Selection Of Patients For Surgery Research Articles

Characteristics of Patients who Survived Less than Three Months or Greater than Two Years after Surgery for Spinal Metastases: Can We Avoid Inappropriate Patient Selection?

Introduction The survival of patients with metastatic cancer has improved at the cost of increased presentation with metastatic spinal disease. For patients with (impending) pathological spinal fractures and/or spinal cord compression, surgical intervention may relieve pain and improve mobility and quality of life. It is generally accepted that surgery is inappropriate if anticipated survival is less than three months, and survival greater than two years is uncommon. The aim of this international multicenter prospective cohort study was to analyze data from surgical patients who died within three months, or after two years from surgery, to identify any preoperative factors which might be associated particularly with poor survival, to avoid inappropriate selection of patients for surgery in the future. Patients and Methods A total of 1266 patients were treated surgically for (impending) pathological fractures and/or neurological deficits and were prospectively followed. Data collected included tumor characteristics, preoperative fitness (ASA), neurological status (ASIA), performance status (KPS), and quality of life (EQ-5D). Primary outcomes were survival at three months and two years postsurgery. Univariate and multivariate logistic regression analysis were used to find preoperative factors associated with short- and long term survival. Results In univariate analysis age, emergency surgery, KPS, EQ-5D, ASA, ASIA, and Tokuhashi/Tomita scores were all significantly associated with short survival. In multivariate analysis, however, only KPS was significantly associated with short survival (OR 1.40; CI 1.18–1.67). Associated with longer survival in univariate analysis were age, number of spinal levels included in the surgery, KPS, EQ-5D, ASIA, and Tokuhashi/Tomita scores. In multivariate analysis, only the number of affected spinal levels included in the surgery was significantly associated with longer survival (OR 1.21; CI 1.03–1.41). Conclusion Poor performance status at presentation is the strongest indicator of poor survival (less than 3 months), whereas a low disease load with fewer involved spinal levels is strongly associated with longer term survival.

Robotic transmural ablation of bladder tumors using high‐intensity focused ultrasound: Experimental study

To evaluate the feasibility of robot-assisted laparoscopic high-intensity focused ultrasound for targeted, extravesical, transmural, full-thickness ablation of intact bladder wall and tumor. In three fresh cadavers and one acute porcine model, the transperitoneal robotic approach was used to mobilize the bladder and create a midline cystotomy. "Mimic" bladder tumors (2 tumors/case) were created by robotically suturing a piece of striated muscle (2.5×2.5cm) to the luminal, urothelial surface of the bladder wall. The cystotomy was suture-repaired and bladder distended with 250mL saline. A laparoscopic high-intensity focused ultrasound probe was robotically placed extravesically in direct contact with the serosal surface of the bladder wall to image the "mimic" tumor. Targeted, transmural, full-thickness high-intensity focus ultrasound ablation of the "mimic" tumor and adjacent bladder was carried out under real-time ultrasound and robotic monitoring. Untreated areas of the bladder served as a comparison. Post-procedure, gross and microscopic examinations were carried out. Laparoscopic high-intensity focused ultrasound ablation was feasible for all "mimic" tumors (100%). Real-time ultrasound clearly visualized the "mimic" tumor. Simultaneous display of the pre-planning and real-time treatment ultrasound images confirmed targeting precision. Mean operative room times for ultrasound localization, laparoscopic high-intensity focused ultrasound probe coupling, high-intensity focus ultrasound ablation, and total procedure were 3, 5, 6 and 60min, respectively. On necropsy, no thermal/mechanical injuries occurred to the untreated bladder wall, adjacent organs or ureters. Gross inspection distinguished the treated from untreated areas. Histopathology confirmed sharply demarcated thermal coagulative necrosis and shrinkage effects between the treated and untreated areas. Laparoscopic extravesical high-intensity focus ultrasound for transmural, full-thickness targeted ablation of intact bladder wall and tumor is feasible. This has implications for bladder-sparing surgery in select patients with solitary muscle-invasive bladder cancer.

