Selection Of Patients For Surgery Research Articles

Does exploratoratory laporotomy alone versus staging result in improved life expectancy in patients with potentially resectable pancreatic adenocarcinoma. A clinical decision model

Purpose: The optimal management of patients with potentially resectable pancreatic carcinoma is controversial.It is unknown whether preoperative staging with a combination of CT, EUS and MRI allows for better selection of patients for surgery to improve survival than does a strategy of exploratory laparotomy alone for all patients. Methods: We constructed a decision model to determine whether a strategy utilizing cross-sectional imaging to pre-select patients to receive palliative care or curative surgery results in an increased overall survival in patients with potentially resectable pancreatic adenocarcinoma. The baseline model was selected as a patient with suspected pancreatic cancer based on CT scan and clinical symptoms, with no evidence on CT of metastatic disease. Probability estimates for the baseline model were obtained from a review of the medical literature. One-way sensitivity analyses were performed on all variables included in the model. Two-way sensitivity analyses were performed on the sensitivity and specificity of the cross-sectional imaging tests (CT, EUS and MRI). Results:In the baseline model, exploratory laporotomy alone for all patients resulted in a 7% greater life expectancy than the strategy of triage using only CT, EUS and MRI. Sensitivity analyses revealed that for a combination of EUS, CT and MRI to improve mortality beyond that of exploratory laparotomy the combined sensitivity of all tests needed to exceed 92%. We also found that increasing the overall specificity of the combined imaging studies did not improve patient survival beyond that of exploratory laporotomy alone. Conciusion:Our model demonstrates a survival benefit of preoperative testing over exploratory laporotomy alone in patients with potentially resectable pancreatic adenocarcinoma if the combined sensitivity of the imaging modalities for determining disease resectability is greater than 92%.Based on the results of this model the use of preoperative testing to triage patients with potentially resectable pancreatic cancer to surgical or medical therapy should be reassessed. Further study is needed to determine whether preoperative multi-modality staging exceeds the threshold sensitivity predicted by this model.

Ruptured abdominal aortic aneurysm: difference in selection criteria for surgery between vascular surgeons in district general and teaching hospitals

Abstract Background This audit was devised in order to examine outcome following presentation with ruptured abdominal aortic aneurysm (AAA) in one Deanery. Identification of differences in practice and outcome were sought. Methods Some 18 consultant vascular surgeons in eight district general hospitals (DGHs) and one university hospital (UH) participated in a prospective audit of ruptured AAA from March 1997 to February 1998. Results Some 159 patients were included in the audit. Outcome is shown in the Table below. There was no difference in operative mortality rate between the UH and DGHs nor was there an increased mortality rate in the group of patients transferred from hospital to hospital despite the time delay incurred. In 47 patients admitted to the UH serum creatinine was the only laboratory test which correlated with outcome. Conclusion This audit clearly highlighted the differing attitude to selection of patients for surgery between the vascular surgeons in the UH and DGHs, although there was no overall statistical difference in outcome.

Diagnosis and Surgical Management of Thoracic Outlet Syndrome

The clinical and other relevant factors of 126 cases of thoracic outlet syndrome (TOS) are analyzed. A new clinical grading system is introduced, as well as a new classification of TOS based on clinical findings, neuroelectric tests results, stress tests, and radiographic data. The surgical technique of the anterior supraclavicular approach is described in detail, with emphasis on the ways and means of dealing with the normal and many anomalous structures encountered in 142 operations. The good outcome and infrequent complications of this diagnostic and management approach to TOS argue strongly for the author's recommendations of stringent patient selection for surgery and painstaking regards to details during surgery.

