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Oncologic effects of preoperative biliary drainage in resectable hilar cholangiocarcinoma: Percutaneous biliary drainage has no adverse effects on survival.
Zhang XF, Beal EW, Merath K, Ethun CG, Salem A, Weber SM, Tran T, Poultsides G, Son AY, Hatzaras I, Jin L, Fields RC, Weiss M, Scoggins C, Martin RCG, Isom CA, Idrees K, Mogal HD, Shen P, Maithel SK, Schmidt CR, Pawlik TM
(2018) J Surg Oncol 117: 1267-1277
MeSH Terms: Aged, Bile Duct Neoplasms, Drainage, Endoscopy, Female, Follow-Up Studies, Humans, Klatskin Tumor, Male, Middle Aged, Preoperative Care, Prognosis, Survival Rate
Show Abstract · Added April 10, 2018
BACKGROUND AND OBJECTIVES - The objective of the current study was to define long-term survival of patients with resectable hilar cholangiocarcinoma (HCCA) after preoperative percutaneous transhepatic biliary drainage (PTBD) versus endoscopic biliary drainage (EBD).
METHODS - Between 2000 and 2014, 240 patients who underwent curative-intent resection for HCCA were identified at 10 major hepatobiliary centers. Postoperative morbidity and mortality, as well as disease-specific survival (DSS) and recurrence-free survival (RFS) were analyzed among patients.
RESULTS - The median decrease in total bilirubin levels after biliary drainage was similar comparing PTBD (n = 104) versus EBD (n = 92) (mg/dL, 4.9 vs 4.9, P = 0.589) before surgery. There was no difference in baseline demographic characteristics, type of surgical procedure performed, final AJCC tumor stage or postoperative morbidity among patients who underwent EBD only versus PTBD (all P > 0.05). Patients who underwent PTBD versus EBD had a comparable long-term DSS (median, 43.7 vs 36.9 months, P = 0.802) and RFS (median, 26.7 vs 24.0 months, P = 0.571). The overall pattern of recurrence relative to regional or distant disease was also the same among patients undergoing PTBD and EBD (P = 0.669) CONCLUSIONS: Oncologic outcomes including DSS and RFS were similar among patients who underwent PTBD versus EBD with no difference in tumor recurrence location.
© 2017 Wiley Periodicals, Inc.
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13 MeSH Terms
Gallbladder Cancer Presenting with Jaundice: Uniformly Fatal or Still Potentially Curable?
Tran TB, Norton JA, Ethun CG, Pawlik TM, Buettner S, Schmidt C, Beal EW, Hawkins WG, Fields RC, Krasnick BA, Weber SM, Salem A, Martin RCG, Scoggins CR, Shen P, Mogal HD, Idrees K, Isom CA, Hatzaras I, Shenoy R, Maithel SK, Poultsides GA
(2017) J Gastrointest Surg 21: 1245-1253
MeSH Terms: Aged, Bilirubin, Blood Vessels, CA-19-9 Antigen, Drainage, Female, Gallbladder Neoplasms, Humans, Jaundice, Obstructive, Lymphatic Vessels, Male, Middle Aged, Neoplasm Invasiveness, Postoperative Complications, Reoperation, Survival Rate, United States
Show Abstract · Added April 10, 2018
BACKGROUND - Jaundice as a presenting symptom of gallbladder cancer has traditionally been considered to be a sign of advanced disease, inoperability, and poor outcome. However, recent studies have demonstrated that a small subset of these patients can undergo resection with curative intent.
METHODS - Patients with gallbladder cancer managed surgically from 2000 to 2014 in 10 US academic institutions were stratified based on the presence of jaundice at presentation (defined as bilirubin ≥4 mg/ml or requiring preoperative biliary drainage). Perioperative morbidity, mortality, and overall survival were compared between jaundiced and non-jaundiced patients.
RESULTS - Of 400 gallbladder cancer patients with available preoperative data, 108 (27%) presented with jaundice while 292 (73%) did not. The fraction of patients who eventually underwent curative-intent resection was much lower in the presence of jaundice (n = 33, 30%) than not (n = 218, 75%; P < 0.001). Jaundiced patients experienced higher perioperative morbidity (69 vs. 38%; P = 0.002), including a much higher need for reoperation (12 vs. 1%; P = 0.003). However, 90-day mortality (6.5 vs. 3.6%; P = 0.35) was not significantly higher. Overall survival after resection was worse in jaundiced patients (median 14 vs. 32 months; P < 0.001). Further subgroup analysis within the jaundiced patients revealed a more favorable survival after resection in the presence of low CA19-9 < 50 (median 40 vs. 12 months; P = 0.003) and in the absence of lymphovascular invasion (40 vs. 14 months; P = 0.014).
