RESUMEN
BACKGROUND: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This review compares the experiences of patients with esophageal cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy conference (TMC). METHODS: The records of patients with carcinoma of the esophagus at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy, and adherence to national treatment guidelines. Summary data were compared for patients treated before and after the TMC was initiated. RESULTS: Between 2001 and 2007, 117 patients were treated before the initiation of the TMC and 138 patients within the TMC. The number of patients receiving, respectively, a complete staging evaluation (67% and 97%, p < 0.0001), multidisciplinary evaluation before therapy (72% and 98%, p < 0.0001), and adherence to National Comprehensive Cancer Network treatment guidelines (83% and 98%, p < 0.0001) all increased significantly, whereas mean days from diagnosis to treatment significantly decreased (27 and 16, respectively; p < 0.0001). CONCLUSIONS: A multidisciplinary TMC increased the percentage of patients receiving complete staging, a multidisciplinary evaluation, and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with esophageal cancer benefit from being evaluated in a prospective, multidisciplinary manner.
Asunto(s)
Carcinoma/terapia , Conferencias de Consenso como Asunto , Neoplasias Esofágicas/terapia , Guías de Práctica Clínica como Asunto , Adulto , Anciano , Carcinoma/diagnóstico , Terapia Combinada , Neoplasias Esofágicas/diagnóstico , Femenino , Estudios de Seguimiento , Adhesión a Directriz , Humanos , Indiana , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Neoplasias Torácicas/diagnóstico , Neoplasias Torácicas/terapiaRESUMEN
BACKGROUND: Thymectomy is recognized as a significant component in the treatment of myasthenia gravis. However, controversy exists as to the optimal surgical approach. This investigation summarizes our experience performing extended thymectomy using a robotic technique in a large group of patients with significant follow-up. METHODS: Data collection for patients undergoing robotic thymectomy for nonthymomatous myasthenia gravis over a 6-year period was prospectively performed. Patients were assessed using the Myasthenia Gravis Foundation of America's quantitative disease severity score and the post intervention status classification. RESULTS: During the study period, 75 patients underwent thymectomy by this method. Mean preoperative myasthenia gravis severity score was 2.7. Mean operative time was 113±46 minutes. Extubation in the operating room occurred in 73 (98%) patients. Mean intensive care stay and total hospital length of stay were 0.9 and 2.2 days respectively. Mean interval between surgery and return to work (or prethymectomy activities of daily living) was 15±6 days. Significant improvement of myasthenia gravis symptoms occurred in 65 (87%) patients with a mean follow-up of 45±14 months. CONCLUSIONS: Robotic-assisted thymectomy is a safe and effective technique for patients with symptomatic myasthenia gravis. It allowed an extended thymectomy to be performed without the associated length of stay or recovery period of a transsternal approach while producing comparable rates of symptom improvement.
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Miastenia Gravis/cirugía , Robótica/métodos , Timectomía/métodos , Adolescente , Adulto , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Miastenia Gravis/diagnóstico , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC). METHODS: The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines. The summary data of patients treated before and after the TMC were initiated, and then compared. RESULTS: Between 2001 and 2007, 535 patients were treated prior to the initiation of the TMC and 687 patients within the TMC. The number of patients receiving a complete staging evaluation (79%/93%: p<0.0001), multidisciplinary evaluation prior to therapy (62%/96%: p<0.0001) and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines (81%/97%: p<0.0001) all increased significantly while mean days from diagnosis to treatment significantly decreased (29/17: p<0.0001) following the initiation of a TMC. CONCLUSION: A multidisciplinary thoracic malignancy conference increased the percentage of patients receiving complete staging, a multidisciplinary evaluation and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with non-small-cell lung cancer benefit from being evaluated in a prospective, multidisciplinary care conference.
