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ABSTRACT: Background: Routine axillary lymph node dissection (ALND) for elderly women with invasive breast cancer has been questioned because it rarely alters therapy yet carries a significant morbidity rate. Sentinel lymphadenectomy (SLND) improves axillary staging and alters therapy in women with T1 breast cancer, but it is not clear whether SLND alters therapy in elderly women with breast cancer.Methods: A prospective breast cancer data base was used to identify women 70 years old and older who underwent SLND for axillary staging of invasive breast cancer between 1991 and 1998.Results: There were 75 invasive breast cancers in 73 women. The mean patient age was 74.5 years (range, 70–90 years). Median tumor size was 1.4 cm (range, 0.1– 6.2 cm). Of the 75 tumors, 42 (56%) had favorable primary characteristics; the remaining tumors had unfavorable characteristics. SLND was performed alone in 17 cases (23%) and was followed by completion ALND in 58 cases (77%). Positive lymph nodes were identified in 32 cases (43%); 26 (81.3%) were detected by hematoxylin and eosin stains, and 6 (18.7%) were detected by immunohistochemistry alone. Five patients (6.9%) received adjuvant chemotherapy. Seven patients (9.6%) received axillary/supraclavicular radiation for positive nodes. Ten (13.7%) of 73 patients had obvious alterations in therapy because of axillary nodal status. As a result of SLND, 3 (13.6%) of 22 patients with tumors 1.0 cm or smaller received tamoxifen, and 7 (15%) of 46 patients with tumors between 1.0 and 3.0 cm in size had changes in therapy. When patient and tumor characteristics were analyzed to determine relationships to therapeutic decision-making, nodal status was the variable most significantly associated with changes in therapy (P 5 .0001).Conclusions: SLND improves axillary staging in elderly women with invasive breast cancer. Results of immunohistochemistry do not alter therapy in this group of individuals (P 5 .6367). In patients with small primary tumors, SLND alters therapy by increasing the number of patients receiving tamoxifen. In addition, SLND affects adjuvant systemic chemotherapy and regional radiotherapy in a significant number of patients with larger tumors, particularly tumors between 1.0 and 3.0 cm.
Annals of Surgical Oncology 04/2012; 7(6):406-410. · 4.17 Impact Factor
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ABSTRACT: In October 2009, an acute care surgery (ACS) model was implemented to facilitate urgent surgical consults. This study examines the impact of ACS on the timeliness of care and length of hospitalization for patients with acute cholecystitis. A retrospective cohort study was performed of patients presenting to the emergency department (ED) with acute cholecystitis who underwent early cholecystectomy. Patients with choledocholithiasis, pancreatitis, biliary colic, or cholelithiasis without cholecystitis were excluded. There were two study cohorts: ACS (October 2009 to July 2010) and pre-ACS (October 2008 to September 2009). Primary outcome measures were length of stay (LOS) and time from the ED to the operating room (OR). One hundred fifty-two cases were identified: 71 in the ACS group and 81 in the pre-ACS group. Patient demographics were similar. The ACS group had a significantly shorter average time from the ED to the OR (24.6 vs 35.0 hours, P = 0.0276). Overall LOS was reduced by a mean of 14.7 hours in the ACS group (mean 3.23 vs 2.63 days, P = 0.11). There was no significant difference in OR time (2.45 vs 2.38 hours, P = 0.562). There was a significant decrease in after-hours cases in the ACS group (5.6 vs 21%, P = 0.004) and a decrease in complication rates (18.5 vs 7.0%, P = 0.032). In conclusion, the ACS model decreased time from the ED to the OR, decreased after-hours cases, decreased length of hospitalization, and decreased complications for patients with acute cholecystitis.
