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PubMedDate not supplied

Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.

Adenocarcinoma↗
PubMed1997

Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study.

BACKGROUND: The influence of prior coronary artery bypass surgery (CABG) versus medical therapy for reducing the risk of postoperative cardiac complications after noncardiac surgery continues to be debated. To further clarify this controversy we studied 24,959 participants in the Coronary Artery Surgery Study (CASS) database with suspected coronary disease by identifying those who required noncardiac surgery during more than 10 years of follow-up. METHODS AND RESULTS: CASS registry enrollees were either treated with CABG or medical therapy after initial entry. During follow-up, patients who required noncardiac operations were evaluated for hospital death or out-of-hospital death within 30 days of noncardiac surgery and nonfatal postoperative myocardial infarction (MI). At a mean follow-up of 4.1 years, 3368 patients underwent noncardiac surgery, with abdominal (36%), urologic (21%), orthopedic (15%), and vascular being most common. Abdominal, vascular, thoracic, and head and neck surgery each had a combined MI/death rate among patients with nonrevascularized coronary disease >4%. Among 1961 patients undergoing higher-risk surgery, prior CABG was associated with fewer postoperative deaths (1.7% versus 3.3%, P=.03) and MIs (0.8% versus 2.7%, P=.002) compared with medically managed coronary disease. Contrariwise, 1297 patients undergoing urologic, orthopedic, breast, and skin operations had mortality of <1% regardless of prior coronary treatment. Prior CABG was most protective in patients with advanced angina and/or multivessel coronary artery disease. CONCLUSIONS: In patients with known coronary artery disease, noncardiac surgeries involving the thorax, abdomen, vasculature, and head and neck are associated with the highest cardiac risk, which is reduced among patients with prior CABG.

Bone Diseases↗
PubMed1993

[Treatment of thoracic malignancy accompanied with cardiovascular disease].

We treated 10 cases of thoracic malignancy accompanied with cardiovascular disease. Among thoracic malignancy, 7 cases were lung cancer and 3 were esophageal cancer. Accompanied cardiovascular diseases were ischemic heart disease (2 cases), valvular disease (3 cases), WPW syndrome (1 case), aortic aneurysm (4 cases). The mean age was 66, ranged from 51 to 79. The simultaneous occurrence of the two lesions were observed in 6 cases and thoracic malignancy was diagnosed after a varying interval of time following surgery of cardiovascular disease in 4 cases. In cases of thoracic malignancy accompanied with heart disease, the treatment of heart disease should precede the operation of malignant disease to reduce the risk of surgery. For the patient with esophageal cancer, posterior mediastinal esophagostomy should be applied who may have heart surgery in future. In cases of coexisting malignancy and aortic aneurysm, the priority of treatment should be determined considering the size of aneurysm. If the transverse diameter of aneurysm is larger than 7 cm, there is a high risk of rupture, so surgery for the aneurysm precedes operation of malignant diseases. It is desirable to avoid concomitant operation of malignancy and cardiovascular disease.

Aged↗
PubMed2004

Emerging options for thromboprophylaxis after orthopedic surgery: a review of clinical data.

In four randomized, controlled studies of patients undergoing orthopedic surgery, the antithrombotic efficacy and safety of subcutaneous fondaparinux 2.5 mg once/day were compared with those of subcutaneous enoxaparin regimens that were approved by the United States Food and Drug Administration. In patients undergoing elective hip replacement surgery, fondaparinux significantly reduced the frequency of venous thromboembolism (VTE). However, in a second trial that compared fondaparinux with enoxaparin 30 mg twice/day beginning 12-24 hours after surgery, a 26% risk reduction in favor of fondaparinux was not statistically significant. In patients undergoing elective knee replacement surgery, fondaparinux significantly reduced the risk of VTE compared with enoxaparin without increasing the risk of clinically relevant bleeding, although the risk of major bleeding defined by the bleeding index was significantly higher with fondaparinux. Fondaparinux was superior to enoxaparin 40 mg once/day in the setting of hip fracture surgery, with no increased risk of major bleeding. Meta-analysis of the four studies confirms the superior antithrombotic efficacy of fondaparinux over enoxaparin in orthopedic surgery and suggests that the risk of major bleeding is similar to that of enoxaparin when the first dose of fondaparinux is given at least 6 hours after surgery.

Anticoagulants↗
PubMed2005

Preoperative heart rate variability in relation to surgery outcome in refractory epilepsy.

