Selection Of Patients For Surgery Research Articles

Short-term and long-term results of cardiac surgery in elderly and very elderly patients

Cardiac operations in elderly patients are increasingly frequent and imply major clinical, ethical, and economic issues. Operative and 5-year results of cardiac operations in patients aged 79 years or more are known in limited series, and a debate is ongoing on the appropriateness of selection of patients for surgery. We retrospectively reviewed our experience in 6802 patients aged 79 years or more who had received a cardiac operation. Surgical candidates were selected according to functional status, crude operative risk, and social context and were managed according to a multimodality protocol. Mean age was 82 years and surgery was nonelective in 1613 cases (23.5%, 31 salvage). Procedures consisted of valve replacement (aortic, 2817; mitral, 532; and tricuspid, 2 cases), valve repair (aortic, 66; mitral, 532; and tricuspid, 232 cases), coronary bypass grafting (12,034 coronary vessels bypassed), and replacement of the thoracic aorta (ascending, 315; arch, 28 cases). Overall operative mortality was 3.4%. Nonelective presentation, need for aortic counterpulsation, cardiopulmonary bypass time, blood transfusion, depressed systolic function, and chronic lung disease predicted operative mortality. Five-year cumulative mortality was 7.5%. Poor systolic function, previous myocardial infarction, and combined coronary/mitral surgery predicted late mortality. The operative risk of nonagenarians operated on electively did not differ from that of risk-matched octogenarians. Cardiac surgery in elderly and very elderly patients can be performed with acceptable mortality provided that accurate selection and a multifactorial risk evaluation are adopted. Whenever possible, nonelective operations should be avoided and earlier surgery should be encouraged. Five-year survival and functional recovery are good.

Carcinoma Embryonic Antigen: Its Place in Decision Making for Pulmonary Metastasectomy in Colorectal Cancer

In their review of Pulmonary Resection in Metastatic Colorectal Cancer, Pfannschmidt et al.1 consider carcinoma embryonic antigen (CEA) as an adverse feature in the prognosis of patients who have had pulmonary metastasectomy for colorectal cancer, a consistent finding in multivariable analyses of clinical case series.2,3 Kanemitsu et al.3 published a predictive model on the basis of 313 patients operated on between 1989 and 1998. Their five prognostic factors were primary histology, hilar or mediastinal lymph node involvement, number of metastases, preoperative CEA level, and extrathoracic disease. However, CEA was not statistically significant in the most recent Memorial Sloane Kettering report.4 They found that in patients younger than 65 years, female sex, apparent disease free interval (DFI) less than 1 year, and number of metastases more than three to be predictive of recurrence and went on to make an explicit recommendation: “medical management alone should be considered standard for patients who have both three or more pulmonary metastases and less than 1 year DFI.” This contradiction prompts a consideration of the role of CEA in the surveillance of patients with colorectal cancer and in the selection of patients for surgery and of the limitations of multivariate analysis as a basis for clinical decision making. First, to deal briefly with the statistical issue, the failure to find a “p value” does not mean that CEA would have had no bearing on outcome. If at the case selection stage, there was a clinical policy (explicit or unstated) to avoid operating on patients with high CEA, the range of CEA data will have been curtailed at the input stage; there is a point at which it cannot then emerge as a prognostic factor. Other factors will then come to the fore. It should also be remembered that there is a limit to the number of factors that will emerge as significant and an inevitable degree of variation in their apparent ranking. The contradiction merits attention for surgeons who have to make decisions about how to use CEA in their selection of patients.5,6 In the systematic review by Fiorentino et al.,7 approximately a third of 51 included publications reported the preoperative CEA in a way that could be used in the analysis (Figure 1). Approximately half of these patients in the operated series had an increased CEA in the earlier era falling to approximately a third more recently. This illustrates the point alluded to above; there may have been a conscious avoidance of metastasectomy for patients with high CEA. The knowledge provided in earlier reports might quite rightly have altered the practice, and hence the case mix, for later reports. When CEA and survival data were available, these showed (Figure 2) an evident and consistent relationship: patients with increased CEA have consistently worse survival. This suggests that the importance of a raised CEA as an adverse prognostic feature for survival should not be forgotten just because it now features less prominently in the input data set. In the course of developing the PulMiCC trial,8,9 we discovered that gastroenterologists and thoracic surgeons were at cross purposes in the use of CEA in patients with recurrence of colorectal cancer. While as thoracic surgeons we were interpreting CEA as an adverse feature,3 some gastroenterologists were using the CEA measurement as a surveillance tool: when CEA became increased, this prompted a computed tomography scan and possible referral to thoracic surgery if this revealed pulmonary metastases. The practice may have stemmed in part from a philosophy of care of colorectal cancer in which routine CEA testing was used to prompt “second look” surgery to deal with local recurrence10 and was at least temporally related to the growth in hepatic metastasectomy for colorectal cancer.11 CEA measurement was then shown to be not cost effective, because although it picked up asymptomatic patients earlier, it made no impact on survival.10,12,13 From the thoracic surgeons’ viewpoint, it would seem reasonable to obtain a CEA measurement, and if it is high, it should go in the balance pan adding weight against metastasectomy. It is critical that the statistical findings are used appropriately in surgical decision making. To rather stretch the point, but to illustrate the point, here is a wry Clinical Operational Research Unit, University College London, London, UK. Disclosure: The author declares no conflicts of interest. Address for correspondence: Tom Treasure, MD, Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, United Kingdom. E-mail: tom.treasure@gmail.com Copyright © 2010 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/10/0506-0179