Die chirurgische Therapie der chronischen thrombembolischen pulmonalen Hypertonie

Background: Chronic thromboembolic pulmonary artery obstruction from unresolved pulmonary emboli is characterized by persistent elevation of pulmonary vascular resistance and progressive right heart dysfunction and failure. The diagnosis of chronic thromboembolic pulmonary hypertension is difficult and often missed. Medical therapy is ineffective in these patients. The prognosis is poor and depends on the degree of pulmonary hypertension. Pulmonary thromboendarterectomy has proven to be an effective and potentially curative surgical therapy for this clinical entity although less than 1000 cases have been reported in the surgical literature. Methods: The current principles of diagnosis, patient selection for surgery, surgical technique, and postoperative management are summarized. Results: 156 pulmonary thromboendarterectomy procedures have been performed. Based on modifications of the operative and postoperative management, early mortality rates could be decreased from 24 % in 109 patients operated on before 1995 to 8.5 % in 47 patients operated on since January 1995. 56 patients reported a substantial improvement of clinical symptoms after a mean follow-up period of 31 months. At follow-up, mean pulmonary vascular resistance and pulmonary artery pressures were significantly reduced compared to preoperative and postoperative values. Conclusions: Pulmonary thromboendarterectomy is an effective and potentially curative surgical procedure for chronic pulmonary embolism. The operative risk can be decreased to an acceptable level. Long-term clinical and hemodynamic results are excellent.

Surgery for melanoma metastatic to the gastrointestinal tract.

Gastrointestinal (GI) metastasis from melanoma has a dismal prognosis with few long-term survivors. We evaluated the role of operative intervention for melanoma metastases to the GI tract and attempted to identify prognostic factors to improve selection of patients for surgery. Between 1977 and 1997, 68 of the 7965 patients with melanoma admitted to Memorial Sloan-Kettering Cancer Center underwent surgical exploration for melanoma metastatic to the GI tract. Characteristics of the primary tumor, regional lymph nodes, and metastatic pattern were reviewed. Data concerning the presenting signs and symptoms, laboratory values, operative findings, extent of surgical resection, recurrence pattern, and survival were analyzed. The most common presenting clinical features included anemia (n = 41; 60%) or abdominal pain (n = 40; 59%). The most frequently involved portion of the GI tract was the small bowel (n = 62; 91%), and the most common operative procedure was small bowel resection (n = 54; 79%). Postoperative mortality and morbidity were 2.9% (n = 2) and 8.8% (n = 6), respectively. Presenting symptoms were relieved in 90% of patients (n = 61). Median survival for all 68 patients following operative intervention was 8.2 months, with 18% survival at 5 years. By multivariate analysis, complete resection rendering the patient free of all identifiable disease (n = 19, median survival 14.9 months, 38% survival at 5 years) and a low preoperative serum lactate dehydrogenase (LDH) (n = 28, median survival 13.6 months, 35% survival at 5 years) were identified as independent favorable prognostic factors for survival. Operative intervention for melanoma metastatic to the GI tract is recommended for palliative reasons and can be performed with low morbidity and mortality. It is associated with prolonged survival in patients rendered free of all identifiable disease following surgical resection and in those with a low preoperative serum LDH.

Combined ultrasonographic and cytological studies in the diagnosis of thyroid nodules

Many aspects of thyroid nodule evaluation and management remain controversial. Widespread application of ultrasonography has resulted in frequent discovery of incidental nodules in the general population which has created a management dilemma for physicians. In this paper we have introduced a novel approach for evaluation of solid nodules, using an index derived from ultrasonographic and cytologic studies. Briefly thyroid nodules were classified ultrasonographically into four grades, with increasing score numbers (1–4) as progression to malignantly suspicious lesions was present. Similarly, four grades of a cytologic classification of fine needle biopsy aspirates were introduced with scores of 1–6 (benign to malignant diagnosis). The sum of the ultrasonographic and cytologic scores were the basis of a diagnostic index: benign (2–4), doubtful (5), suspicious (6) and malignant (7–10). Sixty patients with an index equal or higher than 6 were submitted to thyroidectomy and the prevalence of thyroid cancer ( n = 46) in the excised nodules was 76.6%. Most series report a 10% to 30% incidence of malignancy in excised nodules with suspicious diagnosis. We concluded that using an index derived from combined ultrasonographic and cytologic studies will result in a better patient selection for surgery.

