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Biomedical subjects

John D Urschel

Publications and source records attributed to John D Urschel.

10 recordsLinked to original sources
PubMed2005

How to analyze an article.

In clinical research investigators generalize from study samples to populations, and in evidence-based medicine practitioners apply population-level evidence to individual patients. The validity of these processes is assessed through critical appraisal of published articles. Critical appraisal is therefore a core component of evidence-based medicine (EBM). The purpose of critical appraisal is not one of criticizing for criticism's sake. Instead, it is an exercise in assigning a value to an article. A checklist approach to article appraisal is outlined, and common pitfalls of analysis are highlighted. Relevant questions are posed for each section of an article (introduction, methods, results, discussion). The approach is applicable to most clinical surgical research articles, even those of a nonrandomized nature. Issues specific to evidence-based surgical practice, in contrast to evidence-based medicine, are introduced.

Evaluation Studies as Topic↗
PubMed2004

Mortality secondary to esophageal anastomotic leak.

BACKGROUND: Esophageal anastomotic leak is a potentially life threatening complication of esophagectomy and esophagogastrectomy. We reviewed our experience with this complication and tried to identify factors predictive of mortality after esophageal anastomotic leak. METHODS: Records of patients undergoing esophagectomy and esophagogastrectomy for benign or malignant disease over a 10-year period (1989-1999), who developed esophageal anastomotic leaks, were reviewed. RESULTS: Three-hundred and seven patients underwent esophagectomy or esophagogastrectomy. Twenty-three (7.5%) developed esophageal anastomotic leaks. Eight of these patients (35%) died. Four of 23 (17%) patients had seemingly normal postoperative contrast studies. Factors potentially predictive of death included age (died, 72.8+/-8.3 years; survived, 65.3+/-8.8 years; p=0.063), location of anastomosis (cervical, 3/9 died; thoracic, 5/14 died; p=0.91), leak presentation (clinical, 6/12 died; contrast study, 2/11 died; p=0.11), time of leak (<7 days, 3/5 died; > or =7 days, 5/18 died; p=0.18), presence of gastric necrosis (necrosis, 3/3 died; no necrosis, 5/20 died; p=0.019), and treatment (surgical, 4/4 died; conservative, 4/19 died; p=0.005). CONCLUSIONS: Postoperative esophageal anastomotic leaks prove fatal in a significant number of cases. The lethal potential of cervical anastomotic leaks should not be underestimated. Gastric necrosis is an important predictor of subsequent death. Advanced age, early postoperative (<7 days) leakage, and clinically apparent signs of leakage may be predictive of death but these factors did not reach statistical significance in our study. Surgical treatment of esophageal anastomotic leaks is associated with subsequent death, but this relationship is unlikely to be causal; severely ill patients tend to be treated surgically.

Aged↗
PubMed2003

A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer.

BACKGROUND: Esophagectomy is a standard treatment for resectable esophageal cancer but relatively few patients are cured. Combining neoadjuvant chemoradiation with surgery may improve survival but treatment morbidity is a concern. We performed a meta-analysis of randomized controlled trials (RCTs) that compared the use of neoadjuvant chemoradiation and surgery with the use of surgery alone for esophageal cancer. METHODS: Medline and manual searches were done to identify all published RCTs that compared neoadjuvant chemoradiation and surgery with surgery alone for esophageal cancer. A random-effects model was used and the odds ratio (OR) was the principal measure of effect. Systematic quantitative review was done for outcomes unique to the neoadjuvant chemoradiation treatment group, such as pathological complete response. RESULTS: Nine RCTs that included 1,116 patients were selected with quality scores ranging from 1 to 3 (5-point Jadad scale). Odds ratio (95% confidence interval [CI]; P value), expressed as chemoradiation and surgery versus surgery alone (treatment versus control; values <1 favor chemoradiation-surgery arm), was 0.79 (0.59, 1.06; P = 0.12) for 1-year survival, 0.77 (0.56, 1.05; P = 0.10) for 2-year survival, 0.66 (0.47, 0.92; P = 0.016) for 3-year survival, 2.50 (1.05, 5.96; P = 0.038) for rate of resection, 0.53 (0.33, 0.84; P = 0.007) for rate of complete resection, 1.72 (0.96, 3.07; P = 0.07) for operative mortality, 1.63 (0.99, 2.68; P = 0.053) for all treatment mortality, 0.38 (0.23, 0.63; P = 0.0002) for local-regional cancer recurrence, 0.88 (0.55, 1.41; P = 0.60) for distant cancer recurrence, and 0.47 (0.16, 1.45; P = 0.19) for all cancer recurrence. A complete pathological response to chemoradiation occurred in 21% of patients. The 3-year survival benefit was most pronounced when chemotherapy and radiotherapy were given concurrently (OR 0.45, 95% CI 0.26 to 0.79, P = 0.005) instead of sequentially (OR 0.82, 95% CI 0.54 to 1.25, P = 0.36). CONCLUSIONS: Compared with surgery alone, neoadjuvant chemoradiation and surgery improved 3-year survival and reduced local-regional cancer recurrence. It was associated with a lower rate of esophageal resection, but a higher rate of complete (R0) resection. There was a nonsignificant trend toward increased treatment mortality with neoadjuvant chemoradiation. Concurrent administration of neoadjuvant chemotherapy and radiotherapy was superior to sequential chemoradiation treatment scheduling.