The American surgeon 10/2011; 77(10):1318-21. · 1.28 Impact Factor
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ABSTRACT: Debate continues over the recommended extent of routine lymphadenectomy for gastric cancer. Although evidence of improved locoregional control with extended dissection accumulates, understaging and stage migration continue to confound the issue. Our objective was to determine whether D2 lymph node dissection improves staging compared with D1 in patients with gastric adenocarcinoma. We performed a retrospective study of 79 consecutive patients who underwent resection of gastric adenocarcinoma at a single institution. The American Joint Committee on Cancer (AJCC) 7th edition (2010) was used for TNM staging. Twenty-seven patients (34%) underwent D2 lymphadenectomy; 52 underwent D1 lymphadenectomy. There was no significant difference in age, gender, or operation. Significantly more lymph nodes were removed with a D2 than a D1 lymphadenectomy (mean, 26 vs 9; P < 0.0001). Significantly more patients had at least 15 nodes removed in the D2 cohort (85 vs 17%, P < 0.001). Within the D2 cohort, nine patients (39%) demonstrated additional lymph node metastases on extended dissection. This altered nodal status in five patients (20%) and altered TNM stage in four patients (16%). There was no significant difference in perioperative morbidity. D2 lymphadenectomy significantly increases node retrieval and AJCC compliance for gastric adenocarcinoma, resulting in improved staging.
The American surgeon 10/2011; 77(10):1326-9. · 1.28 Impact Factor
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ABSTRACT: Single-institution case series suggest that elderly patients do as well as younger patients after pancreaticoduodenectomy.
To compare morbidity and mortality after pancreaticoduodenectomy in patients older than 70 years vs younger patients.
Elderly patients have worse 30-day outcomes.
Retrospective cohort study.
American College of Surgeons-National Surgical Quality Improvement Program hospitals.
All patients who had a pancreaticoduodenectomy from January 1, 2005, to December 31, 2007, were identified.
Multiple logistic regression models were developed to assess the association between age and 30-day outcomes.
Thirty-day postoperative morbidity and mortality.
Of the 2610 patients identified, 977 (37.4%) were elderly and 1633 (62.6%) were younger. Overall morbidity was 36.5%. Elderly patients had a higher likelihood of developing at least 1 morbidity (surgical site infection, wound disruption, outpatient pneumonia, unplanned intubation, pulmonary embolism, prolonged ventilation, acute renal failure, urinary tract infection, stroke, cardiac arrest, deep venous thrombosis, sepsis, or return to the operating room) compared with that of younger patients (40.7% vs 34.0%; odds ratio, 1.27; 95% confidence interval, 1.06-1.51; P = .01). Overall mortality was 2.7%. Elderly patients had a higher likelihood of mortality compared with that of younger patients (4.3% vs 1.7%; adjusted odds ratio, 2.01; 95% confidence interval, 1.18-3.43; P = .01). In patients who had at least 1 morbidity, mortality was 10.1% in the elderly compared with 4.1% in the younger patients (P = .002).
Advanced age is independently associated with morbidity and death following pancreaticoduodenectomy. In addition, the elderly have a higher mortality after a complication compared with that of younger patients, suggesting that advanced age may have a role in "failure to rescue."
Archives of surgery (Chicago, Ill.: 1960) 06/2011; 146(6):715-23. · 4.32 Impact Factor
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ABSTRACT: Completion axillary lymph node dissection (CLND) is presently the standard of care after a positive sentinel lymph node biopsy (SLNB). We hypothesize that the incidence of axillary recurrence in patients who do not undergo CLND for micrometastases is low, and CLND is not necessary for locoregional control. We performed a retrospective chart review of patients with invasive breast carcinoma and micrometastases detected on SLNB. The Memorial Sloan Kettering Nomogram (MSKN) predicting the likelihood of nonsentinel lymph node (NSN) metastases was compared with the incidence of positive NSN. There were 61 patients identified with a mean follow-up of 70 months. The average tumor size was 2 cm. The median number of positive SLNs was one. Twenty-eight (46%) patients had a CLND; of these, 20 patients had one positive NSN (2 of 28 [7%]) and the mean MSKN score was 12 per cent. There were 33 (54%) patients who had SLNB alone, and their mean MSKN score was 13 per cent. Axillary recurrence in this group was 1.6 per cent. We conclude the incidence of axillary recurrence in patients with micrometastases detected by SLN biopsy who do not undergo CLND is low. The use of a predictive nomogram to estimate likelihood of metastatic disease to NSN may overestimate the actual incidence of positive NSN in patients with micrometastases.
