Antibiotic prophylaxis for preventing wound infection after breast surgery: a systematic review and metaanalysis.
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Adult↗
Biomedical subjects
Philip I Haigh
Publications and source records attributed to Philip I Haigh.
The effect of parathyroidectomy on bone fracture risk in patients with primary hyperparathyroidism.
BACKGROUND: Parathyroidectomy may increase bone density in primary hyperparathyroidism (PHPT), but it is unclear whether fracture risk is decreased. HYPOTHESIS: Parathyroidectomy decreases fracture risk. DESIGN: Retrospective cohort study with median follow-up of 6.5 years. SETTING: Twelve regional hospitals in California. PATIENTS: One thousand five hundred sixty-nine patients with PHPT. INTERVENTIONS: Parathyroidectomy or observation. Main Outcome Measure Fracture-free survival. RESULTS: Mean initial calcium, parathyroid hormone, and creatinine levels were 11.2 mg/dL (2.8 mmol/L), 123.0 pg/mL, and 0.9 mg/dL (79.6 micromol/L), respectively. Parathyroidectomy was performed in 452 (28.8%) patients, and 1117 (71.2%) were observed. The 10-year fracture-free survival after PHPT diagnosis was 73% in patients treated with parathyroidectomy compared with 59% in those observed (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.38-0.73; P < .001). Parathyroidectomy decreased the 10-year hip fracture rate by 8% (P = .001) and the upper extremity fracture rate by 3% (P = .02). Parathyroidectomy was independently associated with a decreased fracture risk (HR, 0.68; 95% CI, 0.47-0.98), whereas female sex (HR, 1.82; 95% CI, 1.19-2.80) and increased creatinine level (HR per 1-mg/dL [88.4-micromol/L] increment, 2.05; 95% CI, 1.22-3.46) remained independently associated with an increased fracture risk. Age of 50 years or older (HR, 1.62; 95% CI, 0.99-2.66), initial parathyroid hormone level (HR, 1.00; 95% CI, 0.99-1.02), and calcium level (HR, 1.02; 95% CI, 0.75-1.37) were not independently associated with fracture risk after adjusting for all other variables. CONCLUSIONS: Parathyroidectomy is associated with a decreased risk of fracture in PHPT. The largest decrease was in hip fractures. Parathyroidectomy should be considered for all patients with PHPT to reduce fracture risk, regardless of age or calcium or parathyroid hormone levels.
Bone Density↗
Surgical approach to the patient with familial hyperparathyroidism.
Familial hyperparathyroidism encompasses the diagnoses of multiple endocrine neoplasia (MEN) type 1, MEN type 2A, and familial isolated primary hyperparathyroidism. All patients should undergo bilateral neck exploration and identification of all four or more parathyroid glands to evaluate for gross abnormalities. MEN-1 patients should have subtotal parathyroidectomy and cervical thymectomy because this operation achieves an appropriate balance between optimizing the potential for cure yet minimizing the risk of permanent hypocalcemia. However, MEN-2A patients may best be treated by selective resection of abnormal parathyroid glands, although some experts recommend a total parathyroidectomy and autotransplantation in the forearm. Familial isolated hyperparathyroidism is a rare disorder, and authors have described success in treatment with subtotal parathyroidectomy or limited adenoma resections. Some patients with familial isolated hyperparathyroidism also have jaw tumors, and members of these families are more likely to have parathyroid carcinoma. Concurrent cryopreservation of parathyroid tissue for all of these disorders is recommended if there is any concern for possible permanent hypoparathyroidism.
Humans↗
Hospitalization for acute diverticulitis does not mandate routine elective colectomy.