BACKGROUND: Epilepsy patients may have an impaired autonomic cardiac control, which has been associated with an increased incidence of sudden unexpected death among people with epilepsy (SUDEP). The risk of SUDEP is particularly high among epilepsy surgery candidates with refractory epilepsy. This risk seems to be reduced after successful surgery but whether this is an effect of surgery or reflects pre-existing differences between good and poor responders is under debate. METHODS: We used spectral analysis to analyze prospectively heart rate variability (HRV) preoperatively in 21 consecutive patients with temporal lobe epilepsy who were planned for epilepsy surgery. The presurgical HRV based on ambulatory 24 hours EKG recordings was analyzed in relation to seizure control at 1 year after surgery. RESULTS: Patients had significantly lower SD of RR-intervals, total power, very low frequency power and low frequency power than matched healthy controls. Patients with good outcome of surgery (Engel class I; n = 11) did not differ from their controls while those with poor outcome (Engel class II-IV; n = 10) had significantly lower power in all domains than those with a favorable outcome. CONCLUSIONS: Measurements of heart rate variability preoperatively indicate that patients with a poor outcome of surgery have a more pronounced impairment of sympathetic as well as parasympathetic cardiac control than those with good outcome. Reduced heart rate variability may be associated with an increased risk of sudden unexpected death among people with epilepsy (SUDEP). Good surgery candidates may a priori have a lower risk of SUDEP.

Arrhythmias, Cardiac↗
PubMed2003

Risk factors for surgical site infection in spinal surgery.

OBJECT: The objective of this study was to identify specific independent risk factors for surgical site infections (SSIs) occurring after laminectomy or spinal fusion. METHODS: The authors performed a retrospective case-control study of data obtained in patients between 1996 and 1999 who had undergone laminectomy and/or spinal fusion. Forty-one patients with SSI or meningitis were identified, and data were compared with those acquired in 178 uninfected control patients. Risk factors for SSI were determined using univariate analyses and multivariate logistic regression. The spinal surgery-related SSI rate (incisional and organ space) during the 4-year study period was 2.8%. Independent risk factors for SSI identified by multivariate analysis were postoperative incontinence (odds ratio [OR] 8.2, 95% confidence interval [CI] 2.9-22.8), posterior approach (OR 8.2, 95% CI 2-33.5), procedure for tumor resection (OR 6.2, 95% CI 1.7-22.3), and morbid obesity (OR 5.2, 95% CI 1.9-14.2). In patients with SSI the postoperative hospital length of stay was significantly longer than that in uninfected patients (median 6 and 3 days, respectively; p < 0.001) and were readmitted to the hospital for a median additional 6 days for treatment of their infection. Repeated surgery due to the infection was required in the majority (73%) of infected patients. CONCLUSIONS: Postoperative incontinence, posterior approach, surgery for tumor resection, and morbid obesity were independent risk factors predictive of SSI following spinal surgery. Interventions to reduce the risk for these potentially devastating infections need to be developed.

Adolescent↗
PubMed2001

Risk factors reducing blood transfusion requirements in pediatric open heart surgery after introduction of vacuum assisted circuits.

OBJECTIVES: Open heart surgery without homologous blood transfusion remains difficult in children. The introduction of vacuum-assisted cardiopulmonary bypass circuits to reduce priming volume for pediatric patients has improved the percentage of transfusion-free operations. We retrospectively analyzed blood transfusion risk factors to further reduce blood transfusion requirements after vacuum-assisted circuit introduction. METHODS: From March 1995 to June 1996, 49 patients weighing between 5 and 20 kg underwent cardiac surgery with cardiopulmonary bypass at our institution, excluding hospital deaths. We retrospectively analyzed risk factors influencing blood use in 37 patients with no blood priming in cardiopulmonary bypass after introducing a vacuum-assisted system. Factors selected for univariate analysis were age, body weight, cyanosis, preoperative Hb, operation time, cardiopulmonary bypass time, aortic cross-clamping time, and intraoperative and postoperative bleeding volume. Correlation between total bleeding volume/body weight and cardiopulmonary bypass time was studied by regression analysis. RESULTS: As risk factors, univariate analysis identified cyanotic disease, longer operation time (> 210 minutes), longer cardiopulmonary bypass time (> 90 minutes), longer aortic cross-clamping time (> 45 minutes), greater intraoperative bleeding volume/body weight (> 4 ml/kg), and greater postoperative bleeding volume/body weight (> 15 ml/kg). Regression analysis showed a significant positive correlation between total bleeding volume/body weight and cardiopulmonary bypass time. CONCLUSIONS: Cyanotic disease and long bypass time are risk factors in reducing blood transfusion requirements in pediatric open heart surgery after introduction of vacuum-assisted circuits. Further efforts are needed, however, to reduce blood transfusion requirements, particularly in these children.

Blood Loss, Surgical↗
PubMed2003

Risk factors and risk reduction of breast and ovarian cancer.

