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Biomedical subjects

Lloyd A Mack

Publications and source records attributed to Lloyd A Mack.

8 recordsLinked to original sources
PubMed2005

Preoperative chemoradiotherapy (modified Eilber protocol) provides maximum local control and minimal morbidity in patients with soft tissue sarcoma.

BACKGROUND: Local recurrence rates of 15% to 30% after treatment of soft tissue sarcoma (STS) are still common but unacceptable. Our hypothesis was that a refined neoadjuvant chemotherapy and radiation protocol (modified Eilber protocol) improves local control rates while minimizing major morbidity. METHODS: Consecutive patients with STS deep to the fascia of the extremity or trunk during 1984 to 1996 were treated with 3 days of doxorubicin (30 mg/day) and sequential radiation (300 cGy/day for 10 days). Wide excision with limb preservation was performed 4 to 8 weeks after radiation completion. Treatment complications, margins, local recurrence, and survival were prospectively documented. RESULTS: Of 75 patients, 66% had tumors >5 cm, and 71% were grade 2/3. In eight patients, negative margins were not achieved, and four of these had amputation (95% limb salvage). Three of the remaining four had local recurrence with a 5- and 7-year actuarial local control rate of 50% and 25%, respectively. In contrast, of the 67 patients with negative margins, a local control rate of 97% at 5 years and 94% at 7 years and an overall survival of 63% were achieved. Although margin (P = .001) and stage (P = .035) were correlated, these were not significant on multivariate Cox regression analysis. Risk factors for death included tumor stage (hazard ratio, 1.54; P = .001) and tumor grade (hazard ratio, 1.4; P = .02). Three patients (4%) required reoperation for tissue loss, and eight patients (10.6%) developed minor wound complications. CONCLUSIONS: This modified Eilber protocol seems to maximize local control and minimize major wound complications for extremity/truncal STS.

Adolescent↗
PubMed2004

Controversies in the management of metastatic melanoma to regional lymphatic basins.

The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.

Axilla↗
PubMed2004

Asymptomatic primary hyperparathyroidism: a surgical perspective.

Since the advent of multichannel autoanalyzers and routine screening of serum calcium levels, prevalence of primary hyperparathyroidism (pHPT) has increased to between 0.1% and 0.4%. As more patients present with "asymptomatic" pHPT, ideal treatment of "mild" disease becomes more controversial, with the possibility of safe, nonoperative management in a selected group of patients. Accumulated evidence confirms that the majority of these patients suffer from vague, nonspecific complaints that are very real and can improve following parathyroidectomy. Furthermore, parathyroidectomy in patients with pHPT has been demonstrated to improve bone mineral density, reduce fracture risk, and improve health-related quality of life and possibly overall survival. Therefore, all patients with primary hyperparathyroidism should be referred for surgical evaluation by an experienced endocrine surgeon.

Bone Diseases↗
PubMed2004

Decompressive tube esophagostomy: a forgotten palliative procedure?

Many patients with complete, irreversible upper gastrointestinal (GI) tract obstruction will require decompression for relief of intractable nausea and vomiting. Nasogastric (NG) tubes are associated with patient discomfort and risk. Gastrostomy tubes may not be technically feasible in a small subset of patients with advanced upper GI tract malignancy. Decompressive tube esophagostomy is an underutilized, minimally invasive alternative in such patients. We present a case report, a description of the procedure, and a review of the literature for this palliative procedure.

Adult↗
PubMed2004

Gastric decompression and enteral feeding through a double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy.

OBJECTIVE: The objective of this study was to assess the feasibility and safety of inserting a double-lumen gastrojejunostomy tube (GJT) after pancreaticoduodenectomy (PD) and to evaluate associated outcomes. BACKGROUND: Gastroparesis is a frequent postoperative event following PD. This often necessitates prolonged gastric decompression and nutritional support. A double-lumen GJT may be particularly useful in this situation: gastric decompression may be achieved through the gastric port without a nasogastric tube; enteral feeding may be administered through the jejunal port. METHODS: Thirty-six patients with periampullary tumors were randomized at the time of PD to insertion of GJT or to the routine care of the operating surgeon. Outcomes, including length of stay, complications, and costs, were followed prospectively. RESULTS: The 2 groups had similar characteristics. Prolonged gastroparesis occurred in 4 controls (25%) and in none of the patients who had a GJT (P = 0.03). Complication rates were similar in each group. Mean postoperative length of stay was significantly longer in controls compared with patients who had a GJT (15.8 +/- 7.8 days versus 11.5 +/- 2.9 days, respectively; P = 0.01). Hospital charges were 82,151 +/- 56,632 dollars in controls and 52,589 +/- 15,964 dollars in the GJT group (P = 0.036). CONCLUSIONS: In patients undergoing PD, insertion of a GJT is safe. Moreover, insertion of a GJT improves average length of stay. At the time of resection of periampullary tumors, GJT insertion should be considered, especially given this is a patient population in which weight loss and cachexia are frequent.

Aged↗
PubMed2004

Survey of colorectal cancer screening practices in a large Canadian urban centre.

INTRODUCTION: Colorectal carcinoma (CRC) is an ideal tumour for population-based screening policies. Screening guidelines are based on differing levels of evidence and opinion. The objective of this study was to determine current CRC screening practices in Alberta. METHODS: A questionnaire was mailed to all family physicians, gastroenterologists, general and colorectal surgeons, and general internal medicine specialists in a large Canadian urban centre. Results tabulated included response rate, specialty, presence/absence of a screening policy, and policy type. RESULTS: The 922 surveys mailed resulted in a 61% response rate. Among the responses, 58% (95% confidence interval [CI] 53.6%-62.6%) of physicians recommended screening to healthy individuals without a family history of CRC, and 96% (CI 94.7%-98%; p < 0.0001) to those with a family history. For patients without a family history of CRC, the majority of physicians chose the age of 50 to initiate screening (63%) by fecal occult blood testing (79%) or, less frequently, colonoscopy (26%). Screening frequency varied by the modality used. In individuals with a family history of CRC, most physicians initiated screening prior to the index case (45%) or by age 40 (31%), mostly with colonoscopy (84%); screening frequency varied mainly by modality. CONCLUSION: Despite the evidence supporting CRC screening in all persons at average risk, only 58% of physicians currently recommend screening to patients with no family history of CRC. Fecal occult blood testing was recommended most frequently in this subgroup, whereas most physicians screen people with a family history of CRC via colonoscopy, suggesting that they believe it to be a superior screening modality. As this looks to be the trend in practice, a randomized controlled trial comparing fecal occult testing with screening colonoscopy is needed.

Adult↗