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Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Carcinoma de Pulmón de Células no Pequeñas/patología , Terapia Combinada , Conferencias de Consenso como Asunto , Adhesión a Directriz , Humanos , Neoplasias Pulmonares/patología , Estadificación de Neoplasias , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: Sympathectomy for severe palmar hyperhidrosis occasionally fails. This investigation reviews our experience with reoperative thoracoscopic sympathectomy (RS) for patients with persistent or recurrent palmar hyperhidrosis after sympathectomy. METHODS: A retrospective analysis of patients undergoing RS for palmar hyperhidrosis was conducted. Comparison was made with all patients undergoing an initial thoracoscopic sympathectomy (TS) for palmar hyperhidrosis at our institution during the same period. RESULTS: Over 6 years, 40 patients underwent bilateral (32) or unilateral (8) RS for refractory (35) or recurrent (5) palmar hyperhidrosis. During the same period, 321 patients underwent bilateral TS for palmar hyperhidrosis. Previous methods of sympathectomy included percutaneous ablation (25), TS (10), axillary thoracotomy (3), and a posterior transthoracic approach (2). Twenty-two RS patients and 11 TS patients required a third port to complete the procedure because of pleural adhesions (p = 0.0001). Twenty-three RS and 11 TS patients required postoperative pleural drainage (p = 0.0004). Mean length of stay was1.6 for the RS group and less than 1 day for the TS group (p = 0.0001). Alleviation of palmar hyperhidrosis occurred in 38 RS patients and 316 TS patients (p = 0.18). Compensatory sweating was identified in 21 RS patients and 101 TS patients (p = 0.01). CONCLUSIONS: Reoperative thoracoscopic sympathectomy produced a rate of improvement comparable to that of TS. However, RS was associated with an increased need for postoperative pleural drainage, longer hospital stay, a more difficult operative procedure, and a higher rate of compensatory sweating than TS was. Reoperative sympathectomy should be considered a safe and effective option for patients with palmar hyperhidrosis who remain severely symptomatic after a sympathectomy.
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Hiperhidrosis/cirugía , Simpatectomía/métodos , Adulto , Endoscopía , Femenino , Mano , Humanos , Tiempo de Internación , Masculino , Complicaciones Posoperatorias/epidemiología , Recurrencia , Reoperación , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Traditional therapy for spontaneous esophageal perforation has most often been urgent operative repair. This investigation summarizes the treatment of spontaneous perforations of the esophagus using an occlusive removable esophageal stent. METHODS: During a 48-month period, patients with a spontaneous esophageal perforation were offered endoluminal esophageal stent placement as the initial therapy instead of operation. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically using general anesthesia and fluoroscopy. Adequate drainage of infected areas was achieved. Leak occlusion was confirmed by esophagram. RESULTS: Twenty-one esophageal stents were placed in 19 patients for spontaneous esophageal perforations. Associated endoscopic (n = 19) or surgical procedures (n = 9) were also simultaneously performed. Leak occlusion occurred in 17 patients (89%). Fifteen patients (79%) were able to initiate oral nutrition within 72 hours of stent placement. Two patients (10%) with a perforation extending across the gastroesophageal junction experienced a continued leak after stent placement and underwent operative repair. Stent migration in 4 patients (21%) required repositioning (n = 4) or replacement (n = 2). Stents were removed at a mean of 20 +/- 15 days after placement. Hospital length of stay was 9 +/- 12 days. CONCLUSIONS: Endoluminal esophageal stent placement is an effective treatment of most spontaneous esophageal perforations. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidities of operative repair.
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Perforación del Esófago/diagnóstico por imagen , Perforación del Esófago/cirugía , Esofagoscopía/métodos , Stents , Adulto , Anciano , Medios de Contraste , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Manometría , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Dimensión del Dolor , Dolor Postoperatorio/fisiopatología , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Iatrogenic esophageal perforation after endoscopy or surgery can be a devastating event. Traditional therapy has most often consisted of operative repair of the esophagus. This investigation summarizes our experiences treating iatrogenic intrathoracic perforations of the esophagus using an occlusive removable esophageal stent. METHODS: Over a 24-month period, patients found to have an iatrogenic intrathoracic esophageal perforation at a tertiary care medical center were offered endoluminal esophageal stent placement instead of operative repair of the esophagus as initial therapy. Excluded were patients with an esophageal malignancy or a chronic esophageal fistula. Silicone-coated stents were placed endoscopically utilizing general anesthesia and fluoroscopy. Adequate drainage of infected areas was also simultaneously achieved. Leak occlusion was confirmed by esophagram. Patients were followed until their stent was removed and their esophageal leak had resolved. RESULTS: Seventeen patients had 18 esophageal stents placed for acute perforations of the esophagus after endoscopy (8) or surgery (9) during the study period. Associated endoscopic (13) or surgical procedures (7) were performed simultaneously in all 17 patients. Leak occlusion occurred in 16 patients (94%) as confirmed by esophagram. Fourteen patients (82%) were able to initiate oral nutrition within 72 hours of stent placement. One patient (6%) experienced a continued leak after stent placement and underwent operative repair. Stent migration requiring repositioning (2) or replacement (2) occurred in 3 patients (18%). All stents were removed at a mean of 52 +/- 20 days after placement. Hospital length of stay for patients treated with esophageal stent placement was 8 +/- 9 days (median, 5). CONCLUSIONS: Endoluminal esophageal stent placement is an effective method for the treatment of acute, iatrogenic perforations of the intrathoracic esophagus. These stents result in rapid leak occlusion, provide the opportunity for early oral nutrition, may significantly reduce hospital length of stay, are removable, and avoid the potential morbidity of operative repair.