Natural history and risk factors for rupture of thoracic aortic arch aneurysms

The management of degenerative aneurysms of the aortic arch requires careful selection of patients, taking into consideration risk of rupture and operative risks, which is more relevant with the emergence of hybrid debranching and branched and fenestrated endovascular options. The natural history of true arch aneurysms has not been previously studied. We aimed to determine the expansion rate of thoracic aortic arch aneurysm and to identify predictors for rupture. Consecutive patients with known true thoracic aortic arch aneurysms monitored with serial computed tomography from 2000 to 2014 were retrospectively reviewed. Thoracoabdominal aneurysms and aneurysms due to aortic dissection and connective tissue diseases were excluded. Variables studied included patient demographics, aneurysm morphology, and ascending aorta diameter. A size expansion curve for each patient was plotted with serial computed tomography scan data, and the slope obtained by linear interpolation was taken as the expansion rate. Multiple logistic regression analysis was performed to identify independent predictors of rupture. Average yearly risks of rupture for overall and expansion rate substrata were calculated from life-table analysis. A total of 45 arch aneurysms were followed up for a mean of 36.6months (3-104). Aneurysm growth was largely linear, with an average rate of 2.5mm/y (0-16). During surveillance, 10 aneurysms ruptured (22%) and 8 patients died. There was one additional arch aneurysm-related death during follow-up, whereas 14 patients (31%) died of other causes. Aneurysms expanding at >5.5mm/y have a 67% likelihood of rupture compared with 8.3% of those expanding at<5.5mm/y. Aneurysm size >6.5cm(P= .0001) and hyperlipidemia (P= .0321) were positively correlated with fast expansion. On univariate analysis, only aneurysm size and expansion rate were significant predictors of rupture. On multivariate analysis, aneurysm expansion rate was the sole independent risk factor of aneurysm rupture (odds ratio, 1.43; 95% confidence interval, 1.06-1.92; P= .018). Aneurysm expansion rate >5.5mm/y is a significant rupture predictor in addition to size compared with aneurysm morphology and other demographic factors. Aneurysm size >6.5mm and hyperlipidemia are determining factors of expansion rate. These may have implications in selection of patients for surgery. Better control of hyperlipidemia may alleviate the risk of rupture.

Abstract WP55: Predicting Malignant Edema in MCA Infarct Using MRI and MR Perfusion Parameters

Introduction: Malignant edema in large MCA infarct (MMI) is known for high rate of mortality and morbidity. Hemicraniectomy was showed to decrease mortality but not improve functional outcome. Further studies are required for better patient selection for surgery. Among several clinical biomarkers, DWI lesion volume &gt; 82 ml within 6 hours from symptoms onset is the most used predictor for MMI. There is also evidence suggesting brain edema is correspond with severity of tissue ischemia, which could be measured by semiquantitative cerebral blood volume (CBV) and cerebral blood flow (CBF) on MRP map. We hypothesized that DWI volume combining with MRP parameters could provide more predictive value. Methods: Patients in MMI-MRI study (a prospective, multicenter, observational MRI/MRP study of MCA ischemic stroke within 6 hours of symptom onset) and STIR (Stroke Imaging Repository) were included if they met the inclusion criteria: age ≥ 18, MCA infarct with NIHSS ≥ 15, and MRI/MRP study within 12 hours from symptoms onset. Patients underwent thrombectomy, with poor quality images or without follow up images, with bilateral strokes, or developed hemorrhagic transformation were excluded. MMI was defined as NIHSS score &gt;18 with suppressed level of consciousness, and at least 2/3 of the MCA territory infarct on follow-up MRI or CT. Results: Of 89 patients included, 17 (19.1%) developed MMI. A malignant edema predicting score (MEPS) of maximum three points was developed: one point for DWI lesion volume &gt; 82 ml, one point for more than 40% of DWI volume with CBV &lt; 40% of contralateral normal side, and one point for more than 50% DWI volume with CBF &lt; 30% of contralateral normal side. The threshold of a DWI lesion volume &gt; 82 ml predicted malignant edema with sensitivity (0.65, 95% CI 0.39-0.85), specificity (0.86, 95% CI 0.75-0.93), positive predictive value (0.52, 95% CI 0.30-0.74), and negative predictive value (0.91, 95% CI 0.81-0.96). MEPS ≥ 2 predicted malignant edema with sensitivity (0.65, 95% CI 0.39-0.85), specificity (0.98, 95% CI 0.91-1.00), PPV (0.92, 95% CI 0.60-1.00), and NPV (0.92, 95% CI 0.83-0.97). Conclusions: DWI volume is reliable in predicting MMI. The addition of information on tissue ischemia in a multivariate score improves the prediction of MMI over DWI alone.

