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The Impact of Intraoperative Re-Resection of a Positive Bile Duct Margin on Clinical Outcomes for Hilar Cholangiocarcinoma.
Zhang XF, Squires MH, Bagante F, 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) Ann Surg Oncol 25: 1140-1149
MeSH Terms: Aged, Bile Duct Neoplasms, Bile Ducts, Female, Frozen Sections, Humans, Intraoperative Period, Klatskin Tumor, Length of Stay, Male, Margins of Excision, Middle Aged, Neoplasm Recurrence, Local, Neoplasm, Residual, Survival Rate
Show Abstract · Added April 10, 2018
BACKGROUND - The impact of re-resection of a positive intraoperative bile duct margin on clinical outcomes for resectable hilar cholangiocarcinoma (HCCA) remains controversial. We sought to define the impact of re-resection of an initially positive frozen-section bile duct margin on outcomes of patients undergoing surgery for HCCA.
METHODS - Patients who underwent curative-intent resection for HCCA between 2000 and 2014 were identified at 10 hepatobiliary centers. Short- and long-term outcomes were analyzed among patients stratified by margin status.
RESULTS - Among 215 (83.7%) patients who underwent frozen-section evaluation of the bile duct, 80 (37.2%) patients had a positive (R1) ductal margin, 58 (72.5%) underwent re-resection, and 29 ultimately had a secondary negative margin (secondary R0). There was no difference in morbidity, 30-day mortality, and length of stay among patients who had primary R0, secondary R0, and R1 resection (all p > 0.10). Median and 5-year survival were 22.3 months and 23.3%, respectively, among patients who had a primary R0 resection compared with 18.5 months and 7.9%, respectively, for patients with an R1 resection (p = 0.08). In contrast, among patients who had a secondary R0 margin with re-resection of the bile duct margin, median and 5-year survival were 30.6 months and 44.3%, respectively, which was comparable to patients with a primary R0 margin (p = 0.804). On multivariable analysis, R1 margin resection was associated with decreased survival (R1: hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.0-1.7; p = 0.027), but secondary R0 resection was associated with comparable long-term outcomes as primary R0 resection (HR 0.9, 95% CI 0.4-2.3; p = 0.829).
CONCLUSIONS - Additional resection of a positive frozen-section ductal margin to achieve R0 resection was associated with improved long-term outcomes following curative-intent resection of HCCA.
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15 MeSH Terms
Value of intraoperative neck margin analysis during Whipple for pancreatic adenocarcinoma: a multicenter analysis of 1399 patients.
Kooby DA, Lad NL, Squires MH, Maithel SK, Sarmiento JM, Staley CA, Adsay NV, El-Rayes BF, Weber SM, Winslow ER, Cho CS, Zavala KA, Bentrem DJ, Knab M, Ahmad SA, Abbott DE, Sutton JM, Kim HJ, Yeh JJ, Aufforth R, Scoggins CR, Martin RC, Parikh AA, Robinson J, Hashim YM, Fields RC, Hawkins WG, Merchant NB
(2014) Ann Surg 260: 494-501; discussion 501-3
MeSH Terms: Adenocarcinoma, Adult, Aged, Aged, 80 and over, Female, Frozen Sections, Humans, Intraoperative Period, Male, Middle Aged, Multivariate Analysis, Neoplasm Invasiveness, Pancreatic Neoplasms, Pancreaticoduodenectomy, Perineum, Retrospective Studies, Survival Analysis
Show Abstract · Added January 16, 2017
INTRODUCTION - During pancreaticoduodenectomy (PD) for ductal adenocarcinoma, a frozen section (FS) neck margin is typically assessed, and if positive, additional pancreas is removed to achieve an R0 margin. We analyzed the association of this practice with improved overall survival (OS).
METHODS - Patients who underwent PD for pancreatic ductal adenocarcinoma from January 2000 to August 2012 at 8 academic centers were classified by neck margin status as negative (R0) or microscopically positive (R1) on the basis of FS and permanent section (PS). Impact on OS of converting an FS-R1-neck margin to a PS-R0-neck margin by additional resection was assessed.
RESULTS - A total of 1399 patients had FS neck margins analyzed. Median OS was 19.7 months. On FS, 152 patients (10.9%) were R1, and an additional 51 patients (3.6%) had false-negative FS-R0 margins. PS-R0-neck was achieved in 1196 patients (85.5%), 131 patients (9.3%) remained PS-R1, and 72 patients (5.1%) were converted from FS-R1-to-PS-R0 by additional resection. Median OS for PS-R0-neck patients was 21.1 months versus 13.7 months for PS-R1-neck patients (P < 0.001) and 11.9 months for FS-R1-to-PS-R0 patients (P < 0.001). Both FS-R1-to-PS-R0 and PS-R1-neck patients had larger tumors (P = 0.001), more perineural invasion (P = 0.02), and more node positivity (P = 0.08) than PS-R0-neck patients. On multivariate analysis controlling for adverse pathologic factors, FS-R1-to-PS-R0 conversion remained associated with significantly worse OS compared with PS-R0-neck patients (hazard ratio: 1.55; P = 0.009).