OCT imaging of choroidal neovascularisation and its role in the determination of patients’ eligibility for surgery

AIMTo evaluate the optical coherence tomographic characteristics of choroidal neovascularisation (CNV) in age related macular degeneration (AMD) and in idiopathic and inflammatory CNV. The use of this technique in the...

A prospective, longitudinal study on patients with trigeminal neuralgia who underwent radiofrequency thermocoagulation of the Gasserian ganglion

Outcome after radiofrequency thermocoagulation in patients with trigeminal neuralgia was assessed in a prospective, longitudinal study. Forty-eight consecutive patients with chronic facial pain presenting for surgery to a neurosurgeon were studied. Patients were assessed pre-operatively by an independent clinician both clinically, and with the use of two questionnaires: the McGill Pain Questionnaire (MPQ) and the Hospital Anxiety and Depression (HAD) scale. From these assessments, two groups of patients were identified: 31 with pure trigeminal neuralgia (TN group) and 17 with trigeminal neuralgia together with atypical facial pain and mixed trigeminal neuralgia (MTN group). All underwent radiofrequency thermocoagulation at the level of the Gasserian ganglion. Patients were reviewed by the same clinician 3 months later and then followed up by a self-administered questionnaire at 6 months, 1 year, 2 years and 3 years. The mean follow-up time was 30±12 months. The mean time to recurrence of pain was 40 months for the TN group and 36 months for the MTN group. Depression and anxiety dropped more significantly post-operatively in the TN group than the MTN group. TN group were more satisfied with their outcome, complained of fewer complications and were more willing to have repeat surgery if necessary than patients in MTN group. The number and severity of complications varied at different time points. Careful selection of patients for surgery using objective assessments will decrease morbidity and improve satisfaction. Physical morbidity and recurrence rates are insufficient to gauge outcomes. Psychological, sociological and patients' views must be included in evaluations.

Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review.

The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used. All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%), and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the surviving patients, and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients. A solid bone fusion, however, was not necessarily associated with decreased back pain. These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.

Variation in the survival of women with breast cancer in Scotland. The Scottish Breast Cancer Focus Group and The Scottish Cancer Therapy Network.

We have investigated factors influencing the survival of women with early breast cancer in Scotland. In a retrospective study, clinical, treatment and 'service' factors, e.g. surgical case load, deprivation and geographical area (health board of first treatment) were recorded from hospital records. A total of 2148 women with invasive breast cancer diagnosed in 1987 were identified from the Scottish Cancer Registry, of whom 1619 without metastases at diagnosis underwent surgery as part of their primary treatment. In a multivariate analysis, clinical factors (age, clinical stage, pathological tumour size, node status and oestrogen receptor status) all influenced survival. After allowing for these clinical factors, surgical case load and deprivation did not have statistically significant effects on survival. By contrast, health board did affect survival. This was explained in part by the selection of patients for surgery. There appeared, however, to be a residual effect that may be related to differences in the use of adjuvant systemic treatment among the different health boards. We conclude that, in Scotland, geographical variation in both surgical and non-surgical treatment has a greater effect on variability in survival for women with breast cancer than surgical case load and deprivation.

Radiologically placed hepatic artery catheter allows selection of patients with high-volume liver metastases for regional chemotherapy.

Regional chemotherapy has achieved high response rates in hepatic metastases from colorectal cancer and has been shown to improve survival significantly. The present paper reports the use of pre-operative regional therapy to establish marker response as a means of selection of patients for surgery. Fourteen patients underwent radiologically placed hepatic artery catheter (HAC) for chemotherapy. In the 11 patients with carcino-embryonic antigen (CEA) fall the patient proceeded to open surgical placement of HAC. The predictive effect of CEA fall following radiological HAC was good. Non-responding patients are clearly spared the discomfort and inconvenience and costs of an unnecessary operation.

Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review

Object The goal of this study was to review retrospectively the outcome of 95 patients with various disorders leading to instability of the thoracolumbar and lumbar spine who were treated consecutively via a posterior surgical approach with pedicle screw fixation in which the Texas Scottish Rite Hospital system was used. Methods All cases were managed according to the same protocol. Follow-up review averaged 29.6 months. Radiographic evidence of osseous union and the patient's current status were analyzed. Four screws were malpositioned, and there were two dural lacerations of a nerve root and one pedicle fracture. Deep wound infections developed in five patients (5.2%) and three patients had postoperative radicular pain. In one case, the rods disengaged from the screws; in four cases, hardware was removed but there were no broken screws. Neurological deficits improved in 85% of the patients and no patient was worse neurologically after surgery. The rate of osseous union was 96.8%. Three patients developed pseudarthrosis, one of whom was asymptomatic. Back pain improved in 80 patients (85%). A solid bone fusion, however, was not necessarily associated with decreased back pain. Conclusions These results support the use of pedicle screw fixation as an effective and safe procedure for fusion of the thoracolumbar and lumbar spine and support the finding that complications can be minimal when a meticulous surgical technique is used. The proper selection of patients for surgery is probably the most important factor associated with good outcomes.

Improvement in Staging of Esophageal Cancer With the Addition of Positron Emission Tomography

Background. Positron emission tomography with the glucose analogue 2-[ 18F]fluoro-2-deoxy- d-glucose (FDG) has been used to detect and stage a variety of malignancies. We hypothesized that FDG–positron emission tomography would improve staging of patients with esophageal cancer and thereby facilitate selection of candidates for resection. Methods. Fifty-eight patients (42 men and 16 women) with biopsy-proven esophageal cancer were evaluated with both FDG–positron emission tomography and computed tomography. Results. In all but 2 patients, increased FDG uptake was identified at the site of the primary tumor. Six patients were not operative candidates. Seventeen patients were not candidates for resection because of metastatic disease. Positron emission tomography identified the metastatic disease in all 17 (12 of whom underwent confirmatory biopsy), whereas computed tomography was positive for metastases in only 5. The remaining 35 patients underwent surgical exploration, were judged to have resectable disease and had esophagectomy. Pathologic examination of resected specimens identified lymph node metastases in 21 patients. These nodes were detected by positron emission tomography in 11 patients and by computed tomography in 6. Conclusions. Positron emission tomography improved staging and facilitated selection of patients for operation by detecting distant disease not identified by computed tomography alone.

Does Evaluation With the International Prostate Symptom Score Predict the Outcome of Transurethral Resection of the Prostate?

Purpose We determined the reliability of the International Prostate Symptom Score (I-PSS) in predicting the outcome of transurethral prostatectomy and, therefore, how useful it can be in patient selection for surgery. Materials and Methods A prospective trial was done of 105 consecutive patients undergoing transurethral prostatectomy at our institution. Patients were assessed with the I-PSS before and 3 months after surgery. Flow rates and preoperative residual volumes also were measured. Results There was significant postoperative improvement in all parameters of the symptom score and a change in symptom profile. Symptoms remaining with the greatest scores at 3 months postoperatively were frequency, urgency and nocturia. A significant correlation was found between I-PSS and quality of life before and after transurethral prostatectomy, and between postoperative improvement in flow rates and change in I-PSS. Patients with a greater preoperative I-PSS gained the most symptomatic benefit. The positive predictive value of a significant postoperative improvement of at least 7 I-PSS points depended on the preoperative I-PSS criteria applied. With a preoperative I-PSS of more than 17 the positive predictive value was 87% with a corresponding negative predictive value of 71%. Conclusions The preoperative I-PSS predicted a symptomatic improvement of more than 7 points with high sensitivity. The predictive value depends on the definition of significant improvement (magnitude of I-PSS change) and the level of I-PSS symptoms defined as sufficient to warrant transurethral prostatectomy.