5th International ACC Symposium: Surgical Considerations in the Treatment of Adrenocortical Carcinoma: 5th International ACC Symposium Session: Who, When and What Combination?

Significant progress has been made in the understanding of how surgical technique impacts outcome in patients with adrenal cancer. Current and future areas of investigation center on expanding the role of surgery in patients with locally recurrent or metastatic disease, use of neoadjuvant therapy as a bridge to surgery, the impact of formal lymphadenectomy on survival, and improved diagnosis, prognosis, and selection of patients for surgery and other treatments using morphomic analysis.

Reliability (Revalidation) of MSU MRI Classification of Lumbar Disc Herniation in 100 Patients Series: Severity and Objective Surgical Criteria

Background Data: Success rate of discectomy is greatly variable between surgeons due to lack of clear categorization of lumbar disc patients. Valid radiological objective criteria are required especially for patients with uncertain surgical indication to help in pre-operative patient assessment, surgical selection and research of post-operative outcomes of comparable level of pathology. MSU Classification reports size and location in three precise increments, described simply 1-2-3 and A-B-C providing clear objective classification of disc herniation resulting in excellent interexaminarreliability. Purpose To test reliability of MSU MRI classification of lumbar disc herniation in helping surgical selection and correlation with preoperative clinical presentation and postoperative clinical and functional outcome. Study Design Observational analytic retrospective study. Patients and Methods Retrospective investigations of one hundred patientswho underwent lumbar discectomy at Ain Shams University between January 2014 and June 2015 in term of MSU classification. Results Only 2 patients (2%) in our series had grade 1-A. All other 98 patients had MSU grades with size 2 or 3 and/or B or C location or 2 or 3 combination of horizontal disc locations (A, B or C). Two cases of unintended durotomy occurred in MSU grade 3-AB (40%) and the other 3 cases occurred in grade 2-AB (60%). One case of CSF leak occurred in 3-AB herniated disc lesion (50%) and another one in 2-AB lesion (50%). Twelve patients (12%) developed recurrent sciatica with mean interval of 47.92 weeks after first disc surgery. Only 5 patients (5%) underwent second disc surgery with mean interval of 6.2 months. 95 patients (95%) had good to excellent result. Conclusion: MSU classification provides solid, universal and objective radiological description of lumbar disc herniation helping patient selection for surgery. (2016ESJ097)

Intussusception in Adults: The Role of MDCT in the Identification of the Site and Cause of Obstruction

Unlike pediatric intussusception, intestinal intussusception is infrequent in adults and it is often secondary to a pathological condition. The growing use of Multi-Detector Computed Tomography (MDCT) in abdominal imaging has increased the number of radiological diagnoses of intussusception, even in transient and nonobstructing cases. MDCT is well suited to delineate the presence of the disease and provides valuable information about several features, such as the site of intussusception, the intestinal segments involved, and the extent of the intussuscepted bowel. Moreover, MDCT can demonstrate the complications of intussusceptions, represented by bowel wall ischemia and perforation, which are mandatory to promptly refer for surgery. However, not all intussusceptions need an operative treatment. In this paper, we review the current role of MDCT in the diagnosis and management of intussusception in adults, focusing on features, as the presence of a leading point, that may guide an accurate selection of patients for surgery.

Management of resectable colorectal lung metastases.