Influence of surgical interventions on survival in patients with stage IIIb non-small cell lung cancer (NSCLC): The Fox Chase Cancer Center (FCCC) experience.

7067 Background: NSCLC patients (Pts) with T4 and/or N3 disease are categorized as stage IIIB NSCLC. Chemoradiation (CRT) is the standard of care for pts with dry (without malignant pleural effusion) stage IIIB NSCLC. Published results of Intergroup trial, INT 0139, suggests that lobectomy improves survival over CRT in stage IIIA disease. We evaluated the role of surgery in patients with dry stage IIIB to discern whether surgery would have a similar impact in technically resectable cases. Methods: Outcomes of NSCLC pts with dry IIIB disease, treated at FCCC between 01/2000 and 12/2008, were analyzed. Stage IIIB patients were dichotomized in two cohorts, those who had surgery versus those treated non-surgically. The propensity score method was used to balance the two cohorts for histology, age, sex, and smoking status. Kaplan-Meier estimators were used to compare overall survival (OS) between treatment cohorts. Results: The median age was 62 years (y) for the 194 pts with stage IIIb disease, of whom 51% were male. Most pts were Caucasian (85%) and smokers (87%). Sixty two pts had adenocarcinoma (32%), 68 squamous cell (35%) and 64 (33%) had NSCLC not otherwise specified. S was performed in 58 pts (29 lobectomies, 11 pneumonectomies and 18 other procedures) (30%) and 136 (70%) underwent CRT alone. After propensity score based weighting, there were no significant differences in patient characteristics, between the two cohorts. S was significantly superior to CRT (median OS 25 months (mos) vs. 16 mos, p=0.009). One, two and five y OS were 70%, 52% and 40% and 64%, 31% and 13% in the S group and CRT group, respectively. Progression-free survival and OS by T and N descriptors will be presented at the meeting. Conclusions: After propensity based weighting, OS of dry stage IIIB pts treated surgically was superior to pts treated with CRT. A fresh look at the role of surgery in select patients with dry stage IIIB disease may be warranted. No significant financial relationships to disclose.

Utility or futility of prognostic scoring systems for colorectal liver metastases in an era of advanced multimodal therapy

Objectives To assess the general applicability of prognostic scores for colorectal liver metastases (CRLM). Methods Review of English language studies from 1980 to 2008 (Medline and Embase). Search keywords included “Colorectal neoplasms”, “liver metastases”, “liver resection”, “prognostic scoring system”. Results Six scoring systems and fourteen prognostic factors within these studies were identified. No prognostic factor was common in all scoring methods. Five scores retained the number of metastases as a prognostic factor. Size of metastases and time between the onset of the primary tumor and the discovery of metastases were present in four scores. Three scores predicted 5-year survival using carcinoembryonic antigen (CEA) and R1 resection. Only two scores were assessed preoperatively. Successive scoring methods had improved predictive accuracy compared to earlier systems. However, their applicability in general populations remains debatable. An evaluation of the scores applicability to different patient populations demonstrated that the models were minimally effective in predicting disease-specific survival and recurrence, suggesting that stratification of patients by clinical and pathologic factors alone, may be clinically unreliable and not applicable for selection of patients for surgery. Conclusion The utility of prognostic models on general populations is inconsistent. Current clinicopathologic factors may be inadequate to determine disease prognosis in CRLM. Future attempts to develop prognostic scores should include additional biologic and clinical variables, and be validated in larger populations.