PURPOSE OF REVIEW: Breast and ovarian cancer remain a significant burden for women living in the Western world. This paper reviews the risk factors and current strategies to prevent these diseases. RECENT FINDINGS: Established factors associated with the risk of breast cancer include family history, reproductive factors and lactation, as well as age at menarche and menopause. Hormone replacement therapy increases the risk, whereas oral contraceptives probably confer no increased risk. Alcohol moderately increases the risk, whereas a diet rich in folate and carotenoids might be protective. The role of other dietary factors, smoking and physical exercise remain unclear. Important risk factors for ovarian cancer are reproductive factors and possibly the long-term use of hormone replacement therapy. The risk is decreased by oral contraceptives. In carriers of a BRCA1 or BRCA2 gene mutation, prophylactic surgery can significantly reduce the risk of breast as well as ovarian cancer. Tamoxifen may be considered as a chemopreventive agent in women with a high risk of breast cancer, including carriers of a BRCA2 mutation, but is probably not effective in BRCA1 carriers. SUMMARY: During the period of this review, the importance of several known risk factors was confirmed, whereas the effects of other factors became more clear. Chemoprevention and prophylactic surgery have emerged as preventative options that can reduce the risk of breast and ovarian cancer.

Alcoholism↗
PubMedDate not supplied

Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA1/2-positive women: a decision analysis.

PURPOSE: Recent randomized controlled trials have shown that tamoxifen and raloxifene may prevent invasive breast cancer. This decision analysis study compares the outcomes of chemoprevention with tamoxifen, raloxifene, or oral contraceptives with the outcomes of prophylactic surgery among women with high-risk BRCA1/2 mutations. PATIENTS AND METHODS: We used a simulated cohort of 30-year-old women who tested positive for BRCA1/2 mutations and constructed a Markov model with Monte Carlo simulations, incorporating cumulative breast and ovarian cancer incidence rates from the literature and survival figures from SEER data. We assumed that prophylactic surgery reduces ovarian cancer risk by 45% and breast cancer risk by 90%, that tamoxifen reduces invasive breast cancer risk by 49%, and that raloxifene has similar efficacy and safety in premenopausal and postmenopausal women. We used data obtained from high-risk women by a time trade-off questionnaire to calculate quality-adjusted life-years. We based our cost estimates for hospital and ambulatory care on Health Care Financing Administration payments, the SEER-HCFA database, and the Pharmacy Fundamental Reference. RESULTS: In our model, a 30-year-old BRCA1/2+ woman could prolong survival by 0.9 years (95% probability interval, 0.4-1.2 years) by having bilateral oophorectomy, 3.4 years (2.7-3.7 years) by having bilateral mastectomy, and 4.3 years (3.6-4.6 years) by having both procedures instead of surveillance alone. Chemoprevention with tamoxifen and raloxifene increased survival by 1.6 years (1.0-2.1 years) and 2.2 years (1.3-2.8 years), respectively. Chemoprevention yielded more quality-adjusted life-years than did prophylactic surgery, even when treatment was delayed to age 40 or 50 years. All these procedures were cost-effective or cost-saving compared with surveillance alone. DISCUSSION: Our model suggests that although surgery may yield more substantial survival and cost benefits, quality of life issues may make chemoprevention a more attractive option for young women at high genetic risk.

Adult↗
PubMed2003

Preoperative fasting for adults to prevent perioperative complications.

BACKGROUND: Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents during surgery, thus reducing the risk of regurgitation/aspiration. Recent guidelines have recommended a shift in fasting policy from the standard 'nil by mouth from midnight' approach to more relaxed policies which permit a period of restricted fluid intake up to a few hours before surgery. The evidence underpinning these guidelines however, was scattered across a range of journals, in a variety of languages, used a variety of outcome measures and methodologies to evaluate fasting regimens that differed in duration and the type and volume of intake permitted during a restricted fasting period. Practice has been slow to change. OBJECTIVES: To systematically review the effect of different preoperative fasting regimens (duration, type and volume of permitted intake) on perioperative complications and patient wellbeing (including aspiration, regurgitation and related morbidity, thirst, hunger, pain, nausea, vomiting, anxiety) in different adult populations. SEARCH STRATEGY: Electronic databases, conference proceedings and reference lists from relevant articles were searched for studies of preoperative fasting in August 2003 and experts in the area were consulted. SELECTION CRITERIA: Randomised controlled trials which compared the effect on postoperative complications of different preoperative fasting regimens on adults were included. DATA COLLECTION AND ANALYSIS: Details of the eligible studies were independently extracted by two reviewers and where relevant information was unavailable from the text attempts were made to contact the authors. MAIN RESULTS: Thirty eight randomised controlled comparisons (made within 22 trials) were identified. Most were based on 'healthy' adult participants who were not considered to be at increased risk of regurgitation or aspiration during anaesthesia. Few trials reported the incidence of aspiration/regurgitation or related morbidity but relied on indirect measures of patient safety i.e. intra-operative gastric volume and pH. There was no evidence that the volume or pH of participants' gastric contents differed significantly depending on whether the groups were permitted a shortened preoperative fluid fast or continued a standard fast. Fluids evaluated included water, coffee, fruit juice, clear fluids and other drinks (e.g. isotonic drink, carbohydrate drink). Participants given a drink of water preoperatively were found to have a significantly lower volume of gastric contents than the groups that followed a standard fasting regimen. This difference was modest and clinically insignificant. There was no indication that the volume of fluid permitted during the preoperative period (i.e. low or high) resulted in a difference in outcomes from those participants that followed a standard fast. Few trials specifically investigated the preoperative fasting regimen for patient populations considered to be at increased risk during anaesthesia of regurgitation/aspiration and related morbidity. REVIEWER'S CONCLUSIONS: There was no evidence to suggest a shortened fluid fast results in an increased risk of aspiration, regurgitation or related morbidity compared with the standard 'nil by mouth from midnight' fasting policy. Permitting patients to drink water preoperatively resulted in significantly lower gastric volumes. Clinicians should be encouraged to appraise this evidence for themselves and when necessary adjust any remaining standard fasting policies (nil-by-mouth from midnight) for patients that are not considered 'at-risk' during anaesthesia.