CONCLUSION - Jaundice is a powerful preoperative clinical sign of inoperability and poor outcome among gallbladder cancer patients. However, some of these patients may still achieve long-term survival after resection, especially when preoperative CA19-9 levels are low and no lymphovascular invasion is noted pathologically.
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Outcomes of endoscopic repair of cerebrospinal fluid rhinorrhea without lumbar drains.
Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH
(2016) Am J Rhinol Allergy 30: 424-429
MeSH Terms: Adult, Catheters, Cerebrospinal Fluid Rhinorrhea, Drainage, Endoscopy, Female, Follow-Up Studies, Humans, Length of Stay, Male, Middle Aged, Recurrence, Retrospective Studies, Spinal Cord, Treatment Outcome
Show Abstract · Added July 23, 2020
OBJECTIVE - Lumbar drains (LD) are commonly used during endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea, either to facilitate graft healing or to monitor CSF fluid dynamics. However, the indications and necessity of LD placement remains controversial. The current study sought to evaluate endoscopic CSF leak repair outcomes in the setting of limited LD use.
METHODS - Patients who underwent endoscopic repair of CSF rhinorrhea between 2004 and 2014 were identified by a review of medical records. Demographic and clinical data were extracted and compared between patients who had surgery with and patients who had surgery without a perioperative LD. A univariate analysis was performed to identify factors predictive of recurrence.
RESULTS - A total of 107 patients (116 surgical procedures) were identified, with a mean follow-up of 15.8 months. Eighty-eight of 107 patients (82.2%) had surgery without an LD. The mean hospital stay was 4.48 days in the LD group versus 1.03 days in the non-LD group (p < 0.00001). There was no difference in recurrence rate between the LD and non-LD groups. Predictors of recurrence included repair technique (p = 0.04) and size of defect (p = 0.005). Body mass index, leak site (ethmoid, sphenoid, frontal), and etiology (spontaneous, iatrogenic, traumatic) were not predictive of leak recurrence.
CONCLUSION - Use of LDs in endoscopic CSF leak repair was not associated with reduced recurrence rates, regardless of leak etiology, and resulted in a significant increase in hospital length of stay. Although the use of perioperative LDs to monitor CSF dynamics may have some therapeutic and diagnostic advantages, it may not be associated with clinically significant improvements in patient outcomes or recurrence rates.
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Surgical necrotizing enterocolitis.
Robinson JR, Rellinger EJ, Hatch LD, Weitkamp JH, Speck KE, Danko M, Blakely ML
(2017) Semin Perinatol 41: 70-79
MeSH Terms: Biomarkers, Drainage, Enterocolitis, Necrotizing, Enterostomy, Fatty Acid-Binding Proteins, Feces, Humans, Infant, Extremely Premature, Infant, Newborn, Infant, Premature, Diseases, Infant, Very Low Birth Weight, Laparotomy, Leukocyte L1 Antigen Complex, Patient Selection, Predictive Value of Tests, S100A12 Protein, Treatment Outcome
Show Abstract · Added January 16, 2017
Although currently available data are variable, it appears that the incidence of surgical necrotizing enterocolitis (NEC) has not decreased significantly over the past decade. Pneumoperitoneum and clinical deterioration despite maximal medical therapy remain the most common indications for operative treatment. Robust studies linking outcomes with specific indications for operation are lacking. Promising biomarkers for severe NEC include fecal calprotectin and S100A12; serum fatty acid-binding protein; and urine biomarkers. Recent advances in ultrasonography make this imaging modality more useful in identifying surgical NEC and near-infrared spectroscopy (NIRS) is being actively studied. Another fairly recent finding is that regionalization of care for infants with NEC likely improves outcomes. The neurodevelopmental outcomes after surgical treatment are known to be poor. A randomized trial near completion will provide robust data regarding neurodevelopmental outcomes after laparotomy versus drainage as the initial operative treatment for severe NEC.
Copyright © 2016 Elsevier Inc. All rights reserved.
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Indications and outcomes for Draf IIB frontal sinus surgery.
Turner JH, Vaezeafshar R, Hwang PH
(2016) Am J Rhinol Allergy 30: 70-3
MeSH Terms: Chronic Disease, Drainage, Endoscopy, Female, Follow-Up Studies, Frontal Sinus, Humans, Male, Middle Aged, Retrospective Studies, Sinusitis, Treatment Outcome
Show Abstract · Added July 23, 2020
BACKGROUND - Extended frontal surgery techniques are often required when maximal medical therapy and standard endoscopic surgical approaches fail in patients. Although outcomes of the Draf III (modified Lothrop) procedure have been widely reported, postoperative outcomes and indications for the Draf IIB frontal sinusotomy have been relatively underreported. We presented our institution's experience with the Draf IIB procedure.