Corpus callosotomy for medically intractable seizures.

To identify factors influencing outcome and morbidity in patients selected for corpus callosotomy, we retrospectively reviewed 23 patients with intractable generalized seizures who underwent corpus callosotomy between 1991 and 1994. Three patients had a complete corpus callosotomy, while 20 had an anterior callosotomy. Three of those patients subsequently had completion of the anterior callosotomy. Overall, 41% of patients were nearly or completely free of the seizure types targeted for surgical treatment, while another 45% had seizures less than half as frequently. Four patients developed simple partial motor seizures after callosotomy. A transient disconnection syndrome was observed in 57% of patients. The best predictor of good outcome was a normal preoperative MRI. Mentally retarded patients had poorer outcomes. Outcome was not predicted by extent of callosal section or lateralization on neurological examination, EEG, MRI, and SPECT. Completion of anterior callosotomy resulted in significant reductions in seizure frequency. Though most patients do not become seizure-free after corpus callosotomy, worthwhile palliation of an otherwise intractable illness can be achieved. An analysis of prognostic factors should lead to better selection of patients for surgery.

Carotid surgery: the past is prologue. The John Homans lecture.

Carotid surgery: the past is prologue. The John Homans lecture.

Is reparative tubo-ovarian surgery obsolete?

With the availability of in vitro fertilization (IVF), reparative tubo-ovarian microsurgery is considered obsolete. In our institutions, salpingectomy has been performed for Mage score 4 and Brosen score 4 to 5 tubal occlusion. The results of reparative laparoscopic tubo-ovarian surgery (stages 1-3) are better for fimbrioplasty than for salpingoneostomy. The best result is for tubolysis and ovariolysis, often associated with fimbrioplasty. The procedure resulted in 27.7% intrauterine pregnancies and less than 10% ectopic pregnancies. The development of thin, atraumatic endoscopes will probably improve these rates and also reduce costs. We reevaluated reparative surgery after the failure of at least three cycles of IVF. With advances in salpingoscopy, the selection of patients improved for lesions of the ampulla. Women undergoing salpingoscopy had bifocal lesions, but also tubal occlusion with an unfavorable prognosis for the procedure's success. In women with hydrosalpinx, salpingectomy is supposed to improve the results of IVF. We reserve reparative and conservative surgery for women with good salpingoscopic score, which is probably one of the reasons for our encouraging results. For the proximal and isthmic part of the tube, the diagnosis remains difficult, despite the promising results of transcervical tuboscopy. The development of thin atraumatic endoscopes will probably continue to improve evaluation of tubal pathology and permit better patient selection for surgery.

An analysis of opinions considered adverse to the thesis of the main communication

The attempt to develop formal stereotyped or more free-ranging psychological procedures to aid in the selection of patients for operations to relieve pain, or to assay the results thereof, has been studied at least ever since the Minnesota Multi­ phasic Personality Inventory (MMPI) was created. Some of the early efforts were summarized in Volume 1 of the First World Congress on Pain in Florence, Italy in September 1973. In that first volume the psychiatrist Waring and the psychologist Weisz state they were totally unable to confirm the conclusions of the four pre­ vious groups (Hanvik, Phillips, Wiffling et aI., Wiltse and Rocchio) that Hanvik's conversion V profile on the MMPI distinguished cases of presumed psychogenic backache from cases with clear organic disease. In this profile the hysteria (Hs) and hypochondriasis (Hy) scales are elevated, the depression (D) scale is rela­ tively low, and there is a mild rise on the psychasthenia (Pt) scale. A second paper in Volume 1 describes five psychological tests, the only one of which I have heard was the reduced Wechsler Intelligence Test. This intro­ duction intimates the diffuse nature of the problem tack­ led by Nelson et al. Although they cite 105 references, these by no means cover the whole medical literature on the subject. Of the 61 references cited by the four commenting authors, 47 had not been cited in the prin­ cipal paper of Nelson et al. The comprehensive account of Nelson and colleagues on psychological selection criteria for implantation of a spinal cord stimulator leads off with the objective of justi­ fying the time and expense of such a specialized selec

Results of axillofemoral by-passes for aorto-iliac occlusive disease.