Antineoplastic Agents↗
PubMed2003

Complications of salvage esophagectomy.

Definitive chemoradiation (without surgery) is an accepted treatment for esophageal cancer. Persistent or recurrent local disease is not infrequent after chemoradiation, and this is its greatest drawback. Selected patients with isolated local failures of definitive chemoradiation can be salvaged by esophagectomy. However, salvage esophagectomy is a high-risk operation; operative mortality is higher than for standard esophagectomy. In contrast to planned esophagectomy after induction (neoadjuvant) therapy, salvage esophagectomy is often carried out months after completion of definitive chemoradiation. Previous thoracic radiotherapy contributes to the genesis of postoperative complications. Respiratory failure (ARDS, pneumonia) and septic complications of esophageal reconstruction (anastomotic leaks) are major causes of postoperative death. Gastric conduit necrosis, airway necrosis, and tracheogastric fistulae are infrequent but highly lethal complications. We propose modifications of surgical practice that may reduce complications. These include strict guidelines for patient selection, conservative mediastinal dissection, prevention of intraoperative lung injury (barotrauma and oxygen related toxicity), near total esophagectomy with cervical esophagogastric anastomosis, anterior mediastinal reconstruction, judicious use of staged reconstruction, perioperative enteral nutritional support, and aggressive detection and treatment of postoperative complications. By conceptually breaking the operation into component parts, such as resection and reconstruction, and then modifying each component to minimize complications, we believe that the operative mortality of salvage esophagectomy can

Carcinoma, Squamous Cell↗
PubMed2003

Preoperative and intraoperative factors predictive of length of hospital stay after pulmonary lobectomy.

BACKGROUND: Length of hospital stay is an important determinant of overall surgical costs. Health care resources are finite, so reductions in length of stay are desirable. We reviewed our experience with pulmonary lobectomy to identify preoperative and intraoperative factors that predicted the length of postoperative hospital stay. By identifying these factors, we hoped to favorably influence future patient management. METHODS: Records of patients undergoing pulmonary lobectomy for benign or malignant disease over a four-year period (1998-2001) were reviewed. Data was collected on age, sex, pulmonary function, pulmonary pathology, cigarette smoking, type of thoracotomy incision, use of surgical sealants, surgeon, and length of hospital stay. RESULTS: Three hundred and sixty patients underwent lobectomy. Forward stepwise regression identified age (p=0.022), FEV1 (forced expiratory volume in one second) (p=0.047), diffusion capacity (p=0.020), and surgeon (p<0.001) as independent factors predictive of hospital length of stay. When these four factors were analyzed in a multiple linear regression model, the surgeon variable emerged as the strongest predictor of length of stay (p<0.001). CONCLUSIONS: Although patient factors were influential, the individual surgeon was the most important determinant of hospital length of stay after pulmonary lobectomy. It may be possible to reduce length of hospital stay by identifying variations in practice within the surgical group, and encouraging widespread adoption of "best practice" surgical techniques.

Aged↗
PubMed2002

Outcome of major cardiac injuries at a Canadian trauma center.

BACKGROUND: Canadian trauma units have relatively little experience with major cardiac trauma (disruption of a cardiac chamber) so injury outcome may not be comparable to that reported from other countries. We compared our outcomes to those of other centers. METHODS: Records of patients suffering major cardiac trauma over a nine-year period were reviewed. Factors predictive of outcome were analyzed. RESULTS: Twenty-seven patients (11 blunt and 16 penetrating) with major cardiac trauma were evaluated. Injury severity scores (ISS) were similar for blunt (49.6 +/- 16.6) and penetrating (39.5 +/- 21.6, p = 0.20) injuries. Five of 11 blunt trauma patients, and 9 of 16 penetrating trauma patients, had detectable vital signs on hospital arrival (p = 0.43). Ten patients underwent emergency department thoracotomy and 11 patients had cardiac repair in the operating theatre. Eleven patients survived and 16 died. Survivors had a lower ISS (33.7 +/-15.4) than non-survivors (50.4 +/- 20.4; p = 0.03). Two of 11 blunt trauma patients and 9 of 16 penetrating trauma patients survived (p = 0.06). Eleven of 14 patients with detectable vital signs survived; all 13 without detectable vital signs died (p = 0.00003). Ten of eleven patients treated in the operating theatre survived, while only one of the other 16 patients survived (p = 0.00002). CONCLUSIONS: Patients with major cardiac injuries and detectable vital signs on hospital arrival can be salvaged by prompt surgical intervention in the operating theatre. Major cardiac injuries are infrequently encountered at our center but patient survival is comparable to that reported from trauma units in other countries.

Adolescent↗
PubMed2002

A meta-analysis of randomized controlled trials that compared neoadjuvant chemotherapy and surgery to surgery alone for resectable esophageal cancer.

