measures were morbidity and mortality after umbilical hernia repair.

Results: A total of 390 patients with ascites and/or esophageal varices formed the study group, and the remaining 22 952 patients formed the control group. The overall morbidity and mortality rates for the study group were 13.1% and 5.1%, whereas these rates were 3.9% and 0.1% for the control group, respectively (P < .001). For the study group, the mortality after elective repair among patients with a model for end-stage liver disease (MELD) score greater than 15 was 11.1% compared with 1.3% in patients with a MELD score of 15 or less. The patients with ascites and/or esophageal varices underwent emergency surgery more frequently than the control group (37.7% vs 4.9%; P < .001). Emergency surgery for the study group was associated with a higher morbidity than elective surgery (20.8% vs 8.3%; P < .001) but not a significantly higher mortality (7.4% vs 3.7%; P = .11). However, logistic regression analysis showed that age older than 65 years, MELD score higher than 15, albumin level less than 3.0 g/dL (to convert to grams per liter, multiply by 10), and sepsis at presentation were more predictive of postoperative mortality.

Conclusions: Umbilical hernia repair in the presence of ascites and/or esophageal varices is associated with significant postoperative complication rates. Emergency surgery is associated with higher morbidity rates but not significantly higher mortality rates. Elective repair of umbilical hernia should be avoided for those with adverse predictors, such as age older than 65 years, MELD score higher than 15, and albumin level less than 3.0 g/dL.

Hypothesis: Surgeon-performed ultrasound (SUS) and fine-needle aspiration (FNA) may guide the management of dominant thyroid nodules of the isthmus.

Design: Retrospective review of prospectively collected data.

Setting: Tertiary academic referral center.

Patients: Of 942 patients who underwent preoperative SUS and FNA, followed by thyroidectomy, between January 1, 2002, and April 10, 2010, a total of 28 patients had a dominant thyroid nodule of the isthmus.

Main outcome measures: Preoperative SUS features and FNA findings and final pathologic results.

Results: Of 28 patients (3%) who had a dominant thyroid nodule of the isthmus, 16 had benign final pathologic results, with all having at least 2 benign SUS features and 9 having 3 benign SUS features; 15 of 16 patients had an FNA finding that was benign or indeterminate. Of 12 patients with malignant final pathologic results, 8 had 3 malignant SUS features, and all had an FNA finding that was malignant or suspicious for a malignant neoplasm. Among these 12 patients, final pathologic results demonstrated multifocal disease (8 patients), extracapsular invasion (4 patients), or lymph node involvement (7 patients). When 11 patients with a malignant dominant thyroid nodule of the isthmus were compared with an overall group of 270 other well-differentiated papillary thyroid carcinomas 1 cm or larger on final pathologic results, patients with isthmus nodules trended toward having higher rates of multifocal disease (P = .08), extracapsular invasion (P = .09), and lymph node involvement (P = .09).

Conclusions: Preoperative SUS features and FNA findings in patients with dominant thyroid nodules of the isthmus can accurately predict malignant or benign thyroid disease and direct the extent of thyroidectomy. For malignant isthmus nodules, total thyroidectomy and possible central node dissection are recommended owing to high rates of multifocal disease and lymph node involvement. For benign isthmus nodules, thyroid lobectomy with isthmusectomy or isthmusectomy alone may be appropriate.

OBJECTIVE To determine whether increasing body mass index (BMI) is associated with more aggressive disease and adverse surgical outcomes in patients with papillary thyroid cancer (PTC). DESIGN Retrospective review of a prospective database. SETTING Single academic tertiary care center. PATIENTS A total of 443 patients older than 18 years who underwent total thyroidectomy for PTC from January 1, 2004, through March 31, 2011, were included in the analysis. Patients were organized into 4 BMI (calculated as weight in kilograms divided by height in meters squared) groups: normal (18.5-24.9), overweight (25-29.9), obese (30-39.9), and morbidly obese (≥40). MAIN OUTCOME MEASURES Disease stage at presentation, histologic subtype, duration of anesthetic induction and extubation, duration of surgery, surgical complications, length of hospital stay, and American Society of Anesthesiologists (ASA) class. RESULTS Ages ranged from 18 to 89 years. Greater BMI was associated with more advanced disease stage at presentation (P < .001) and more aggressive PTC histopathologic subtype (P = .03). Morbidly obese patients presented more frequently with stage III or IV disease (odds ratio, 3.67; P < .001). Greater BMI was also associated with longer duration of anesthetic induction (P < .001), increased length of stay (P < .001), and higher ASA class (P < .001). Duration of surgery was not associated with BMI. There was a trend toward larger tumors with increasing BMI (P = .06). Obese BMI was associated with more preoperative vocal cord paralysis due to local invasion (odds ratio, 9.21; P = .001). CONCLUSIONS Obese patients present with more advanced stage and more aggressive forms of PTC. This finding suggests that obese patients should be screened for thyroid cancer.