A Supplementary Grading Scale for Selecting Patients With Brain Arteriovenous Malformations for Surgery

Patient age, hemorrhagic presentation, nidal diffuseness, and deep perforating artery supply are important factors when selecting patients with brain arteriovenous malformations (AVMs) for surgery. We hypothesized that these factors outside of the Spetzler-Martin grading system could be combined into a simple, supplementary grading system that would accurately predict neurologic outcome and refine patient selection. A consecutive, single-surgeon series of 300 patients with AVMs treated microsurgically was analyzed in terms of change between preoperative and final postoperative modified Rankin Scale scores. Three different multivariable logistic models (full, Spetzler-Martin, and supplementary models) were constructed to test the association of combined predictor variables with the change in modified Rankin Scale score. A simplified supplementary grading system was developed from the data with points assigned according to each variable and added together for a supplementary AVM grade. Predictive accuracy was highest for the full multivariable model (receiver operating characteristic curve area, 0.78), followed by the supplementary model (0.73), and least for the Spetzler-Martin model (0.66). Predictive accuracy of the simplified supplementary grade was significantly better than that of the Spetzler-Martin grade (P = .042), with receiver operating characteristic curve areas of 0.73 and 0.65, respectively. This new AVM grading system supplements rather than replaces the well-established Spetzler-Martin grading system and is a better predictor of neurologic outcomes after AVM surgery. The supplementary grading scale has high predictive accuracy on its own and stratifies surgical risk more evenly. The supplementary grading system is easily applicable at the bedside, where it is intended to improve preoperative risk prediction and patient selection for surgery.

Laparoendoscopic single-site surgery in urology

To analyze the current literature regarding advances in laparoscopic single-site (LESS) surgery in urology. Since its initial urologic description in 2007, there has been a surge of interest in LESS surgery. Published descriptions of LESS procedures now include virtually all extirpative and reconstructive urologic procedures. Novel instrumentation and techniques have been developed that offset many of the inherent increased technical demands with LESS surgery. Substantial clinical data have recently been reported that attest to the safety and efficacy of LESS surgery in select patients. Initial data have also been reported comparing morbidity outcomes with standard laparoscopy. LESS is now an established technique within the field of minimally invasive urologic surgery. Further study is needed to determine the true benefits of the technique and the extent of its clinical application. Further refinements in technology will likely be needed before the widespread adoption of LESS.

Diagnostic Intracranial Pressure Monitoring and Surgical Management in Idiopathic Normal Pressure Hydrocephalus

To review our experience of managing idiopathic normal pressure hydrocephalus (iNPH) during the 6-year period from 2002 to 2007, when intracranial pressure (ICP) monitoring was part of the diagnostic workup. The review includes all iNPH patients undergoing diagnostic ICP monitoring during the years 2002 to 2007. Clinical grading was done prospectively using a normal pressure hydrocephalus (NPH) grading scale (scores from 3 to 15). The selection of patients for surgery was based on clinical symptoms, enlarged cerebral ventricles, and findings on ICP monitoring. The median follow-up time was 2 years (range, 0.3-6 years). Both static ICP and pulsatile ICP were analyzed. A total of 214 patients underwent the diagnostic workup, of whom 131 went on to surgery. Although 1 patient died shortly after treatment, 103 of the 130 patients (79%) improved clinically. This improvement lasted throughout the observation period. The static ICP observed during ICP monitoring was a poor predictor of the response to surgery. In contrast, among 109 of 130 patients with increased ICP pulsatility (ie, ICP wave amplitude >4 mm Hg on average and >5 mm Hg in >10% of recording time), 101 (93%) were responders (ie, increase in the NPH score of >2). Correspondingly, only 2 of 21 (10%) without increased ICP pulsatility were responders. Superficial wound infection was the only complication of ICP monitoring and occurred in 4 (2%) patients. Surgical results in iNPH were good with almost 80% of patients improving after treatment. The data indicate that improvement after surgery can be anticipated in 9 of 10 iNPH patients with abnormal ICP pulsatility, but in only 1 of 10 with normal ICP pulsatility. Diagnostic ICP monitoring had a low complication rate.