BACKGROUND: Esophagectomy is often considered the standard treatment for resectable esophageal cancer but the rate of cure is low. Combining neoadjuvant chemotherapy with surgery has theoretical appeal and some clinical evidence suggests a benefit. We performed a meta-analysis of randomized controlled trials (RCTs) that compared neoadjuvant chemotherapy and surgery with surgery alone for esophageal cancer. METHODS: Medline and manual searches were done to identify all published RCTs that compared neoadjuvant chemotherapy and surgery to surgery alone for esophageal cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Outcomes assessed by meta-analysis included 1-, 2-, and 3-year survival, rate of resection, rate of complete resection, operative mortality, anastomotic leaks, postoperative pulmonary complications, all treatment mortality, local-regional cancer recurrence, distant cancer recurrence, and all cancer recurrence. A random-effects model was used and odds ratio was the principal measure of effect. Systematic quantitative review was done for outcomes unique to the neoadjuvant chemotherapy treatment group (clinical response, pathological complete response, and chemotherapy mortality). RESULTS: Eleven RCTs, which included 1,976 patients, were selected with quality scores ranging from 1 to 3 (5-point Jadad scale). Odds ratio (95% confidence interval [CI]; P value), expressed as chemotherapy and surgery versus surgery alone (treatment versus control; values <1 favor chemotherapy-surgery arm), was 1.00 (0.76, 1.30; P = 0.98) for 1-year survival, 0.88 (0.62, 1.24; P = 0.45) for 2-year survival, 0.77 (0.37, 1.59; P = 0.48) for 3-year survival, 1.71 (1.22, 2.40; P = 0.002) for rate of resection, 0.71 (0.58, 0.87; P = 0.001) for rate of complete resection, 0.94 (0.66, 1.35; P = 0.76) for operative mortality, 1.08 (0.45, 2.60; P = 0.87) for anastomotic leaks, 1.31 (0.77, 2.23; P = 0.32) for postoperative pulmonary complications, 1.36 (0.83, 2.25; P = 0.22) for all treatment mortality, 0.71 (0.36, 1.42; P = 0.33) for local-regional cancer recurrence, 0.79 (0.57, 1.10; P = 0.16) for distant cancer recurrence, and 0.63 (0.28, 1.41; P = 0.26) for all cancer recurrence. A clinical response to chemotherapy was observed in 31% of patients and 5% had a complete pathological response. Chemotherapy mortality (before surgery) was 1.6%. CONCLUSIONS: Compared with surgery alone, neoadjuvant chemotherapy and surgery is associated with a lower rate of esophageal resection but a higher rate of complete (R0) resection. It does not increase treatment related mortality. This meta-analysis did not demonstrate a survival benefit for the combination of neoadjuvant chemotherapy and surgery.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2002

Pyloric drainage (pyloroplasty) or no drainage in gastric reconstruction after esophagectomy: a meta-analysis of randomized controlled trials.

BACKGROUND/AIM: A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. The gastric emptying may be impaired after this operation, so some esophageal surgeons routinely add a pyloric drainage procedure (pyloroplasty or pyloromyotomy). We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of pyloric drainage on patient outcomes. METHODS: Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of pyloric drainage procedures during gastric conduit reconstruction of the esophagus. The selection process was inclusive; no trials were excluded. Trial validity assessment was done, and a trial quality score was assigned. Early outcomes assessed by meta-analysis included operative mortality, esophagogastric anastomotic leaks, pulmonary morbidity, pyloric drainage complications, fatal pulmonary aspiration, and gastric outlet obstruction. A random-effects model was used, and the relative risk was the principal measure of effect. Systematic semiquantitative review was used for late outcomes such as gastric emptying, bile reflux, nutritional status, and obstructive foregut symptoms. RESULTS: Nine RCTs, that included a total of 553 patients, were selected, with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. The relative risk (95% CI; p value), expressed as pyloric drainage versus no drainage (treatment vs. control), was 0.92 (0.34, 2.44; p = 0.86) for operative mortality, 0.90 (0.47, 1.76; p = 0.77) for esophagogastric anastomotic leaks, 0.69 (0.42, 1.14; p = 0.15) for pulmonary morbidity, 2.55 (0.34, 18.98; p = 0.36) for pyloric drainage complications, 0.25 (0.04, 1.60; p = 0.14) for fatal pulmonary aspiration, and 0.18 (0.03, 0.97; p = 0.046) for gastric outlet obstruction. Systematic semiquantitative review showed a nonsignificant trend favoring pyloric drainage for the late outcomes of gastric emptying, nutritional status, and obstructive foregut symptoms. For the late outcome of bile reflux, there was a nonsignificant trend favoring the no-drainage group. The scintographic gastric emptying time, expressed as a ratio (pyloric drainage/no drainage), was 0.53. CONCLUSIONS: Data synthesized from existing RCTs show that pyloric drainage procedures reduce the occurrence of early postoperative gastric outlet obstruction after esophagectomy with gastric reconstruction, but they have little effect on other early and late patient outcomes.

Drainage↗