The American surgeon 10/2010; 76(10):1088-91. · 1.28 Impact Factor
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ABSTRACT: Completion axillary lymph node dissection (ALND) is not required for regional control in patients with metastases in the sentinel lymph node (SLN).
Prospective cohort study.
Urban teaching hospital.
Fifty patients with breast cancer who underwent breast-conserving surgery, had an SLN positive for metastasis, and did not undergo completion ALND.
Breast-conserving surgery with SLN biopsy, breast irradiation, and systemic therapy.
Locoregional and distant recurrence and survival.
The mean patient age was 57 years (range, 29-83 years). The mean tumor size was 1.9 cm (range, 0.4-5 cm). The mean number of positive nodes was 1.3 (median, 1; range, 1-2). Fourteen patients (30%) had macrometastases (>2 mm), and 33 patients (71%) had micrometastases. The mean duration of follow-up was 82 months (median, 79 months; range, 6-142 months). One patient with an SLN micrometastasis (1 of 33; 3%) and 1 patient with an SLN macrometastasis (1 of 14; 7%) developed an axillary recurrence with distant metastasis at 84 months and 28 months, respectively. There was 1 death (2%) not related to breast cancer.
Patients with SLN metastases who do not undergo ALND have a low incidence of regional recurrence. Axillary lymph node dissection is not necessary for regional control in patients with micrometastatic disease.
Archives of surgery (Chicago, Ill.: 1960) 06/2010; 145(6):564-9. · 4.32 Impact Factor
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ABSTRACT: One component of the Surgical Care Improvement Project (SCIP) is the prevention of surgical site infections (SSIs) by: 1) timing the administration of prophylactic antibiotics (PAs) within 1 hour of incision; 2) using approved PA regimens; and 3) discontinuing PA within 24 hours. We sought to evaluate institutional compliance with SCIP recommendations in patients undergoing elective colorectal surgery and determine whether they affected the incidence of SSI. One hundred four elective colorectal cases were reviewed. In 58 patients (56%), PAs were administered within 1 hour of incision. In 71 cases (68%), the PA choice was considered compliant. There were a total of 12 SSIs (11.5%) overall. The incidence of SSI was significantly higher in cases in which PAs were not administered within 1 hour of incision (10 of 46 or 22% vs two of 58 or 3.5%, P = 0.005). There was no significant difference in the incidence of SSI in patients who received compliant versus noncompliant PA (12.7% vs 9.1%, P = 0.75). Timely PA administration significantly reduces the incidence of SSI in patients undergoing elective colorectal surgery. Efforts should focus on ensuring that PAs are given in a timely manner to reduce SSI in colorectal surgery.
The American surgeon 11/2008; 74(10):1012-6. · 1.28 Impact Factor
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ABSTRACT: Advances in molecular genetics aimed at individualizing breast cancer treatment have been validated. We examined the use of gene assays predictive of distant recurrence in breast cancer and their impact on adjuvant treatment. A retrospective chart review of 58 T1/T2, node-negative, estrogen-receptor positive breast cancer patients that underwent Oncotype DX gene assay testing between January and December 2006 was performed. We compared treatment received after gene assay evaluation to treatment based on National Comprehensive Cancer Network guidelines. Patients were grouped using these recommendations: Low-risk group (T1a/T1b), no chemotherapy; High-risk group (T1c/T2), chemotherapy. Oncotype DX recommendations are as follows: Low recurrence risk, no chemotherapy; high recurrence risk, chemotherapy. A change in management was defined as chemotherapy for T1a/T1b disease and no chemotherapy for T1c/T2 disease. Two T1a/T1b patients had high risk of recurrence per gene assay scores and were treated with chemotherapy (P < 0.05). Eighteen T1c/T2 patients had low recurrence risk scores; 13 (72%) were spared chemotherapy. The recurrence score increased the number of patients classified as low risk of recurrence by 12 per cent and downstaged 63 per cent of high-risk patients (P < 0.003). Gene assay results changed management in 15 of 58 (26%) patients (P < 0.05). The use of gene assays allowed us to better tailor treatment in a significant number of our patients.
