RESUMEN
OBJECTIVES: Most patients with advanced head and neck cancer receiving chemoradiotherapy need tube feeding for at least some weeks. For these periods gastrostomy tubes have advantages over nasogastric tubes. Tube feeding may start earlier and thus loss of weight may be limited if the gastrostomy tube already is in place. The objective of this study is to analyse the results of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement and early tube feeding. DESIGN: Retrospective chart review. SETTING: Multidisciplinary head and neck oncology team in a general hospital. PARTICIPANTS: Fifty consecutive patients with unresectable stage III and IV head and neck cancer treated with concurrent chemoradiotherapy. In all patients prophylactic PEG placement was performed. Tube feeding was initiated if food-intake became insufficient or loss of weight occurred. MAIN OUTCOME MEASURES: Loss of weight during treatment, complication rate, PEG duration. RESULTS: The mean loss of weight during treatment for all patients was only 2.8%. One complication of tube placement occurred: a colon perforation, treated successfully by surgery. The median duration of the PEG was 178 days. Three of the 17 patients (18%) with no evidence of disease (NED) still had a PEG at their last follow-up visit. Of the 26 patients who died of their cancer, 13 used the PEG until death. CONCLUSIONS: Loss of weight was limited after prophylactic gastrostomy placement and early tube feeding. Moreover, the complication rate was low. In 82% of the NED patients the PEG could eventually be removed.
Asunto(s)
Trastornos de Deglución/prevención & control , Endoscopía Gastrointestinal/métodos , Nutrición Enteral/instrumentación , Gastrostomía/métodos , Neoplasias de Cabeza y Cuello/tratamiento farmacológico , Neoplasias de Cabeza y Cuello/radioterapia , Pérdida de Peso , Adulto , Anciano , Anciano de 80 o más Años , Trastornos de Deglución/etiología , Femenino , Estudios de Seguimiento , Neoplasias de Cabeza y Cuello/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
A case is described involving ulnar artery thrombosis attributed to vigorous applause. This is a previously unrecognized cause of ulnar artery thrombosis.
Asunto(s)
Mano/irrigación sanguínea , Trombosis/etiología , Arteria Cubital , Adulto , Humanos , MasculinoRESUMEN
Review of 46 consecutive patients undergoing immediate breast reconstruction with tissue expanders and subsequent implant placement was conducted to assess the potential liability of adjuvant chemotherapy. Twenty-three patients required chemotherapy, while 23 did not. Critical comparison of complications and outcome of the two groups revealed no significant differences. Within the parameters of the study (avoidance of expansion or surgery during the period of chemotherapy), there appeared to be no disadvantage posed to the immediate reconstruction patient by adjuvant chemotherapy. We feel that this option can continue to be offered despite the anticipation of probable chemotherapy.
Asunto(s)
Implantes de Mama , Neoplasias de la Mama/terapia , Quimioterapia Adyuvante/efectos adversos , Mamoplastia , Dispositivos de Expansión Tisular , Neoplasias de la Mama/epidemiología , Estudios de Casos y Controles , Femenino , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Demineralized bone powder has been shown previously to successfully induce bone formation. The purpose of this study was to use demineralized bone powder in an onlay graft situation using implantable molds. Demineralized bone powder was placed within a mold and rigidly attached to the frontal bones of 30 New Zealand White rabbits by screw fixation. Periosteum was not closed over the mold. A control group had the mold placed without demineralized bone powder used. After 12 weeks of growth, the animals were sacrificed and the frontal bone was analyzed for bone growth using standardized histology and fluorescent microscopy. One hundred percent of the animals (30 of 30) that received demineralized bone powder underwent bone growth in the precise shape of the mold (p < 0.001). There was no new bone development in the control group (n = 8). Placement of larger molds duplicated these results (n = 20) with a 650 percent increase in frontal bone thickness within 12 weeks after placement of demineralized bone powder. This model mimics onlay bone grafting, and perhaps this technique may replace onlay grafting or alloplastic implantation in certain circumstances, avoiding the extra morbidity and donor-site defects associated with bone grafting.