Breast conservation in locally advanced breast cancer

Absence of breast cancer screening in India, lack of awareness in rural population, social inhibitions and poor socioeconomic status leads to a situation where a large proportion of women in India are still presenting with locally advanced breast cancer (LABC) at the time of initial diagnosis, although, there are relatively more of early stage cases detected in the metros and urban areas than maybe a decade ago. With advances in care and introduction of newer chemotherapeutic agents, it has now become feasible to offer neoadjuvant therapy with effective tumor downsizing, thus making it possible to even consider breast conservation surgery in select patients with locally advanced and unresectable disease at presentation. With reports suggesting apparent safety of the procedure, breast conservation treatment after chemotherapy is now being offered as routine care in most major centers for selective women with LABC. Multimodality therapy is the standard of care with neoadjuvant systemic therapy for all women with LABC.

Validation of the renogram with immediate diuretic stimulus

Objective The aim of this study is to determine the diagnostic reliability of the renogram with diuretic stimulus simultaneously at the administration of the dose, comparing two groups of 59 patients each one (F0 and F+10), to select patients for surgery. Material and Methods This is a retrospective study including two groups of 59 patients in whom the diuretic renogram was carried out by stimulus (furosemide), due to suspicion of ureteropelvic or vesicoureteral obstruction, using 99m Tc-Mercaptoacetylglicine. In the first one, the study was conducted applying the diuretic stimulus 600 seconds after the administration of the dose of the radiotracer (F+10). In the second one, it was carried out simultaneously to the administration (F0). For the interpretation, visual analysis, the parameters of the curves and the percentage of elimination after modification by the severity and micturition were evaluated. Statistical analysis of the information was made. Results The F+10 renogram shows a sensitivity of 96.7 %, specificity of 96.1 %, positive predictive value of 90.6 %, and a negative predictive value of 98.6 %. The F0 renogram shows a sensitivity of 95.2 %, specificity of 98.9 %, positive predictive value of 95.2 %, and a negative predictive value of 98.9 %. Conclusion The performance of the renogram by means of the administration of diuretic stimulus at the same time as the administration of the radiotracer is a useful and comfortable method in paediatric patients, and does not mean a significant loss in the efficacy parameters of the test in the selection of patients for surgery.

Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age

Decompressive surgery can be life saving after malignant cerebral infarction. However, severe residual disability occurs in a significant number of surviving patients. Most discussion about the benefits of surgery is based on studies performed in patients who are < or = 60 years of age. Less is known about the benefits of the procedure in the elderly population. The authors undertook a review of the literature on decompressive craniectomy for malignant cerebral infarction and compared the mortality and outcome data published in patients older and younger than 60 years of age. The authors discuss their analysis, with specific reference to the limitations of the studies analyzed, the outcome measures used, and the special considerations required when discussing stroke recovery in the elderly. Studies on decompressive craniectomy for malignant middle cerebral artery infarction reported in the English literature were analyzed. A cutoff point for age of > 60 or < or = 60 years was set, and the study population was segregated. No studies specifically analyzed patients > 60 years old. A total of 19 studies was identified, 10 of which included patients who were > 60 years of age. A comparison between the 2 age groups was made within the 10 studies and also among all the patients in the 19 studies. Mortality rates and outcome scores were assessed for each study, and a Barthel Index (BI) score of < 60 or a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome. Rates were compared using the Fisher exact test, and p values < 0.05 were considered statistically significant. Nineteen studies were found, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarcts. Ten of these studies included 73 patients (26.7%) who were > 60 years of age. The mean follow-up times ranged from 5.75 to 12.3 months in the > 60-years group and 4.2 to 28 months in the < or = 60-years group. The mortality rate was significantly higher, at 51.3% in the > 60-years group (37 of 72 patients) compared with 20.8% (41 of 197 patients) in the < or = 60-years group (p < 0.0001). Similarly, patients who survived in the > 60-years group had significantly higher rates of poor outcomes, at 81.8% (27 of 33), compared with 33.1% (47 of 142) in the < or = 60-year-old group (p < 0.0001). The BI was the most commonly used primary outcome measure (15 out of 19 studies), followed by the mRS score, which was used in 4 studies. The mortality rate and functional outcome, as measured by the BI and mRS, were significantly worse in patients > 60 years of age following decompressive craniectomy for malignant infarction. Age is an important factor to consider in patient selection for surgery. However, cautious interpretation of the results is required because the outcome scores that were used only measure physical disability, whereas other factors, including psychosocial, financial, and caregiver burden, should be considered in addition to age alone.