Lung metastases occur in 10-20 % of patients with colorectal cancer. The biology of colorectal lung metastases is poorly understood, however lung metastases are more common in patients with rectal cancer and in patients with RAS mutations. Although the majority of patients have extrapulmonary disease, a small proportion of patients with lung metastases are suitable for lung metastasectomy and surgical resection has become a standard of care, based on data from retrospective series demonstrating a 5-year overall survival of 40-68 %. However, there remains uncertainty regarding the optimal management approach for these patients due to the lack of evidence from randomized controlled trials and current practice varies between institutions. For example, the role for neoadjuvant and adjuvant chemotherapy is not yet defined and there are no randomized trials comparing surgery with alternative treatment options such as radiofrequency ablation and stereotactic ablative radiotherapy. Further research is needed to improve the selection of patients for surgery, but favourable prognostic factors include a normal pre-operative CEA, solitary metastasis, complete resection and a long disease-free interval. There is also evidence that patients with resectable liver and lung metastases may benefit from resection of both sites of disease, and that re-resection may be of benefit in selected patients who relapse with resectable lung metastases. This article summarizes the biology of colorectal lung metastases and discusses the management of patients with lung metastases.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy.

Peritoneal surface malignancies have historically presented a treatment challenge for clinicians. Not infrequently, epithelial cancers can seed the peritoneal cavity. Neoplasms of the appendix can result in peritoneal dissemination of disease and pseudomyxoma peritonei; in colon cancer, up to 25% with recurrent disease will develop a peritoneal surface predominant pattern of recurrence (1), and among those resected advanced gastric cancer, the majority of patients who recur in the first five years following surgery will develop peritoneal disease (2). Among the approximately 21,290 cases of ovarian cancer cases estimated to be diagnosed in 2015 (3), most will present in an advanced disease state, many with evidence of peritoneal carcinomatosis. In addition to epithelial derived cancers, 10-15% of the approximately 2,500 cases of malignant mesothelioma diagnosed in the U.S. will develop in the peritoneal cavity (4). For all these tumor histologies, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been considered in the treatment algorithm for selected patients. Over time, CRS/HIPEC has seen an increased utilization in treating select patients with peritoneal disease patterns previously considered inoperable, and has been associated with favorable survival outcomes. In patients with colorectal peritoneal carcinomatosis, a recent retrospective study of 539 patients undergoing a complete cytoreduction reported a median overall survival of 32.6 months (5). No doubt these observed improved outcomes compared to historical cohorts are multifactorial, reflecting improvements in systemic therapies, refinements in surgical techniques and perioperative care, and a better understanding of tumor biology contributing to better patient selection for surgery. Nonetheless, the remarkably favorable data are compelling and speak for the importance of consideration of CRS/ HIPEC in the context of a multidisciplinary approach for patients with peritoneal surface malignancy. This issue of Journal of Gastrointestinal Oncology (JGO) focuses on CRS/HIPEC and its application for various cancers. A paper led by the editors highlight some of the important historical developments in the evolution of CRS and HIPEC. Dr. Paul Sugarbaker and colleagues share their extensive expertise discussing surgical techniques of CRS/ HIPEC and pharmacology of intraperitoneal chemotherapy, while Dr. Goodman provides an excellent review of the selection of chemotherapeutic agents used for this procedure. Dr. Low presents an interesting summary on the use of MRI in the pre-operative evaluation and surveillance of patients being considered for or treated with CRS/HIPEC. Finally, each of the five tumor histologies discussed above is considered in depth in a separate manuscript, including two original papers studying CRS/HIPEC for high grade appendiceal cancer and ovarian cancer. Also in this issue is an important section on quality issues pertaining to CRS/HIPEC, including a review paper discussing the morbidity and mortality associated with the procedure. These procedures can be extensive, and not without risk, and consideration of these factors in the clinical decision making is essential. Dr. Lambert provides a very thoughtful synopsis of the palliative role of CRS/HIPEC, and Dr. Turaga discusses the impact of surgical volume in centers of these procedures on surgical outcomes. Dr. Votanopoulos presents a review of the indications and outcomes following repeat HIPEC surgery, which can be sometimes considered in select patients. Finally, Dr. Nash discusses current

Comorbidities and Risk of Complications After Surgery for Esophageal Cancer: A Nationwide Cohort Study in Sweden.