The purpose of this study was to review our results with axillofemoral by-passes performed for aorto-iliac occlusive disease. Fifty patients receiving 51 axillofemoral by-passes from January 1989 to December 1994 were retrospectively reviewed. The 30-day post-operative mortality was 4%. Seven patients (14%) presented graft-related local complications and all but one required reoperation. Five patients were lost to follow-up, the mean length of which was 36 months (16-74 months). Forty-nine per cent of the patients died during the follow-up period. At 36 months, the primary patency rate was 51%, the secondary patency rate was 69%, and limb valvage rate was 87%. A statistical difference was seen in the secondary patency rate between axillobifemoral by-pass (87%) and axillo-unifemoral by-pass (56%) at 36 months (P < 0.01), but no difference was seen in the limb salvage rate at 36 months between the two configurations of the by-pass (94% vs 81%) (P = NS). Twenty patients (40%) operated upon for acute ischemia had a significantly higher post-operative mortality rate (10% vs 0), a significantly higher amputation rate (20% vs 6.6%) and a significantly lower patency rate of by-pass (26% vs 63%) (P < 0.01), than the 30 patients (60%) operated on for claudication, rest pain or trophic ulcers. Our findings indicate that the results of axillofemoral by-pass are significantly influenced by the selection of patients for operation, namely the clinical status of ischaemic symptoms, and that since the overall results of axillofemoral by-pass are inferior to those of aortofemoral by-pass, this treatment should be restricted to patients at high risk of aortic clamping.

Controversies in the management of cold, hot, and occult thyroid nodules

Some aspects of thyroid nodule evaluation and management remain controversial. Radionuclide scanning provides functional information about nodules and differentiates cold from hot nodules. Although thyroid cancers are cold on scan, most cold nodules are benign. Ultrasonography visualizes the thyroid gland and nodules with remarkable clarity and provides structural information about location, number, size, and consistency of nodules. Widespread application of ultrasonography has resulted in the frequent discovery of incidental (occult) nodules in the general population. The clinical significance of these nodules remains unknown, and their management has created a dilemma for physicians. Current cost-effective evaluation of nodules does not include scanning or ultrasonography as routine frontline tests. In most centers, fine-needle aspiration biopsy has supplanted imaging studies as the routine initial procedure for differentiating benign from malignant nodules. Cytologic diagnosis is reliable and inexpensive, and it results in a better selection of patients for surgery. Limitations include falsenegative diagnoses, nondiagnostic results, and indeterminate “suspicious” results. Laboratory test results are usually normal, but determination of serum thyrotropin may identify a hot nodule, and plasma calcitonin may help diagnose medullary thyroid carcinoma. Treatment of thyroid nodules is controversial. In some practices, benign colloid nodules are treated with suppressive doses of levothyroxine. Recent reports cast doubt on the efficacy of this approach, and it is no longer acceptable to select patients for surgical treatment on the basis of suppressive therapy. Furthermore, suppressive levothyroxine therapy may be associated with significant bone and cardiac side effects, especially in elderly patients and postmenopausal women. Our approach is observation for most patients, and we suggest a careful risk-benefit analysis when suppression is considered. Hot (autonomous) nodules can be treated with radioiodine, surgery, or ethanol injection. The use of sensitive thyrotropin assays has revealed that the “euthyroid” hot nodule is often associated with subclinical hyperthyroidism, warranting treatment if risks of osteoporosis are significant. Small (≤1.5 cm) occult nodules can be observed. Larger (>1.5 cm) nodules can be selectively evaluated by ultrasonographically guided fine-needle aspiration. It is prudent to consider cost of care, risk-benefit analysis, and the low incidence of malignancy in thyroid nodules when diagnostic tests are selected and the treatment plan is outlined.