Asunto(s)
Huesos , Oseointegración , Prótesis e Implantes , Animales , Polvos , ConejosRESUMEN
The records of 28 patients who underwent free jejunal graft reconstruction after resection for cancer involving the pharynx were analysed. Seven patients had a T3 carcinoma, 15 patients T4 and six patients recurrence after laryngectomy. Ten patients had received radiotherapy in the past. Post-operatively, 15 patients (54%) had complications and two patients (7%) died. No significant difference was observed in the complication rate between the group that received radiotherapy in the past and those who did not. Nineteen patients received post-operative radiotherapy. Nine patients had no radiotherapy on the basis of complete resection or because of serious complications. For the whole group the 2-year recurrence free period and survival were 42% and 51% respectively. The post-operative radiotherapy group had a significantly better survival (73%) and recurrence free period (63%) than the group without post-operative radiotherapy (0%). Thus, post-operative radiotherapy seems indicated irrespective of resection margins.
Asunto(s)
Esófago/cirugía , Yeyuno/trasplante , Laringectomía/rehabilitación , Faringectomía/rehabilitación , Faringe/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Terapia Combinada , Fístula Cutánea/etiología , Supervivencia sin Enfermedad , Femenino , Fístula/etiología , Humanos , Laringectomía/métodos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Enfermedades Faríngeas/etiología , Neoplasias Faríngeas/patología , Neoplasias Faríngeas/radioterapia , Neoplasias Faríngeas/cirugía , Faringectomía/métodos , Cuidados Posoperatorios , Complicaciones Posoperatorias , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
The Dutch Co-operative Head and Neck Oncology Group performed a retrospective, nationwide study of laryngeal cancer between 1975 and 1984. The results for T3 laryngeal cancer treated with primary laryngectomy (n = 137) with post-operative radiotherapy when indicated or planned combined (pre-operative) radiotherapy with laryngectomy (n = 113) are analysed. The disease-free survival independent prognostic factors were treatment modality (planned combined treatment fared better, P = 0.001), incomplete resection of disease (P = 0.006), positive lymph nodes in the neck dissection specimen (P = 0.03) and poor differentiation (P = 0.04). Local control (95% vs. 85%, P = 0.01) as well as regional control (96% vs. 79%, P = 0.0001) was improved in the combined group compared with the primary laryngectomy group. Regional control was 69% for N0 patients if the neck nodes were not treated electively, compared with 98% for the planned combined treatment group. It is concluded that elective treatment of the neck nodes in T3 laryngeal cancer is mandatory. Radiotherapy is preferred, since as well as regional control, local control will also improve.
Asunto(s)
Neoplasias Laríngeas/radioterapia , Neoplasias Laríngeas/cirugía , Laringe/patología , Laringe/cirugía , Estadificación de Neoplasias , Femenino , Humanos , Neoplasias Laríngeas/patología , Laringectomía , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Pronóstico , Dosis de Radiación , Estudios Retrospectivos , SobrevidaRESUMEN
In 511 patients with T3N0-3M0 laryngeal carcinoma, 24 possible prognostic factors were analysed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnoea, and dysphagia, previous tracheotomy, tumour extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumour and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension were also evaluated. Univariate analysis revealed prognostic significance on survival for tumour extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy). In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumour, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.
Asunto(s)
Carcinoma de Células Escamosas/patología , Neoplasias Laríngeas/patología , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/cirugía , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Laríngeas/mortalidad , Neoplasias Laríngeas/cirugía , Laringe/patología , Ganglios Linfáticos/patología , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
During the past several years, a profound change in our approach to bone stabilization in the hand has occurred. Today, standard management of almost any fracture requiring open reduction as well as most arthrodeses and osteotomies will incorporate rigid fixation employing one of the maxillofacial systems. Many of the early concerns, such as increased complexity of the procedure, the need for extensive periosteal stripping, bulkiness of the plates (with potential palpation, tenderness, and the impingement on tendon and joint motion), and the anticipated frequent need for removal, have been allayed. Thinner plates, the smallest screws from the miniplating systems, and the introduction of the microplating systems (Luhr and Synthes) have obviated much of the anticipated difficulty with tendon gliding and have made the necessity for subsequent plate removal a rarity in our practice. The use of these systems allows much earlier mobilization postoperatively, reducing the incidence of joint stiffness and tendon adhesion. This paper discusses our series of 143 patients (average follow-up time over 18 months) and the application of miniplating and microplating systems for a variety of fractures, osteotomies, and arthrodeses in the hand.