BACKGROUND: Previous studies suggest that elective colectomy is often required after an episode of acute diverticulitis. HYPOTHESIS: Acute diverticulitis initially treated nonoperatively does not require elective colectomy. DESIGN: Retrospective cohort study. SETTING: Twelve Kaiser Permanente hospitals in Southern California. PATIENTS: Three thousand one hundred sixty-five patients with acute diverticulitis. INTERVENTIONS: Colectomy or nonoperative treatment with or without percutaneous abscess drainage. MAIN OUTCOME MEASURES: Recurrent diverticulitis. RESULTS: Emergency colectomy was performed in 614 patients (19.4%). Nonoperative treatment was initially used in 2551 patients (80.6%). Of these, 185 patients (7.3%) had an elective colectomy and the remaining 2366 patients (92.7%) did not. Factors associated with undergoing elective colectomy compared with nonoperative treatment were younger age of the patient, fewer comorbidities, and percutaneous abscess drainage. Mean follow-up was 8.9 years, with a maximum of 12 years. After nonoperative treatment, 314 patients (13.3%) recurred-222 patients had a single recurrence and 92 patients had a rerecurrence. After adjusting for other variables, older age (hazard ratio, >/=50 years vs <50 years = 0.68; 95% confidence interval, 0.53-0.87) was associated with a lower recurrence, whereas higher comorbidity was associated with higher recurrence. Gender and percutaneous abscess drainage had no influence on recurrence. All 92 rerecurrences were treated nonoperatively. The risk of a rerecurrence (29.3%) was significantly higher than a first recurrence (P<.001). Age, gender, Charlson comorbidity index, and percutaneous abscess drainage did not predict rerecurrence. CONCLUSIONS: Very few patients with acute diverticulitis treated nonoperatively have recurrence. Younger age was associated with recurrence. A first recurrence was the only factor that predicted rerecurrences. The low recurrence rate argues against routine elective colectomy after successful nonoperative management of acute diverticulitis.
Acute Disease↗
Breast conserving surgery and accelerated partial breast irradiation using the MammoSite system: initial clinical experience.
HYPOTHESIS: Balloon catheter-based accelerated partial breast irradiation (APBI) may result in desirable short-term outcomes in patients undergoing breast conserving surgery. DESIGN: Prospective consecutive case series. SETTING: Tertiary multidisciplinary referral center. PATIENTS: Forty selected patients with invasive breast carcinoma undergoing breast conserving surgery and MammoSite device placement. INTERVENTIONS: Breast conserving surgery, sentinel and/or axillary node dissection, placement of the new balloon catheter applicator (MammoSite device), and APBI. MAIN OUTCOME MEASURES: Infection, early and late seroma, device explantation, time to initiating APBI, acute toxic effects on the skin, and cosmesis using the Harvard Scale. RESULTS: Thirty-nine patients underwent MammoSite device placement at the time of lumpectomy; 1 patient underwent percutaneous device placement after lumpectomy. Nineteen patients (49%) had drainage catheters placed in the breast cavity at the time of lumpectomy. Wound infection developed in 3 patients (8%). Five devices (12%) were explanted because of unfavorable final pathological findings or infection. The mean time to the start of APBI in patients who did not undergo simultaneous drain placement was 7.2 days (range, 5-12 days), compared with 5.1 days (range, 3-8 days) in patients who did (P = .008). With a mean follow-up of 13.3 months (range, 2-28 months), patients completing APBI had limited toxic effects on the skin, with excellent or good cosmetic results in 39 patients (97%). CONCLUSIONS: Use of the MammoSite system in APBI has favorable short-term outcomes. Infection and radiation treatment delay are common and may warrant use of perioperative antibiotics and drain placement, respectively. A small number of patients who have device placement at the time of lumpectomy will require explantation because of unfavorable final pathological findings. Short-term outcomes of MammoSite brachytherapy support further studies comparing APBI with standard whole breast irradiation in patients undergoing breast conserving surgery.
Adult↗
Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis.
BACKGROUND: The role of interval appendectomy (IA) after an episode of acute appendicitis is debated. HYPOTHESIS: Patients treated nonoperatively for acute appendicitis do not require routine IA. DESIGN: Retrospective cohort study using discharge abstract data. SETTING: Twelve regional Kaiser Permanente hospitals in Southern California. PATIENTS: A total of 32 938 patients were hospitalized with acute appendicitis. INTERVENTIONS: Appendectomy or nonoperative treatment with or without abscess drainage. MAIN OUTCOME MEASURES: Hospitalization for recurrent appendicitis or IA. RESULTS: The type of appendicitis was abscess in 7% of patients, peritonitis in 18%, and no peritonitis or abscess in 75%. Emergency appendectomy was performed in 31 926 (97%) patients. Nonoperative treatment was used initially in 1012 patients (3%). Of these, 148 (15%) had an IA and the remaining 864 (85%) did not. Thirty-nine patients (5%) recurred after a median follow-up of 4 years. Using Cox regression, sex had a slight influence on recurrent appendicitis (hazard ratio males vs females = 0.52, 95% CI, 0.27-0.99, P = .05). Age, Charlson comorbidity index, type of appendicitis, or percutaneous abscess drainage had no influence on recurrence. Median length of hospital stay was 4 days for the admission for recurrent appendicitis compared with 6 days for the IA admission (P = .006). CONCLUSIONS: Most patients with acute appendicitis undergo appendectomy initially. For those treated nonoperatively, the recurrence rate is low. Routine IA after initial successful nonoperative treatment is not justified and should be abandoned.