The selection for surgery is multifaceted for patients diagnosed with esophageal cancer. Since it is uncertain how comorbidity should influence the selection, this study addressed comorbidities in relation to risk of severe complications following esophageal cancer surgery. This population-based cohort study was based on prospectively included patients who underwent surgical resection for an esophageal or gastro-esophageal junctional cancer in Sweden during 2001-2005. The participation rate was 90%. Associations between pre-defined comorbidities and pre-defined post-operative complications occurring within 30 days of surgery were analyzed using multivariable logistic regression. The resulting odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for age, sex, tumor stage, tumor histology, neoadjuvant therapy, type of surgery, annual hospital volume, other comorbidities, and other complications. Among 609 included patients, those with cardiac disease (n = 92) experienced an increased risk of pre-defined complications in general (adjusted OR 1.81, 95% CI 1.13-2.90), while patients with hypertension (n = 137), pulmonary disorders (n = 79), diabetes (n = 67), and obesity (n = 66) did not. Patients with a Charlson comorbidity index score ≥2 had substantially increased risks of pre-defined complications (adjusted OR 2.44, 95% CI 1.60-3.72). Cardiac disease and a Charlson comorbidity index score ≥2 seem to increase the risk of severe and early post-operative complications in patients with esophageal cancer, while hypertension, pulmonary disorders, diabetes, and obesity do not. These findings should be considered in the clinical decision-making for improved selection of patients for surgery.

Supratentorial Сerebral hemorrhage: Pathophysiologic Criteria and Tactics of Treatment

Hemorrhagic stroke (HS) constitutes 20 % of acute disorders of cerebral circulation. The incidence of HS in different regions varies between 10 and 35 per 100 thousand population. In spite of modern breakthroughs in neurosurgery and neurology cerebral hemorrhages are characteristic of high lethality and invalidization. Lethality level depends on the size of the hematoma. The lethal outcome is more probable in case of hematoma size over 100 cubic centimeters. The survival rate in patients with larger hematomas may increase provided the conventional surgical treatment is as early as possible before the development of pronounces dislocational manifestations. Hematomas over 80 cubic centimeters case death irrespective of the treatment method due to a combination of large size of hematoma and fast development of intracranial hypertension and dislocation syndrome. Lobar hematomas develop in a more benignant manner while mixed ones may be classified prognostically unfavorable: the lethality in this group is considerably higher than in in other hematomas. The lethality and gravity of clinical manifestations in case of medial hematomas is associated with haigh frequency of intraventricular hemorrhages. Considerable variability of hypertension hematomas’ treatment results testifies to an absence of a common approach to surgical treatment. Surgical treatment may demonstrate its convincing advantages only in case of strict approach to selection of patients for surgery which requires an integral scale for the assessment of the patients’ state. Taking into consideration the high demand for surgical treatment of cerebral hematomas in Russian Federation (about 11 000 operations per year) organization measures are necessary to create additional neurosurgical departments for emergency surgical aid for HS patients.

Using Value-Based Analysis to Influence Outcomes in Complex Surgical Systems

Value-based analysis (VBA) is a management strategy used to determine changes in value (quality/cost) when a usual practice (UP) is replaced by a best practice (BP). Previously validated in clinical initiatives, its usefulness in complex systems is unknown. To answer this question, we used VBA to correct deficiencies in cardiac surgery at Memorial Healthcare System. Cardiac surgery is a complex surgical system that lends itself to VBA because outcomes metrics provided by the Society of Thoracic Surgeons provide an estimate of quality; cost is available from Centers for Medicare and Medicaid Services and other contemporary sources; the UP can be determined; and the best practice can be established. Analysis of the UP at Memorial Healthcare System revealed considerable deficiencies in selection of patients for surgery; the surgery itself, including choice of procedure and outcomes; after care; follow-up; and control of expenditures. To correct these deficiencies, each UP was replaced with a BP. Changes included replacement of most of the cardiac surgeons; conversion to an employed physician model; restructuring of a heart surgery unit; recruitment of cardiac anesthesiologists; introduction of an interactive educational program; eliminating unsafe practices; and reducing cost. There was a significant (p < 0.01) reduction in readmissions, complications, and mortality between 2009 and 2013. Memorial Healthcare System was only 1 of 17 (1.7%) database participants (n = 1,009) to achieve a Society of Thoracic Surgeons 3-star rating in all 3 measured categories. Despite substantial improvements in quality, the cost per case and the length of stay declined. These changes created a savings opportunity of $14 million, with actual savings of $10.4 million. These findings suggest that VBA can be a powerful tool to enhance value (quality/cost) in a complex surgical system.