The American surgeon 10/2008; 74(10):887-90. · 1.28 Impact Factor
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ABSTRACT: Sentinel lymph node biopsy (SLNB) is now an established method of axillary staging in patients with breast cancer. However, the augmented breast poses an interesting challenge to this procedure. We hypothesized that SLNB is feasible in patients with augmented breasts who subsequently develop breast cancer. A retrospective study was performed from 1995 to 2006. Ten patients with augmented breasts underwent breast conservation therapy with SLNB. Sentinel lymph nodes were identified in all 10 patients. Three patients had positive sentinel nodes. Two patients proceeded to axillary lymph node dissection (ALND), and one declined. The subsequent ALND were negative for metastatic cancer. Seven patients had negative sentinel nodes. One patient with a negative sentinel node underwent ALND with all nodes negative for metastasis. Two patients were lost to follow-up. Of the remaining eight patients, the mean duration of follow-up was 71 months. None of these patients had evidence of axillary recurrence or distant metastasis at time of last follow-up. SLNB is a feasible method of axillary node staging in patients who have undergone augmentation mammoplasty who subsequently develop breast cancer. Further studies are needed to better determine the accuracy of lymphatic mapping in this patient population.
The American surgeon 11/2007; 73(10):981-3. · 1.28 Impact Factor
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Journal of the American College of Surgeons 12/2006; 203(5):729-34. · 4.55 Impact Factor
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ABSTRACT: The MammoSite brachytherapy system is a novel form of intracavitary accelerated partial breast irradiation (APBI) that allows treatment over a 5- to 7-day course after breast conserving surgery (BCS). Fifty-one patients with invasive breast carcinoma underwent BCS and APBI using the MammoSite device, with 30 (59%) patients having drain placement in the lumpectomy cavity. Main outcome measures included time to initiating APBI, cosmesis using the Harvard Scale, and local and distant tumor recurrence with short-term follow-up. Five (9.8%) devices were explanted because of unfavorable final pathological findings or infection. Mean time to the start of APBI in patients without drain placement was 7.2 days (range, 5-12 days) compared with 5.1 days (range, 3-8 days) in patients with drains (P = 0.003). Cosmetic results were excellent in 25 (54.3%) patients, good in 19 (41.3%) patients, and fair in 2 (4.4%) patients. With a mean follow-up of 16 months (range, 6-38 months), no ipsilateral breast recurrences developed in any of the 51 patients. Thirteen patients had at least a 2-year follow-up. Two patients developed brain metastases and died at 19 and 23 months, respectively. The favorable short-term outcomes support further studies comparing APBI with standard whole-breast irradiation in patients undergoing BCS.
The American surgeon 11/2006; 72(10):929-34. · 1.28 Impact Factor
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ABSTRACT: Currently, 1 per cent isosulfan blue dye and technetium-99-labeled sulfur colloid (SC) are used in lymphatic mapping (LM). Several reports have suggested that the incidence of adverse drug reactions (ADRs) during LM is high. We report our experience with LM for solid neoplasms in order to determine the incidence and risk factors for development of ADRs. Seven hundred fifty-three patients (90% women, mean age 57) underwent LM with blue dye alone or in combination with SC from 1998 to 2004. The most common malignancy was breast cancer (83%). One hundred ten patients (14%) had injection of both mapping agents. Most patients (87%) underwent intraparenchymal injection of LM agent. Eight patients (1.1%) had an ADR during LM; none had prior exposure to LM. Of these, 7 had limited reactions (mostly blue hives) that quickly resolved. One patient (0.1%) developed anaphylaxis. The ADR incidence in patients with a sulfa allergy was not significantly different than that in patients without a sulfa allergy (3.4 vs 1%, P = 0.12). No risk factors for development of ADR were identified. Overall, the incidence of ADR during LM is low. Patients with sulfa allergies and prior exposure to LM did not demonstrate an increased incidence of ADR. Anaphylaxis, though rare, can occur during LM.
The American surgeon 10/2005; 71(9):720-4. · 1.28 Impact Factor
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ABSTRACT: Balloon catheter-based accelerated partial breast irradiation (APBI) may result in desirable short-term outcomes in patients undergoing breast conserving surgery.
Prospective consecutive case series.
Tertiary multidisciplinary referral center.