CONCLUSIONS - For patients who undergo pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, additional resection to achieve a negative neck margin after positive frozen section is not associated with improved OS.
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17 MeSH Terms
A novel optical approach to intraoperative detection of parathyroid glands.
McWade MA, Paras C, White LM, Phay JE, Mahadevan-Jansen A, Broome JT
(2013) Surgery 154: 1371-7; discussion 1377
MeSH Terms: Humans, Intraoperative Period, Optical Devices, Optical Phenomena, Parathyroid Diseases, Parathyroid Glands, Parathyroidectomy, Spectrometry, Fluorescence, Spectroscopy, Near-Infrared, Thyroid Diseases, Thyroidectomy
Show Abstract · Added March 31, 2014
BACKGROUND - Inadvertent removal of parathyroid glands is a challenge in endocrine operations. There is a critical need for a diagnostic tool that provides sensitive, real-time parathyroid detection during procedures. We have developed an intraoperative technique using near-infrared (NIR) fluorescence for in vivo, real-time detection of the parathyroid regardless of its pathologic state.
METHODS - NIR fluorescence was measured intraoperatively from 45 patients undergoing parathyroidectomy and thyroidectomy. Spectra were measured from the parathyroid and surrounding neck tissues during the operation with the use of a portable, probe-based fluorescence system at 785-nm excitation. Accuracy was evaluated by comparison with histology or visual recognition by the surgeon.
RESULTS - NIR fluorescence detected the parathyroid in 100% of patients. Parathyroid fluorescence was stronger (1.2-18 times) than that of the thyroid with peak fluorescence at 822 nm. Surrounding tissues showed no auto-fluorescence. Disease state did not affect the ability to discriminate parathyroid glands but may account for signal variability.
CONCLUSION - NIR fluorescence spectroscopy can detect intraoperatively the parathyroid regardless of tissue pathology. The signal may be caused by calcium-sensing receptors present in the parathyroid. The signal strength and consistency indicates the simplicity and effectiveness of this method. Its implementation may limit operative time, decrease costs, and improve operative success rates.
Copyright © 2013 Mosby, Inc. All rights reserved.
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11 MeSH Terms
Cerebrovascular autoregulation in pediatric moyamoya disease.
Lee JK, Williams M, Jennings JM, Jamrogowicz JL, Larson AC, Jordan LC, Heitmiller ES, Hogue CW, Ahn ES
(2013) Paediatr Anaesth 23: 547-56
MeSH Terms: Adolescent, Arterial Pressure, Blood Pressure, Carbon Dioxide, Cerebral Angiography, Cerebrovascular Circulation, Child, Child, Preschool, Female, Functional Laterality, Hemoglobins, Homeostasis, Humans, Intraoperative Period, Magnetic Resonance Imaging, Moyamoya Disease, Oximetry, Pilot Projects, Postoperative Period, Spectroscopy, Near-Infrared
Show Abstract · Added March 24, 2020
BACKGROUND - Moyamoya syndrome carries a high risk of cerebral ischemia, and impaired cerebrovascular autoregulation may play a critical role. Autoregulation indices derived from near-infrared spectroscopy (NIRS) may clarify hemodynamic goals that conform to the limits of autoregulation.
OBJECTIVES - The aims of this pilot study were to determine whether the NIRS-derived indices could identify blood pressure ranges that optimize autoregulation and whether autoregulatory function differs between anatomic sides in patients with unilateral vasculopathy.
METHODS - Pediatric patients undergoing indirect surgical revascularization for moyamoya were enrolled sequentially. NIRS-derived autoregulation indices, the cerebral oximetry index (COx) and the hemoglobin volume index (HVx), were calculated intraoperatively and postoperatively to measure autoregulatory function. The 5-mmHg ranges of optimal mean arterial blood pressure (MAPOPT ) with best autoregulation and the lower limit of autoregulation (LLA) were identified.
RESULTS - Of seven enrolled patients (aged 2-16 years), six had intraoperative and postoperative autoregulation monitoring and one had only intraoperative monitoring. Intraoperative MAPOPT was identified in six (86%) of seven patients with median values of 60-80 mmHg. Intraoperative LLA was identified in three (43%) patients with median values of 55-65 mmHg. Postoperative MAPOPT was identified in six (100%) of six patients with median values of 70-90 mmHg. Patients with unilateral disease had higher intraoperative HVx (P = 0.012) on side vasculopathy.