METHODS - Patients who underwent the Draf IIB frontal sinusotomy between 2007 and 2012 were identified by retrospective chart review. Data collected included demographics, imaging, sinus patency, and Sino-nasal Outcome Test 20 scores.
RESULTS - A total of 22 Draf IIB frontal sinusotomies were performed in 18 patients. Thirteen of eighteen patients had previous frontal sinus surgery. The most common indications for the extended approach were chronic frontal sinusitis due to lateralized middle turbinate remnant (8 patients), mucocele (6), postoperative synechiae (5), and frontal sinus mass (3). Sinus ostium patency was maintained in 20 of 22 sinuses over an average follow-up period of 16.2 months. No complications were reported.
CONCLUSIONS - The Draf IIB frontal sinusotomy is a relatively safe procedure, with multiple indications. Long-term sinus ostium patency was maintained in >90% of operated sinuses, which indicated that the Draf IIB procedure may present an acceptable alternative to more aggressive extended frontal sinus approaches in selected patients.
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Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.
Yang D, Amin S, Gonzalez S, Mullady D, Hasak S, Gaddam S, Edmundowicz SA, Gromski MA, DeWitt JM, El Zein M, Khashab MA, Wang AY, Gaspar JP, Uppal DS, Nagula S, Kapadia S, Buscaglia JM, Bucobo JC, Schlachterman A, Wagh MS, Draganov PV, Jung MK, Stevens T, Vargo JJ, Khara HS, Huseini M, Diehl DL, Keswani RN, Law R, Komanduri S, Yachimski PS, DaVee T, Prabhu A, Lapp RT, Kwon RS, Watson RR, Goodman AJ, Chhabra N, Wang WJ, Benias P, Carr-Locke DL, DiMaio CJ
(2016) Gastrointest Endosc 83: 720-9
MeSH Terms: Adult, Aged, Ampulla of Vater, Cholangiopancreatography, Endoscopic Retrograde, Drainage, Endosonography, Female, Follow-Up Studies, Humans, Male, Middle Aged, Pancreatic Pseudocyst, Retrospective Studies, Stents, Time Factors, Treatment Outcome, Ultrasonography, Interventional
Show Abstract · Added May 11, 2016
BACKGROUND AND AIMS - The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution.
METHODS - This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression.
RESULTS - A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03).
CONCLUSIONS - TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.
Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
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The Use of Indwelling Tunneled Pleural Catheters for Recurrent Pleural Effusions in Patients With Hematologic Malignancies: A Multicenter Study.
Gilbert CR, Lee HJ, Skalski JH, Maldonado F, Wahidi M, Choi PJ, Bessich J, Sterman D, Argento AC, Shojaee S, Gorden JA, Wilshire CL, Feller-Kopman D, Ortiz R, Nonyane BAS, Yarmus L
(2015) Chest 148: 752-758
MeSH Terms: Adult, Aged, Aged, 80 and over, Catheters, Indwelling, Drainage, Female, Hematologic Neoplasms, Humans, Male, Middle Aged, Palliative Care, Pleural Effusion, Malignant, Retrospective Studies, Treatment Outcome
Show Abstract · Added July 28, 2015
BACKGROUND - Malignant pleural effusion is a common complication of advanced malignancies. Indwelling tunneled pleural catheter (IPC) placement provides effective palliation but can be associated with complications, including infection. In particular, hematologic malignancy and the associated immunosuppressive treatment regimens may increase infectious complications. This study aimed to review outcomes in patients with hematologic malignancy undergoing IPC placement.
METHODS - A retrospective multicenter study of IPCs placed in patients with hematologic malignancy from January 2009 to December 2013 was performed. Inclusion criteria were recurrent, symptomatic pleural effusion and an underlying diagnosis of hematologic malignancy. Records were reviewed for patient demographics, operative reports, and pathology, cytology, and microbiology reports.
RESULTS - Ninety-one patients (mean ± SD age, 65.4 ± 15.4 years) were identified from eight institutions. The mean × SD in situ dwell time of all catheters was 89.9 ± 127.1 days (total, 8,160 catheter-days). Seven infectious complications were identified, all of the pleural space. All patients were admitted to the hospital for treatment, with four requiring additional pleural procedures. Two patients died of septic shock related to pleural infection.