Recurrent ovarian cancer--qualification and results of surgical treatment

Complete tumor cytoreduction seems to be beneficial for platinum-sensitive women with recurrent ovarian cancer (ROC). Selection of patients who might have a chance for complete debulking constitutes a real challenge. Several predictive models defining a chance for complete cytoreduction and help in patient selection for surgery have been developed. The aim of the study was to evaluate the effectiveness of selected models in one clinical center and the impact of complete resection on treatment outcome. A total of 17 patients with ROC, diagnosed at least 6 months after first-line chemotherapy were recruited for the study. The inclusion criteria were based on the AGO-score (DESKTOP I trial). The group were retrospectively analyzed based on the predictive model International Collaborative Cohort Score (Tian- score). The end point was the percentage of complete cytoreduction. Also, postoperative complications and progression-free survival (PFS) were evaluated. Out of 17 patients who meet the criteria of the the AGO-score, complete debulking was achieved in 13 (76.47%) cases. Comparing the results of the Tian-score, 12 (100%) patients who were considered to be at 'low-risk of surgical failure' were debulked optimally In addition, complete debulking was achieved in 1 patient from the high-risk group. In all optimally operated patients, the number of changes detected during pre-operative imaging was ≤ 3. In 11 patients after complete cytoreduction there was another relapse. The median of PFS was 16 months. The applied predictive models have proven to be effective in selecting patients who will benefit from surgical treatment of ROC.

Cardiac CT Prior to Left Atrial Appendage Closure Device Implantation and Percutaneous Mitral Valve Interventions

Recent advances in percutaneous techniques have allowed them to emerge as an attractive alternative to surgery in select patients. Left atrial appendage closure has emerged as a novel therapeutic option in patients an nonvalvular atrial fibrillation who cannot take anticoagulation therapy. Furthermore, percutaneous mitral valve procedures have shown promising results in high risk patients. These percutaneous procedures require multimodality imaging for preprocedural planning and during the procedure. Computed tomography has emerged as an attractive imaging modality prior to percutaneous procedures given its ability to perform comprehensive assessment of cardiac and extracardiac structures. This review assesses the role of computed tomography as it pertains to left atrial appendage occlusion and mitral valve transcatheter procedures.

The Efficacy of Restaging Endobronchial Ultrasound in Patients With Non-Small Cell Lung Cancer After Preoperative Therapy

Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy. This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy. There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively. Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer.

Approach to thyroid nodules in children and adolescents

Thyroid nodule prevalence is about 1.8% in healthy children; however, malignancy frequency is higher than in adults. Approximately 26.4% of thyroid nodules generate thyroid cancer in childhood. Coexisting thyroid disease, history of irradiation of the neck, post-pubertal age, female sex, and thyroid malignancy in the family are risk factors for developing nodules. After evaluation of the medical history and detailed physical examination, the second step is assessment of thyroid function and measurement of calcitonin level. Thyroid stimulating hormone (TSH) value in the upper range seems to be correlated with cancer. Calcitonin levels must be evaluated, especially if medullary cancer is suspected. Ultrasonography (USG) is the first-line imaging tool in the diagnosis of thyroid nodules. It gives information about the nodule size, echogenicity and location. Hypoechogenicity, microcalcifications, undefined margins, high internodular vascular flow, and subcapsular localization are clues of malignant lesions. Scintigraphy is only recommended in a solid nodule with the presence of suppressed TSH. Fine-needle aspiration biopsy (FNAB) has 90% accuracy and is very useful in the selection of patients for surgery. It must be applied to all nodules &amp;#x2265;1 cm and nodules &amp;#x2264;1 cm suspicious for malignancy. The other diagnostic tools are elastography, immunocytochemical markers and genetic evaluation. In the management of thyroid nodules, surgery is advised, especially if there is difficulty in distinguishing benign lesions from carcinoma.