Forty selected patients with invasive breast carcinoma undergoing breast conserving surgery and MammoSite device placement.
Breast conserving surgery, sentinel and/or axillary node dissection, placement of the new balloon catheter applicator (MammoSite device), and APBI.
Infection, early and late seroma, device explantation, time to initiating APBI, acute toxic effects on the skin, and cosmesis using the Harvard Scale.
Thirty-nine patients underwent MammoSite device placement at the time of lumpectomy; 1 patient underwent percutaneous device placement after lumpectomy. Nineteen patients (49%) had drainage catheters placed in the breast cavity at the time of lumpectomy. Wound infection developed in 3 patients (8%). Five devices (12%) were explanted because of unfavorable final pathological findings or infection. The mean time to the start of APBI in patients who did not undergo simultaneous drain placement was 7.2 days (range, 5-12 days), compared with 5.1 days (range, 3-8 days) in patients who did (P = .008). With a mean follow-up of 13.3 months (range, 2-28 months), patients completing APBI had limited toxic effects on the skin, with excellent or good cosmetic results in 39 patients (97%).
Use of the MammoSite system in APBI has favorable short-term outcomes. Infection and radiation treatment delay are common and may warrant use of perioperative antibiotics and drain placement, respectively. A small number of patients who have device placement at the time of lumpectomy will require explantation because of unfavorable final pathological findings. Short-term outcomes of MammoSite brachytherapy support further studies comparing APBI with standard whole breast irradiation in patients undergoing breast conserving surgery.
Archives of Surgery 09/2005; 140(8):787-94. · 4.24 Impact Factor
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ABSTRACT: Sentinel lymph node (SLN) biopsy is widely used for solid tumors and has been proposed for use in staging colorectal cancer (CRC). Few studies have examined the ex vivo lymphatic mapping (EVLM) technique for staging CRC. We hypothesized that EVLM is technically feasible, sensitive, accurate, and improves the staging of CRC. After standard resection for colorectal cancer, 1 mL of isosulfan blue dye was injected circumferentially around the tumor. Blue-stained nodes were dissected separately and examined by hematoxylin and eosin (H&E) and immunohistochemical (IHC) stains. Routine pathologic evaluation was performed on all other harvested lymph nodes. Forty patients underwent 43 cancer resections with EVLM from July 2000 to December 2003. SLN were identified in 39 of 43 (91%) specimens. The mean number of SLN obtained was 1.9 (range, 0-5). Pathologic evaluation demonstrated nodal metastasis in 16 of 39 (39%) specimens. The SLN was tumor-positive in 9 of these 16 (56%) patients. The overall accuracy of EVLM was 82%. Two patients (9%) with H&E node negative disease were upstaged when found to have micrometastases by IHC staining. In conclusion, EVLM is technically possible in 90 per cent of patients with CRC. Although overall accuracy was high, the SLN status correlated poorly with the true nodal status of the CRC. However, EVLM improves pathologic staging in 9 per cent of patients and therefore may be of value in CRC.
The American surgeon 12/2004; 70(11):937-41. · 1.28 Impact Factor
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ABSTRACT: Lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) have become widely accepted in the setting of breast conservation surgery. We hypothesized that LM can be extended to women undergoing total mastectomy, being technically feasible, yielding highly accurate and sensitive results, improving axillary staging, and reducing postoperative morbidity. Between 1995 and 2003, 99 women (mean age 59 years, range 34-87) underwent 100 mastectomies with LM using blue dye alone. Fifty-nine operations (60%) were followed by a completion axillary lymph node dissection (ALND). Ninety per cent of patients had invasive carcinoma; 10 per cent had in situ carcinoma. Mean tumor size was 2.5 cm (range 0.3-8 cm). One hundred fifty-nine sentinel nodes (SNs) (mean 1.65, range 1-5) were successfully identified in 96 (96%) axillae. Twenty-five (25%) sentinel nodes revealed nodal metastases. Five of 25 (20%) SNs had micrometasteses. Three patients had a false-negative SN, yielding a sensitivity of 91 per cent. The accuracy of LM was 97 per cent. No patient who underwent SLNB alone developed lymphedema, axillary seroma formation, infection, or restricted arm movement. This was contrasted with patients undergoing ALND, where 10 (16%) developed lymphedema and 2 (3%) developed an infection. Ten (25%) patients developed axillary paresthesias after SNB compared with 47 (78%) patients after ALND (P < 0.0001). LM in the setting of mastectomy is accurate and sensitive. This technique improves axillary staging and decreases morbidity. Patients who are not candidates for breast conservation should be offered LM and SLNB at the time of mastectomy.