CONCLUSIONS - NIRS-derived indices may identify hemodynamic goals that optimize autoregulation in pediatric moyamoya.
© 2013 Blackwell Publishing Ltd.
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MeSH Terms
Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations.
Andersen ND, Bhattacharya SD, Williams JB, Fosbol EL, Lockhart EL, Patel MB, Gaca JG, Welsby IJ, Hughes GC
(2012) Ann Thorac Surg 93: 1921-8; discussion 1928-9
MeSH Terms: Aged, Aorta, Thoracic, Blood Coagulation Tests, Blood Transfusion, Blood Vessel Prosthesis Implantation, Cardiopulmonary Bypass, Cohort Studies, Critical Pathways, Dose-Response Relationship, Drug, Factor VIIa, Female, Heart Arrest, Induced, Hemostasis, Surgical, Hospital Costs, Humans, Intraoperative Period, Male, Matched-Pair Analysis, Middle Aged, Postoperative Hemorrhage, Propensity Score, Recombinant Proteins
Show Abstract · Added June 14, 2016
BACKGROUND - Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure.
METHODS - Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 μg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison.
RESULTS - Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 μg/kg (interquartile range [IQR], 16-43 μg/kg) rFVIIa given 51 minutes (42-67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p=0.05; international normalized ratio, 0.8 versus 1.2; p<0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p=0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups.
CONCLUSIONS - Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach.
Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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22 MeSH Terms
Electronic synoptic operative reporting for pancreatic resection.
Brower ST, Katz M, Pisters P, Merchant N, Weber S, Posner M
(2011) J Am Coll Surg 212: 425-6; author reply 426
MeSH Terms: Forms and Records Control, Humans, Intraoperative Period, Medical Records Systems, Computerized, Pancreatectomy, Pancreatic Neoplasms
Added March 26, 2014
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6 MeSH Terms
Autofluorescence and diffuse reflectance spectroscopy and spectral imaging for breast surgical margin analysis.
Keller MD, Majumder SK, Kelley MC, Meszoely IM, Boulos FI, Olivares GM, Mahadevan-Jansen A
(2010) Lasers Surg Med 42: 15-23
MeSH Terms: Breast Neoplasms, Carcinoma, Ductal, Breast, Carcinoma, Intraductal, Noninfiltrating, Feasibility Studies, Female, Humans, Intraoperative Period, Lasers, Gas, Mastectomy, Segmental, Neoplasm, Residual, Predictive Value of Tests, Spectrometry, Fluorescence
Show Abstract · Added March 7, 2014
BACKGROUND AND OBJECTIVE - Most women with early stage breast cancer have the option of breast conserving therapy, which involves a partial mastectomy for removal of the primary tumor, usually followed by radiotherapy. The presence of tumor at or near the margin is strongly correlated with the risk of local tumor recurrence, so there is a need for a non-invasive, real-time tool to evaluate margin status. This study examined the use of autofluorescence and diffuse reflectance spectroscopy and spectral imaging to evaluate margin status intraoperatively.
MATERIALS AND METHODS - Spectral measurements were taken from the surface of the tissue mass immediately following removal during partial mastectomies and/or from tissues immediately after sectioning by surgical pathology. A total of 145 normal spectra were obtained from 28 patients, and 34 tumor spectra were obtained from 12 patients.
RESULTS - After correlation with histopathology, a multivariate statistical algorithm classified the spectra as normal (negative margins) or tumor (positive margins) with 85% sensitivity and 96% specificity. A separate algorithm achieved 100% classification between neo-adjuvant chemotherapy-treated tissues and non-treated tissues. Fluorescence and reflectance-based spectral images were able to demarcate a calcified lesion on the surface of a resected specimen as well.
CONCLUSION - Fluorescence and reflectance spectroscopy could be a valuable tool for examining the superficial margin status of excised breast tumor specimens, particularly in the form of spectral imaging to examine entire margins in a single acquisition.
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12 MeSH Terms
Robust surface registration using salient anatomical features for image-guided liver surgery: algorithm and validation.