CONCLUSIONS - We present, to our knowledge, the largest study examining clinical outcomes related to IPC placement in patients with hematologic malignancy. An overall 7.7% infection risk and 2.2% mortality were identified, similar to previously reported studies, despite the significant immunosuppression and pancytopenia often present in this population. IPC placement appears to remain a reasonable clinical option for patients with recurrent pleural effusions related to hematologic malignancy.
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Impact of pleural manometry on the development of chest discomfort during thoracentesis: a symptom-based study.
Pannu J, DePew ZS, Mullon JJ, Daniels CE, Hagen CE, Maldonado F
(2014) J Bronchology Interv Pulmonol 21: 306-13
MeSH Terms: Aged, Aged, 80 and over, Chest Pain, Cohort Studies, Drainage, Dyspnea, Female, Humans, Linear Models, Male, Manometry, Middle Aged, Paracentesis, Pleural Effusion, Pneumothorax, Pressure, Pulmonary Edema, Retrospective Studies, Thoracic Surgical Procedures, Ultrasonography
Show Abstract · Added July 28, 2015
BACKGROUND - Routine manometry is recommended to prevent complications during therapeutic thoracentesis, but has not definitively been shown to prevent pneumothorax or reexpansion pulmonary edema. As chest discomfort correlates with negative pleural pressures, we aimed to determine whether the use of manometry could anticipate the development of chest discomfort during therapeutic thoracentesis.
METHODS - A retrospective chart review of 214 consecutive adults who underwent outpatient therapeutic thoracentesis at our institution between January 1, 2011 and June 30, 2013 was performed. We compared preprocedural to postprocedural discomfort (using a linear analog scale from 0 to 10) in patients undergoing thoracentesis with or without manometry. We used a multivariate model to adjust for possible confounders. Changes of dyspnea scores were also analyzed.
RESULTS - Manometry was performed in 82/214 patients (38%). On univariate and multivariate analyses, neither the change in chest discomfort nor dyspnea scores was significantly different in the manometry versus the control group (P=0.12 and 0.24, respectively). Similar results were also found in the subgroup of large-volume thoracentesis (P=0.32 for discomfort, P=1.0 for dyspnea).
CONCLUSIONS - In our retrospective study, the use of manometry did not appear to anticipate the development of chest discomfort during therapeutic thoracentesis. Prospective studies are needed to confirm these findings.
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20 MeSH Terms
Pediatric posterior reversible encephalopathy syndrome presenting with isolated cerebellar edema and obstructive hydrocephalus.
Ettinger N, Pearson M, Lamb FS, Wellons JC
(2014) J Neurosurg Pediatr 14: 344-7
MeSH Terms: Adolescent, Antihypertensive Agents, Brain Edema, Cerebellum, Drainage, Fourth Ventricle, Humans, Hydrocephalus, Hypertension, Hypertrophy, Left Ventricular, Magnetic Resonance Imaging, Male, Posterior Leukoencephalopathy Syndrome, Tomography, X-Ray Computed
Show Abstract · Added February 22, 2016
In this report, the authors describe the case of a teenage boy who presented with hypertensive emergency, posterior reversible encephalopathy syndrome, and hydrocephalus due to fourth ventricle outlet obstruction. Posterior reversible encephalopathy syndrome is a well-characterized but uncommon syndrome in children that is generally triggered by severe hypertension. The unusual clinical picture of this patient, who had isolated cerebellar edema leading to obstructive hydrocephalus, has been rarely described in children.
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The role of interventional therapy for pleural diseases.
DePew ZS, Maldonado F
(2014) Expert Rev Respir Med 8: 465-77
MeSH Terms: Drainage, Humans, Pleural Diseases, Thoracoscopy
Show Abstract · Added July 28, 2015
Pleural diseases encompass a vast and heterogeneous group of diseases that have traditionally received relatively little attention from researchers, resulting in empiric approaches to patient management based largely on expert opinions and anecdotal evidence. Yet, paradoxically, pleural diseases represent a considerable burden for patients, providers, and the healthcare system as a whole, with a rising incidence of malignant pleural effusions and pleural space infections, in increasingly complex patients. Fortunately, the last decade has witnessed unprecedented research efforts from the pleural community, which have resulted in substantial advances in risk-stratification, patient selection, treatment efficacy and the development of evidence-based recommendations ultimately leading to improved patient care. In this review, we will present a summary of the current evidence for the management of pleural diseases with an emphasis on interventional procedures, and highlight the need for future research efforts in the field of malignant pleural effusions, pleural space infections and pneumothorax.
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4 MeSH Terms