The evolving management of small renal masses

The incidence of small renal masses (SRMs) continues to rise, largely because of the widespread use of cross-sectional imaging for abdominal symptomatology. Clinical management must balance the risk of disease progression from renal cell carcinoma in these tumors against the potential morbidity of treatment, particularly in elderly patients or those with multiple comorbidities. Moreover, a significant minority of SRMs represent benign lesions. This article reviews the current data for surgical excision, cryoablation, radiofrequency ablation, and active surveillance of SRMs. Surgical excision, predominantly in the form of nephron-sparing surgery, remains the standard of care because of its durable oncologic and favorable functional outcomes. Active surveillance and ablative technologies have emerged as alternatives to surgery in select patients based on short-term oncologic data. Nevertheless, the extent to which treatment alters the natural history of SRMs has yet to be established.

Traumatic Neuroma of Extrahepatic Bile Ducts After Orthotopic Liver Transplantation

Traumatic neuromas (TN) of the biliary tree causing strictures have only occasionally been described after liver transplantation. Herein, we have reported 15 cases of TN that were detected between 1 and 17 months after transplantation (median: 4 months) during surgery for obstructive jaundice (12 cases), after alterations of liver function tests (two cases), or incidentally discovered after retransplantation ( n = 1) we resected the lesion and the biliary anastomosis. Pathological examination and immunostaining for S-100 protein were performed to study the nerve fascicles. After a median follow-up time of 64 months (range = 0–127), 10 patients are alive without any complication related to the previous biliary TN. We propose the following classification: type I: TN originating from and located in the main biliary tract wall, and type II: TN arising from the surrounding tissues next to the main biliary tract. We conclude that TN are not uncommon after liver transplantation and that they are sometimes symptomatic, causing a biliary stricture that requires surgical treatment. We propose a classification to help patient selection for surgery. In our opinion, resection of the TN is the operation of choice, together with resection of the involved biliary tract in type I TN.

Chronic Total Symptomatic Carotid Artery Occlusion Treated Successfully with Stenting and Angioplasty

Treatment of symptomatic chronic totally occluded carotid artery has been limited to medical management. An ongoing clinical trial is examining the role of extracranial to intracranial bypass surgery in select patients with impaired cerebrovascular reserve based on PET imaging parameters. We describe a case utilizing stenting and angioplasty to treat a chronic total carotid occlusion as a potential alternative therapy. A 55-year-old woman presented with a right hemispheric ischemic stroke in the setting due to a right internal carotid artery total occlusion. She was treated medically with antiplatelet therapy and oral vasopressor agents. She returned with new symptoms 1 month later and was successfully treated with stenting and angioplasty. At the 9-month follow-up, she remains neurologically intact. Stenting and angioplasty may be a therapeutic option in select patients with chronic total carotid occlusion. Further study is required to determine the safety profile of this treatment modality.

Balloon Catheter Dilatation for Frontal Sinus Ostium Stenosis in the Office Setting

Frontal sinus ostium stenosis (FSOS) is problematic even for expert surgeons. Balloon catheter (BC) technology has been recently introduced to rhinology. The aim of this study is to assess technical feasibility and effectiveness of BC dilatation of FSOS in the office setting. This retrospective, multi-institutional case series describes all patients who underwent BC dilatation of FSOS in the office setting in the year ending December 31, 2007. Six adult patients underwent a total of seven BC dilatations of FSOS in the clinical setting. The pretreatment ostium size was 1-2 mm. Four of the dilatations were performed with a 5-mm lacrimal BC (LacriCATH, Quest Medical, Allen, TX) and three dilatations were executed with a 7-mm sinus BC (SinuCATH, Quest Medical). All procedures were performed using topical anesthesia only. No complications occurred. Five of the six dilated FSOS dilatations were deemed successful after one BC dilatation. One ostium contracted >50% and required repeat BC dilatation. All ostia have remained patent with a follow-up range of 4-9 months. No subject has required formal surgical revision. This preliminary report describes BC of FSOS in the office setting. The technique may serve as a safe and feasible alternative, potentially avoiding formal revision sinus surgery in select patients.