Clements LW, Chapman WC, Dawant BM, Galloway RL, Miga MI
(2008) Med Phys 35: 2528-40
MeSH Terms: Algorithms, Clinical Medicine, Humans, Image Processing, Computer-Assisted, Intraoperative Period, Liver, Phantoms, Imaging, Surgery, Computer-Assisted
Show Abstract · Added May 27, 2014
A successful surface-based image-to-physical space registration in image-guided liver surgery (IGLS) is critical to provide reliable guidance information to surgeons and pertinent surface displacement data for use in deformation correction algorithms. The current protocol used to perform the image-to-physical space registration involves an initial pose estimation provided by a point based registration of anatomical landmarks identifiable in both the preoperative tomograms and the intraoperative presentation. The surface based registration is then performed via a traditional iterative closest point (ICP) algorithm between the preoperative liver surface, segmented from the tomographic image set, and an intraoperatively acquired point cloud of the liver surface provided by a laser range scanner. Using this more conventional method, the registration accuracy can be compromised by poor initial pose estimation as well as tissue deformation due to the laparotomy and liver mobilization performed prior to tumor resection. In order to increase the robustness of the current surface-based registration method used in IGLS, we propose the incorporation of salient anatomical features, identifiable in both the preoperative image sets and intraoperative liver surface data, to aid in the initial pose estimation and play a more significant role in the surface-based registration via a novel weighting scheme. Examples of such salient anatomical features are the falciform groove region as well as the inferior ridge of the liver surface. In order to validate the proposed weighted patch registration method, the alignment results provided by the proposed algorithm using both single and multiple patch regions were compared with the traditional ICP method using six clinical datasets. Robustness studies were also performed using both phantom and clinical data to compare the resulting registrations provided by the proposed algorithm and the traditional method under conditions of varying initial pose. The results provided by the robustness trials and clinical registration comparisons suggest that the proposed weighted patch registration algorithm provides a more robust method with which to perform the image-to-physical space registration in IGLS. Furthermore, the implementation of the proposed algorithm during surgical procedures does not impose significant increases in computation or data acquisition times.
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8 MeSH Terms
Surgical resection and high dose rate intraoperative radiation therapy for locally recurrent rectal cancer.
Idrees K, Minsky B, Alektiar K, Guillem J, Weiser M, Temple L, Wong WD, Paty P
(2004) Acta Chir Iugosl 51: 11-8
MeSH Terms: Combined Modality Therapy, Disease-Free Survival, Female, Humans, Intraoperative Period, Male, Middle Aged, Neoplasm Recurrence, Local, Pelvic Neoplasms, Radiotherapy Dosage, Rectal Neoplasms, Survival Rate
Show Abstract · Added March 28, 2014
For intra-pelvic recurrence of rectal cancer, surgical resection is technically difficult and must be aggressive to achieve a high rate of negative resection margins. Resection with clear margins can be curative, particularly for those patients with true anastomotic recurrence. HDR-IORT is a safe, feasible, versatile, logistically sound modality that is highly reliable in delivering radiation to at-risk surgical margins in the pelvis. Despite surgery and IORT, overall local failure rates in this population are 33 to 50 percent. The most important prognostic variable is the state of surgical resection margins. At our institution, in patients with negative and positive resection margins the 2-year actuarial local recurrence rates are 33 percent versus 73 percent and 5-year survival rates are 51 percent versus 16 percent, respectively. On subset analysis, the most favorable outcome was seen in patients with true anastomotic recurrences (78 percent 5-year survival).
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12 MeSH Terms
Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome.
Irvin GL, Solorzano CC, Carneiro DM
(2004) World J Surg 28: 1287-92
MeSH Terms: Humans, Hypercalcemia, Hyperparathyroidism, Immunoradiometric Assay, Intraoperative Period, Monitoring, Intraoperative, Parathyroid Hormone, Parathyroid Neoplasms, Parathyroidectomy, Postoperative Period, Radiopharmaceuticals, Technetium Tc 99m Sestamibi, Treatment Failure
Show Abstract · Added March 5, 2014
Intraoperative parathyroid hormone (PTH) assay (QPTH) has made possible less invasive operative approaches in the treatment of primary hyperparathyroidism with stated advantages. When compared to the traditional bilateral neck exploration (BNE), only the targeted, hypersecreting gland is excised, leaving in situ non-visualized but normally functioning parathyroids. The QPTH-guided limited parathyroidectomy (LPX) must be able to identify multiglandular disease (MGD), predict a successful outcome, and have a low recurrence rate. In our series, 421 patients who underwent LPX were compared to 340 undergoing BNE; all operative failures and patients followed for 6 months or longer were included. Operative failure occurred if serum calcium and PTH levels were elevated within 6 months of parathyroidectomy. Multiglandular disease was defined in the LPX group as more than one gland excision guided by QPTH or operative failure after removal of a single abnormal gland; in the BNE group it was defined as excision of more than one enlarged gland. Recurrence was defined as elevated calcium and PTH after 6 months of eucalcemia. Operative failure and MGD rates were compared using chi-squared analysis. The method of Kaplan-Meier and the log-rank test were used to compare recurrence rates. Operative success was seen in 97% of LPX patients and in 94% of the BNE group ( p = 0.02). Multiglandular disease was identified in 3% of LPX patients and 10% of BNE patients ( p < 0.001). There was no statistical difference in the overall recurrence rates ( p = 0.23). The QPTH-guided parathyroidectomy identifies MGD and allows an improved success rate with the same low recurrence rate when compared to the results of BNE.
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13 MeSH Terms