Asunto(s)
Placas Óseas , Fijación de Fractura/instrumentación , Fracturas Óseas/cirugía , Traumatismos de la Mano/cirugía , Adolescente , Adulto , Femenino , Traumatismos de los Dedos/diagnóstico por imagen , Traumatismos de los Dedos/cirugía , Fracturas Óseas/diagnóstico por imagen , Traumatismos de la Mano/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , RadiografíaRESUMEN
Computer-generated slide graphics have significantly altered the face of audiovisual presentations. However, it remains to be determined if dramatic effects enhance presentation clarity and increase information retrieval. This study compared color combination and print type graphics. Ninety medical students were shown a 29-minute, 45-slide presentation addressing aspects of plastic surgery. Each slide represented one of 15 color combinations and one of 3 fonts. The students studied each slide for 10 seconds and then in 25 seconds recorded all information they could recall. Statistical analysis (using ANOVA) revealed a significant difference in information retrieval among slides and a significant interaction between color and font. The "best" was orange block print on a raspberry background. The "worst" was yellow cursive print on a black background. This study demonstrated that (1) color influences information gleaned from a slide presentation and (2) font type simplicity may result in improved retention.
Asunto(s)
Recursos Audiovisuales , Gráficos por Computador , Cirugía Plástica/educación , Color , HumanosRESUMEN
We report an inexpensive, easy-to-apply vaginal stent for use in McIndoe vaginal reconstruction using Surgi-Stuf inserted in a sterile condom. This material's easy compressibility and good "memory" facilitate good apposition for the skin grafts while being easily placed into the depth of the new vaginal pocket.
Asunto(s)
Stents , Vagina/anomalías , Vagina/cirugía , Anomalías Congénitas/cirugía , Femenino , Humanos , Cuidados PosoperatoriosRESUMEN
We present a case report of a 4-year-old in whom the distal fibula and epiphyseal plate had been traumatically destroyed. A free vascularized epiphyseal transfer using the ipsilateral proximal fibula was performed which provided good bony stability at the ankle, as well as excellent long-term growth characteristics. We demonstrate immediate postoperative results, as well as long-term (5 years) follow-up.
Asunto(s)
Trasplante Óseo , Peroné/cirugía , Trasplante Autólogo/métodos , Preescolar , Epífisis/trasplante , Peroné/diagnóstico por imagen , Peroné/lesiones , Estudios de Seguimiento , Humanos , Masculino , Radiografía , Colgajos QuirúrgicosRESUMEN
In a total of 511 patients with T3,N0-3,M0 laryngeal carcinoma, 24 possible prognostic factors were analyzed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnea, and dysphagia, previous tracheotomy, tumor extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumor and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension ware also evaluated. In a univariate analysis for the whole group, tumor extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy) were considered to be prognostic factors of corrected actuarial survival. In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumor, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.
Asunto(s)
Carcinoma de Células Escamosas/mortalidad , Neoplasias Laríngeas/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Femenino , Humanos , Neoplasias Laríngeas/patología , Neoplasias Laríngeas/terapia , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
A case of follicular carcinoma arising in the lingual thyroid of a 23-year-old woman is added to the 22 previous reports. The embryology and the clinical and pathologic differential diagnoses are discussed. Histologic criteria useful in diagnosing follicular malignancy in this area include local and vascular invasiveness, hypercellularity, mitotic activity, and necrosis. The use of the immunohistochemical marker thyroglobulin and electron microscopy are described for the first time and confirm a thyroid follicular cell origin.