Impact of Upper Airway Surgery on CPAP Compliance in Difficult-to-Manage Obstructive Sleep Apnea

To study the role of adjunctive upper airway surgery in obese patients with obstructive sleep apnea (OSA) who were poorly compliant with continuous positive airway pressure (CPAP) therapy. Retrospective study of obese patients with OSA and documented poor CPAP compliance who underwent noncurative upper airway surgery for anatomical obstruction. Data collected included polysomnogram (PSG) parameters, CPAP settings and compliance, and surgical complications. An urban academic county hospital with an 8-bed sleep laboratory. Data were collected retrospectively from 2002 through 2005. Subjects who met the following criteria: (1) documented OSA (apnea-hypopnea index [AHI] > or =5.0) treated with CPAP therapy, (2) poor CPAP compliance (<4 hours per night), (3) subjected to upper airway surgery, (4) repeated PSG after surgery revealed persistent OSA (AHI > or = 5) requiring continued treatment with CPAP, and (5) availability of presurgery and postsurgery CPAP compliance data. Compliance with CPAP. Data from 11 patients were available for analysis. Their PSG parameters revealed the mean AHI (79.0 before surgery vs 30.2 after surgery; P < .001) and mean CPAP pressure setting (11.8 cm H(2)O before surgery vs 10.4 cm H(2)O after surgery; P = .09) improved following surgery. A mean increase of 48.6 minutes in CPAP compliance was noted after surgery (P = .03). Eight of the 11 patients improved their CPAP compliance following surgical intervention, including 5 who improved by more than 1 hour. Upper airway surgery in select patients with OSA may improve CPAP compliance and should be considered as a potential adjunctive therapeutic measure in poorly compliant patients with OSA.

Management of asymptomatic severe aortic stenosis: is aortic valve replacement indicated?

Patients with asymptomatic, severe aortic stenosis are at risk of cardiac death. In this Viewpoint, Pellikka and Sundt assert that aortic valve replacement should be considered in these patients, if surgery is likely to prolong life expectancy. Risk stratification of the asymptomatic aortic stenosis patient remains inadequate, however, and the decision to operate must be individualized, particularly in the elderly. The authors call for a randomized trial to help optimize the selection of patients for surgery.

Adjuvant Therapy for Adenocarcinoma of the Pancreas: Analysis of Reported Trials and Recommendations for Future Progress

The delivery of postoperative combined modality adjuvant therapy for completely resected pancreatic cancer was initially shown to be beneficial on the basis of a prospective, randomized trial published in 1985. Since then, oncologists have debated whether chemotherapy, chemoradiation, or both is optimal adjuvant therapy after pancreatectomy for ductal adenocarcinoma of the pancreas; no global consensus has emerged. Unfortunately, despite the completion of a number of subsequent randomized trials of adjuvant therapy since 1985, no further improvements in overall survival have materialized. This lack of progress is not simply the result of ineffective systemic therapies, but in part the result of poor trial design and calls for a more disciplined approach to the selection of patients for surgery, pathologic assessment of surgical resection margins, and postoperative (pretreatment) imaging. This is the only way to ensure that patients who receive adjuvant therapy are actually receiving therapy for radiographically occult possible microscopic disease, rather than therapy for incompletely resected locally advanced disease or early postoperative metastases. A critical analysis of completed adjuvant trials will be provided and a framework for the conduct of future trials of adjuvant therapy proposed.