The American surgeon 10/2004; 70(10):881-5. · 1.28 Impact Factor
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ABSTRACT: To determine in patients with localized primary melanoma of the trunk or extremities the optimal excision margin that achieves the highest disease-free survival and overall survival and the lowest local recurrence rate.
Trials comparing 2 different excision margins were identified by searching MEDLINE from 1966 to May 2002 using the term "melanoma," subheading "surgery," and limiting the search to human studies and randomized controlled trials (RCTs). Additional studies were found using the MeSH term "surgical procedures, operative," combining with "melanoma," and limiting to human studies. We searched EMBASE and the Cochrane Library in May 2002 using similar terminology. No language restriction was applied.
We selected studies for the overview using the following inclusion criteria: design--an RCT with wide excision versus narrower excision (margin width was not specified a priori); population--adult patients (> 18 yr) with cutaneous melanoma of the trunk or extremities without evidence of metastasis; intervention--surgical excision of the primary melanoma; and outcomes--at least 1 of overall survival, disease-free survival, local recurrence, wound complications and necessity for skin grafting.
Information was abstracted for each outcome reported in the studies, and results were pooled by consensus. Statistical analysis was performed using RevMan 4.1 (The Cochrane Collaboration) software program. Relative risk and risk difference were reported with 95% confidence intervals. The number needed to harm was calculated for the need for skin grafting by taking the inverse of the risk difference.
Three trials and their follow-up studies met the inclusion criteria and included 2087 adults with localized cutaneous melanoma of the trunk or extremities. No statistically significant differences were found between wide surgical excision (margins ranging from 3-5 cm) and narrower surgical excision (margins ranging from 1-2 cm) with respect to mortality, disease-free survival or local recurrence rate.
Surgical excision margins no more than 2 cm around a melanoma of the trunk or extremities are adequate; overall survival, disease-free survival and recurrence rate are not adversely affected compared with a wider excision. There is more data to support a 2-cm margin than a 1-cm margin as the minimum margin of excision. Surgical margins should be no less than 1 cm around the primary melanoma.
Canadian journal of surgery. Journal canadien de chirurgie 12/2003; 46(6):419-26. · 1.05 Impact Factor
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ABSTRACT: Recent studies have demonstrated a reduction in hospital stay and postoperative complications in elderly patients undergoing laparoscopy-assisted colectomy, and have attributed the shorter stays and reduced morbidity to the laparoscopic approach. We questioned whether the improved outcomes in these studies were a result of the laparoscopic procedure alone or a result of early postoperative feeding and early hospital discharge. We hypothesized that early feeding in elderly patients undergoing open colorectal resection results in a short hospital stay and favorably affects postoperative morbidity.
Patients aged 70 years and older who were undergoing elective open colon resection were placed on an early postoperative feeding protocol. The early feeding protocol consisted of clear liquids on postoperative day 2, regular diet on postoperative day 3, and discharge to home as tolerated. The main outcomes measurements included early feeding tolerance, hospital stay, postoperative morbidity, and requirement for postoperative assisted care.
There were 87 study patients (42 men and 45 women, mean age 77 years). The most common operation was right hemicolectomy (53%). Overall 78 of 87 patients (89.6%) tolerated early feeding. Five patients (5.7%) initially tolerated a diet but required readmission for ileus. Nine patients (10.4%) did not tolerate early feeding initially. The mean hospital stay for all patients was 3.9 days. There were 15 postoperative complications in 13 patients (14.9%), the most common of which was urinary retention. There were no deaths, anastomotic leaks, abscesses, or pneumonia. Only 3 of 86 patients (3.5%) who were previously independent required assisted care after colectomy.
In elderly patients undergoing elective open colon resection, early feeding results in a short hospital stay and low postoperative morbidity. These results are comparable to those reported for laparoscopy-assisted colectomy.