Asunto(s)
Adenocarcinoma/patología , Coristoma/patología , Glándula Tiroides , Neoplasias de la Lengua/patología , Adenocarcinoma/ultraestructura , Adulto , Coristoma/ultraestructura , Femenino , Humanos , Técnicas para Inmunoenzimas , Tiroglobulina/análisis , Glándula Tiroides/anomalías , Neoplasias de la Lengua/ultraestructuraRESUMEN
A new method of nipple reconstruction called the "inchworm" flap is described. The name comes from the manipulation method used to position the flap for nipple projection. Experience with over 50 patients and including 58 breasts has been reviewed. There was adequate followup for 36 breasts in which overall maintenance of projection was 78% for this technique. When used after submuscular expansion for breast reconstruction, maintenance of projection reached 89%. The technique of flap manipulation is described in detail. This flap appears to be a reliable method for obtaining moderate nipple projection, particularly in the submuscular expansion breast reconstruction cases. It is not recommended for use in TRAM flap cases.
Asunto(s)
Mamoplastia/métodos , Pezones/cirugía , Colgajos Quirúrgicos/métodos , Femenino , HumanosRESUMEN
To assess the usefulness of ultrasound and ultrasound-guided fine-needle aspiration cytology in detecting occult cervical lymph node metastases, 107 patients with squamous cell carcinoma of the head and neck, who underwent 132 elective neck dissections, had preoperative ultrasound examination. During the assessment of the last 54 patients, who underwent 70 elective neck dissections, ultrasound-guided aspiration cytology was available. Although ultrasound was able to detect lymph node metastases in the majority of patients, the accuracy of this technique never exceeded 70% (93 of 132 procedures). With ultrasound-guided aspiration cytology, accuracy was 89% (62 of 70 procedures). This latter technique seems to be the modality of choice for the assessment of the clinically negative neck. Its use obviates the need for elective neck dissection, done because of the high risk of occult metastasis.
Asunto(s)
Carcinoma de Células Escamosas/patología , Neoplasias de Cabeza y Cuello/patología , Ganglios Linfáticos/patología , Ultrasonografía , Biopsia con Aguja/métodos , Carcinoma de Células Escamosas/secundario , Humanos , Metástasis Linfática , Cuello , Disección del Cuello , Estadificación de Neoplasias , Sensibilidad y EspecificidadRESUMEN
In a series of 100 patients with head and neck carcinoma, the preoperative histopathologic findings of palpation and magnetic resonance imaging were compared with regard to both laterality and lymph node level (I through V). The overall error for palpation in detecting affected sides was 32%. Gadolinium-enhanced magnetic resonance images reliably upgraded 60% of the clinically negative necks, the overall error of magnetic resonance imaging being 16%. However, for both modalities, the sensitivity per level was too low to allow for selective neck dissections in case of only one positive level. These findings show that apart from primary tumor grading, magnetic resonance imaging can improve the preoperative grading of cervical lymph nodes. In selected cases, this may change the treatment plan to a "wait-and-see" policy or a more conservative type of neck dissection.
Asunto(s)
Carcinoma de Células Escamosas/secundario , Neoplasias de Cabeza y Cuello/patología , Metástasis Linfática/diagnóstico , Imagen por Resonancia Magnética , Palpación , Anciano , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patología , Medios de Contraste , Gadolinio , Humanos , Escisión del Ganglio Linfático , Ganglios Linfáticos/patología , Metástasis Linfática/patología , Masculino , Persona de Mediana Edad , Cuello , Sensibilidad y EspecificidadRESUMEN
Thirty-five patients scheduled to undergo a neck dissection for squamous cell carcinoma of the head and neck were evaluated preoperatively by magnetic resonance (MR) imaging. Axial and occasionally sagittal and coronal images were obtained. To define the most reliable technique to detect cervical lymph node metastasis, we compared several MR pulse sequences with and without Gd-DTPA administration to histopathologic findings in the neck dissection specimens. T1-weighted spin echo combined with T2-weighted gradient recalled echo (GE) sequences were found to be more useful than any other combination of pulse sequences in localizing lymph nodes. On T2-weighted GE images, lymph nodes were depicted with intermediate to high signal intensity in contrast to low signal muscular and fatty tissue. Gadolinium DTPA enhanced T1-weighted GE images reliably depict central lymph node necrosis, the most specific criterion for lymph node metastasis.