Orthodontic Expansion Treatment and Adenotonsillectomy in the Treatment of Obstructive Sleep Apnea in Prepubertal Children

Rapid maxillary expansion and adenotonsillectomy are proven treatments of obstructive sleep apnea (OSA) in children. Our goal was to investigate whether rapid maxillary expansion should be offered as an alternative to surgery in select patients. In addition, if both therapies are required, the order in which to perform these interventions needs to be determined. Prepubertal children with moderate OSA clinically judged to require both adenotonsillectomy and orthodontic treatment were randomized into 2 treatment groups. Group 1 underwent adenotonsillectomy followed by orthodontic expansion. Group 2 underwent therapies in the reverse sequence. Thirty-two children (16 girls) in an academic sleep clinic. Clinical evaluation and polysomnography were performed after each stage to assess efficacy of each treatment modality. The 2 groups were similar in age, symptoms, apnea-hypopnea index, and lowest oxygen saturation. Two children with orthodontic treatment first did not require subsequent adenotonsillectomy. Thirty children underwent both treatments. Two of them were still symptomatic and presented with abnormal polysomogram results following both therapies. In the remaining 28 children, all results were significantly different from those at entry (P = 0.001) and from single therapy (P = 0.01), regardless of the order of treatment. Both therapies were necessary to obtain complete resolution of OSA. In our study, 87.5% of the children with sleep-disordered breathing had both treatments. In terms of treatment order, 2 of 16 children underwent orthodontic treatment alone, whereas no children underwent surgery alone to resolve OSA. Two children who underwent both treatments continued to have OSA.

Vitrectomy for diabetic macular oedema

To briefly review and discuss the literature on vitrectomy for diabetic macular oedema. Literature review. There is a copious literature on the subject of vitrectomy for diabetic macular oedema (DMO). The most commonly hypothesised mechanism for the potential benefit of vitrectomy is relief of vitreomacular traction; however, both transvitreal oxygenation and improved growth factor diffusion away from the premacular retina have also been suggested to be potentially beneficial effects. Other systemic and local factors including duration of oedema, extent of ischaemia and exudation, and extent of laser may result in permanent photoreceptor and capillary damage, which precludes anatomical or visual benefit. Much of the literature on the subject of vitrectomy for DMO is retrospective and uncontrolled but strongly suggestive of a benefit in terms of improved acuity and reduced macular thickness following vitrectomy. There are five published small randomised controlled trials on this subject. Taken as a whole, these studies do not suggest a benefit from surgery. Selection of patients for surgery on the basis of OCT partial vitreomacular separation or clinical signs of traction such as an epiretinal membrane or taut thickened hyaloid has been reported to be associated with a modest improvement in prospective studies but this has not been subjected to controlled study. The evidence at present suggests that vitrectomy for DMO should be restricted to those with clinical or OCT signs of traction.

Changing indications for surgery in patients with stage IV breast cancer

Evolving concepts of cancer biology and emerging evidence of a potential survival benefit from local surgery have raised the question of an expanded role for surgery in select patients with metastatic breast cancer (MBC). To determine whether such developments have influenced clinical practice, the authors evaluated surgical practice patterns in the study institution over the last 15 years. Two institutional databases were screened to identify patients with MBC who underwent breast surgery (1990-2005). Retrospective review was conducted to assess trends over time and to evaluate the role of surgery in the more modern era (1995-2005). The overall frequency of mastectomy remained stable over time (1.7%); however, between early (1990-1995) and late (2000-2005) periods the rate of 'symptom control' mastectomy decreased (41% to 25%), whereas the rate of 'local control' mastectomy increased (34% to 66%). Conversely, the overall frequency of wide-local excision (WLE) increased over time (1995-2001), from 1% to 9% (P< .001) with no differences noted between rates of symptom control or local control procedures. In the modern era (1995-2005), 256 of 12,529 patients (2%) with MBC underwent breast surgery (33% mastectomy, 52% WLE); most frequently to 'optimize local control' (50%) and primarily in the setting of limited/stable distant disease. Surgery was performed for palliation in only 19% of patients. At a median follow-up of 33.9 months (range, 0-198.7 months), 136 of 256 patients (53%) in this cohort remained alive; 88% were free of local disease. Although surgery in MBC has historically been reserved for palliation, the authors observed a decreasing rate of traditional 'toilet mastectomy' and a broadened surgical approach to the asymptomatic patient. When viewed in parallel with evolving concepts in cancer biology, these data reflect a change in the traditional approach to patients with MBC and warrant further investigation.