Transanal endoscopic microsurgery: a review

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.

Therapeutic Option in Patients over 60 Years with Esophageal and Esocardial Cancer

Abstract Background: Treatment of esophageal and esocardial cancer in patients over 60 years involves a particular management. Considering the comorbidities specific to this category of patients, recent data from the literature indicate an increased incidence of mortality and morbidity following therapy. Material and method: We retrospectively studied a group of 55 patients admitted to the Surgical Clinic I of the County Emergency Clinical Hospital Tîrgu Mureș, in the January 1st, 2007 - December 31st, 2011 period, diagnosed with esophageal and esocardial cancer. Patients were divided into two groups: group I under the age of 60 years, and group II over this age. Inclusion criteria were age, diagnosis (tumor location), and we followed a series of parameters: demographics, type of surgery, the biological profile of patients, immediate postoperative morbidity and mortality. Results: No statistically significant differences were observed in terms of demographics: gender (p = 0.78), area of origin (p = 0.69). The number of hospitalization days (p = 0.20) was influenced by the type of surgery, as well as pre- and postoperative comorbidities. Immediate postoperative mortality was 16.56%, the differences between the two groups was not statistically significant (p = 0.58). Parameters with statistical significance were found to be: age (p &lt;0.0001), tumor location, type of surgery (p = 0.0031) and radical versus palliative surgery (p = 0.03). Conclusions: Therapeutic attitude in patients over 60 years should be correlated with specific particularities to this category. Selection of patients for surgery and type of surgery is dictated by the patient's condition and quantified by anesthesia and surgery team

Alvimopan and enhanced recovery pathways in colorectal surgery

Postoperative ileus negatively impacts patient outcomes and healthcare utilization, increasing both postoperative length of stay and health care costs. In efforts to optimize perioperative care, efforts have been placed into developing tools to minimize postoperative ileus. Alvimopan (Entereg®) was developed to meet this need. Alvimopan has permitted accelerated return of bowel function after abdominal surgery in select patients. Alvimopan has the potential to significantly improve clinical and financial results, and research is ongoing to determine effective further applications of this medication.

Secondary Complete Cytoreduction in Recurrent Ovarian Cancer: Benefit of Optimal Patient Selection Using Scoring System

Complete tumor cytoreduction seems to be beneficial for patients with recurrent epithelial ovarian cancer (REOC). The challenge is to identify patients eligible for such surgery. Several scores based on simple clinical parameters have attempted to predict resectability and help in patient selection for surgery in REOC.The aims of this study were to assess the performance of these models in an independent population and to evaluate the impact of complete resection. A total of 194 patients with REOC between January 2000 and December 2010 were included in 2 French centers. Two scores were used: the AGO DESKTOP OVAR trial score and a score from Tian et al.The performance (sensitivity, specificity, and predictive values) of these scores was evaluated in our population. Survival curves were constructed to evaluate the survival impact of surgery on recurrence. Positive predictive values for complete resection were 80.6% and 74.0% for the DESKTOP trial score and the Tian score, respectively. The false-negative rate was high for both models (65.4% and 71.4%, respectively). We found a significantly higher survival in the patients with complete resection (59.4 vs 17.9 months, P < 0.01) even after adjustment for the confounding variables (hazard ratio [HR], 2.53; 95% confidence interval, 1.01-6.3; P = 0.04). In REOC, surgery seems to have a positive impact on survival, if complete surgery can be achieved. However, factors predicting complete resection are not yet clearly defined. Recurrence-free interval and initial resection seem to be the most relevant factors. Laparoscopic evaluation could help to clarify the indications for surgery.