Adult↗
PubMedDate not supplied

Percutaneous pulmonary valvuloplasty.

At Guy's Hospital percutaneous pulmonary valvuloplasty has been performed in 30 children with pulmonary valve stenosis. In 24 cases the results were satisfactory. There was little change in the stenoses of six children; three of these were found to have dysplastic valves at surgery. One child had a valvuloplasty performed twice. Follow up in eight children has shown the long term success of the procedure with no complications. Before percutaneous pulmonary valvuloplasty was available the only treatment for pulmonary valvular stenosis was surgery. This entailed a lengthy stay in hospital, a long postoperative period and an unsightly midline chest scar. The average length of time spent in hospital for surgery is two weeks, and for valvuloplasty a few days. Percutaneous pulmonary valvuloplasty should be considered as the initial treatment of choice for most congenital pulmonary valve stenosis. It is safe, effective, can be performed at any age and can reduce the risks of surgery.

Cardiac Catheterization↗
PubMed1999

Aortic arch aneurysms.

Aneurysms involving the aortic arch are formidable surgical challenges. Though the first successful surgery was performed more than 40 years ago, the risk of surgical treatment remained prohibitively high until recently. Intra-operative protection of the brain from ischaemic injury was the main concern. Deep hypothermic circulatory arrest with retrograde cerebral perfusion technique has considerably reduced the risk of surgery to acceptable levels.

Aortic Aneurysm, Thoracic↗
PubMed1997

Pro: intraoperative transesophageal echocardiography is a cost-effective strategy for cardiac surgical procedures.

TEE is an expensive but useful intraoperative diagnostic strategy for cardiac surgical procedures. It can alter surgical management with tremendous potential benefits to the patient. It also has the potential to avoid unnecessary surgery and reduce the risk of complications such as reoperation, thromboembolism, and stroke. As with any new technology, the indications for its use must be evaluated on the basis of cost, benefits, and efficacy to determine the true value and cost-effectiveness in a particular application. Based on the information presented in this report, it can be concluded that TEE is a cost-effective strategy for valvular and congenital heart repairs. Current data are very convincing that TEE has the potential to be cost-effective in reducing the risk of stroke in selected populations of cardiac surgical patients. As experience with the use of TEE in its various applications increases and the technology itself continues to improve, it will undoubtedly become a more valuable and cost-effective strategy for cardiac surgery.

Aortic Diseases↗
PubMed1999

Selection of patients for carotid endarterectomy: the role of ultrasound.

Stroke is the third leading cause of death in the western world and the major cause of disability among the middle aged and elderly populations. Carotid artery stenosis is the single most important risk factor for stroke. The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have demonstrated that the risk of stroke is reduced by surgery in patients with high grade stenosis. Carotid plaque morphology also plays an important role; plaques which are ulcerated and echolucent are associated with a higher risk of stroke. Arteriography has long been regarded as the gold standard diagnostic tool for evaluation of carotid artery disease, but it is an invasive and costly technique which carries the risk of potentially serious complications. Doppler ultrasound can provide functional and anatomical information on vessel stenosis and plaque morphology at sub-millimetric resolutions and is an inexpensive and noninvasive tool. Color and spectral Doppler ultrasound are now recognized as the best screening tests for carotid artery stenosis. The evidence for its use as the sole diagnostic imaging modality prior to carotid endarterectomy is examined. The recent availability of ultrasound contrast agents helps to distinguish between pseudo- and true occlusions, improves ultrasound images and should help to reduce operator variability.

Blood Flow Velocity↗