Asunto(s)
Carcinoma de Células Escamosas/diagnóstico , Neoplasias de Cabeza y Cuello/diagnóstico , Ganglios Linfáticos/patología , Imagen por Resonancia Magnética/métodos , Adulto , Anciano , Medios de Contraste , Femenino , Gadolinio , Gadolinio DTPA , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Cuello , Disección del Cuello , Compuestos Organometálicos , Ácido PentéticoRESUMEN
A retrospective study of a selected group of 58 patients with T3 and T4 squamous cell carcinomas of the larynx presenting between 1974 and 1984 was undertaken. These patients were treated primarily with radical radiotherapy and salvage surgery in reserve. The aim of this study was to examine survival, recurrence rate and the complications after salvage surgery. In 30 patients the tumor was classified as a T3 and in 28 as a T4. In 14 patients (24%) nodal disease in the neck was present prior to the radiotherapy. Follow-up in all patients continued for at least 3 years or until death. Nineteen patients (33%) developed locally recurrent tumor and five (9%) developed nodal metastases to the neck. The recurrence in almost every patient was detected within 2 years after completion of the irradiation. Thirty patients (52%) are alive of whom 29 have no evidence of disease. Of these 30 patients 22 (73%) have their larynx intact and functioning. The 5-year adjusted acturial survival for the whole group of patients is 73%, for the T3N0 group 87% and for the T4N0 group 75%. Patients with nodal disease responded poorly. After salvage surgery severe postoperative complications developed in 37% of the patients. There were no deaths following salvage surgery.
Asunto(s)
Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Neoplasias Laríngeas/radioterapia , Neoplasias Laríngeas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Laríngeas/complicaciones , Neoplasias Laríngeas/mortalidad , Neoplasias Laríngeas/patología , Laringectomía , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Complicaciones Posoperatorias/epidemiología , Dosificación Radioterapéutica , Estudios RetrospectivosRESUMEN
A comparative study of irrigating solutions that contained various clot-active substances and/or vasodilating substances was done using a crush injury model of the rat's femoral artery. A routine microanastomosis was done with one of seven irrigation solutions employed in the study. The patency rate of lactated Ringer's solution (10%) (the control solution) was compared with solutions of heparin (35%) urokinase (50%), phentolamine (35%) tissue plasminogen activator (tPA) (15%), a combination of urokinase, heparin, and phentolamine (55%), and a combination of tPA, heparin, and phentolamine (42.5%). Statistically significant improvement in patency rates were obtained with heparin (p less than 0.0005), phentolamine (p less than 0.03), urokinase (p less than 0.001), the tPA, heparin and phentolamine combination (p less than 0.001), and the urokinase, heparin, and phentolamine combination (p less than 0.0001). There seems to be a benefit with the addition of either vasoactive agents or clot-active agents to the microvascular irrigating solution during construction of a compromised microanastomosis.
Asunto(s)
Anastomosis Quirúrgica , Microcirugia , Irrigación Terapéutica , Procedimientos Quirúrgicos Vasculares , Animales , Arteria Femoral/cirugía , Heparina/farmacología , Masculino , Fentolamina/farmacología , Ratas , Ratas Endogámicas , Activador de Tejido Plasminógeno/farmacología , Activador de Plasminógeno de Tipo Uroquinasa/farmacología , Grado de Desobstrucción Vascular/efectos de los fármacosRESUMEN
A critical comparison of the contracture rate in subglandular versus subpectoral augmentations was done in a personal series (senior author's) of 100 consecutive augmentation patients, 50 with subglandular augmentation and 50 with subpectoral augmentation. The average followup for the series was 27 months. Baker's classification of capsule contracture was utilized. Overall contracture rate in the subglandular group was 58% (29 of 50 patients) while in the subpectoral group it was 22% (11 of 50 patients), p less than 0.0002. Considering only the more severe contractures (Baker III & IV), the subglandular patients had 48% (24/50) while the subpectoral patients had 14% (7/50), p less than 0.0002. Comparing the more severe contractures in individual breasts, the subglandular group had 41% and the subpectoral group had 8%, p less than 0.0001. We conclude that in this personal series of patients, subpectoral placement of the prosthesis has significantly reduced but not eliminated the occurrence of capsule contracture without sacrificing a normal breast appearance.