Journal of the American College of Surgeons 12/2003; 197(5):747-52. · 4.55 Impact Factor
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ABSTRACT: Reoperations for breast cancer predispose to a higher risk of postoperative wound infections than primary procedures. We accomplished a retrospective chart review of 320 women who underwent multiple breast cancer procedures between 10/97 and 8/02. The mean number of procedures was 2.4 (range, 2-5). The overall incidence of wound infection was 6.1 per cent. Wound infections developed, on average, 12 days after surgery (range, 2-30). There was a statistically significant difference in the incidence of wound infection comparing the initial procedure versus the subsequent operation (1.6% vs. 9.4%, P < 0.001). This was also seen with reoperation after an operative biopsy compared to operation after a core biopsy (11.1% vs. 9.7%, P < 0.01). The incidence was increased to 22.0 per cent when the initial operation involved lymph node dissection (sentinel lymph node biopsy or complete axillary lymph node dissection). Wire localization did not increase the incidence of postoperative wound infections, and prophylactic antibiotics were associated with a decreased incidence of wound infection in the reoperative setting. The incidence of wound infection is increased with reoperation after operative biopsy compared to operation after core biopsy and is further increased when the initial biopsy involved lymph node dissection.
The American surgeon 10/2003; 69(10):852-6. · 1.28 Impact Factor
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ABSTRACT: Serosanguinous drainage after mastectomy and axillary lymph node dissection has traditionally been treated with the temporary use of closed suction drainage catheters. Use of drainage catheters is associated with wound infection, discomfort, nerve injury, and impaired arm movement. Commercially produced fibrin sealant has been proposed to reduce postoperative serosanguinous collections. We hypothesized that the intraoperative application of low-dose (2-5 cm3) fibrin sealant would reduce serosanguinous drainage and allow earlier removal of closed suction drainage catheters after operation for breast cancer. Fifty-five women with known breast cancer underwent either total mastectomy, modified radical mastectomy, or isolated level I and II axillary lymph node dissection. Twenty-six patients were treated with fibrin sealant and 29 served as control subjects. The application of fibrin sealant resulted in a significant reduction in overall duration catheters were needed (7 vs 8.3 days; P = 0.05). More importantly fibrin sealant reduced the time until 24-hour drain output was less than 30 cm3 (4.9 vs 6.2 days). Additionally fibrin sealant application resulted in a 60 per cent reduction in overall drainage amount after total mastectomy and a 32 per cent reduction after modified radical mastectomy. The application of fibrin sealant after axillary lymph node dissection did not decrease overall drainage amount. In conclusion fibrin sealant reduces serosanguinous drainage after total mastectomy and modified radical mastectomy and may allow earlier removal of closed suction drainage catheters.
The American surgeon 02/2003; 69(1):77-81. · 1.28 Impact Factor
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ABSTRACT: Early postoperative feeding after open colon resection has been shown to be safe and effective. However, approximately 13 per cent of patients fail to tolerate it. We hypothesized that the use of promotility agents may decrease failure of early postoperative feeding after elective open colectomy. As part of a consecutive case series metoclopramide or cisapride was administered to patients undergoing open colectomy as part of an early feeding protocol. The early feeding protocol consisted of instituting a clear liquid diet on postoperative day (POD) 2, followed by a regular diet on POD 3. One hundred fifty-one patients received early-feeding without promotility agents (Group I). The next 49 patients were treated with metoclopramide (Group II), and 31 patients received cisapride (Group III). In Group I 20 of 151 patients (13.2%) failed early feeding, and the mean hospital stay was 3.77 days (range 3-11 days). In Group II seven of 49 patients (14.2%) failed early postoperative feeding, and the mean hospital stay was 3.67 days (range 3-8 days). Group III had no patients who failed to tolerate early feeding, and the mean hospital stay was 3.32 days (range 3-5 days). There were no anastomotic leaks or abdominal abscesses in any group. No cardiac arrhythmias were associated with cisapride. A decrease in early feeding failure was observed with cisapride, administration.
The American surgeon 01/2003; 68(12):1093-6. · 1.28 Impact Factor