Abdominal Abscess↗
The treatment and prognosis of Hürthle cell follicular thyroid carcinoma compared with its non-Hürthle cell counterpart.
BACKGROUND: This population study compared the treatment and prognosis of Hürthle cell follicular thyroid carcinoma (HCFC) and non-HCFC. METHODS: The Surveillance, Epidemiology and End Results database identified patients with HCFC and non-HCFC from 1988 to 1993 who were followed to 2001. Treatment of each carcinoma was compared, and the effect of prognostic factors on survival was analyzed. RESULTS: Eight hundred forty-five patients were identified; 172 patients (20%) had HCFC and 673 patients (80%) had non-HCFC. Total thyroidectomy was performed in 80% of patients with HCFC compared with 69% with non-HCFC (P = .005). Radioactive iodine was used in 33% with HCFC and 45% with non-HCFC (P = .003). The crude 10-year survival was 73% in HCFC and 83% in non-HCFC patients. Older age (> or =50 vs <50 years; hazard ratio, 6.35; 95% CI, 4.07-9.93), men (hazard ratio, 2.07; 95% CI, 1.52-2.81), larger tumor size (>5 vs < or =5 cm; hazard ratio, 2.20; 95% CI, 1.55-3.13; >10 cm vs < or =5 cm; hazard ratio, 3.28; 95% CI, 1.12-9.61), nodal metastases (hazard ratio, 3.11; 95% CI, 1.80-5.37), and distant metastases (hazard ratio, 3.91; 95% CI, 1.94-7.90) were associated with a higher mortality rate. Histologic type (non-HCFC vs HCFC; hazard ratio, 0.85; 95% CI, 0.60-1.19; P = .34), local extension, extent of thyroidectomy, and radioactive iodine use had no effect on the mortality rate. CONCLUSIONS: Histologic distinction between HCFC and non-HCFC is not as prognostically important as age, gender, and tumor stage. This study suggests that patients with HCFC should be treated the same as patients with equivalent stage non-HCFC.
Adenocarcinoma, Follicular↗
Adverse drug reactions during lymphatic mapping and sentinel lymph node biopsy for solid neoplasms.
Currently, 1 per cent isosulfan blue dye and technetium-99-labeled sulfur colloid (SC) are used in lymphatic mapping (LM). Several reports have suggested that the incidence of adverse drug reactions (ADRs) during LM is high. We report our experience with LM for solid neoplasms in order to determine the incidence and risk factors for development of ADRs. Seven hundred fifty-three patients (90% women, mean age 57) underwent LM with blue dye alone or in combination with SC from 1998 to 2004. The most common malignancy was breast cancer (83%). One hundred ten patients (14%) had injection of both mapping agents. Most patients (87%) underwent intraparenchymal injection of LM agent. Eight patients (1.1%) had an ADR during LM; none had prior exposure to LM. Of these, 7 had limited reactions (mostly blue hives) that quickly resolved. One patient (0.1%) developed anaphylaxis. The ADR incidence in patients with a sulfa allergy was not significantly different than that in patients without a sulfa allergy (3.4 vs 1%, P = 0.12). No risk factors for development of ADR were identified. Overall, the incidence of ADR during LM is low. Patients with sulfa allergies and prior exposure to LM did not demonstrate an increased incidence of ADR. Anaphylaxis, though rare, can occur during LM.
Adolescent↗
Extent of thyroidectomy is not a major determinant of survival in low- or high-risk papillary thyroid cancer.
BACKGROUND: The optimal extent of thyroidectomy for papillary thyroid cancer (PTC) is controversial. Our objective was to evaluate the effect of total thyroidectomy or partial thyroidectomy on survival in low- and high-risk patients. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify PTC patients who underwent thyroidectomy. The independent effects of age, distant metastases, extrathyroidal extension, tumor size, sex, lymph node metastases, radioactive iodine use, and extent of thyroidectomy on survival were analyzed for low- and high-risk PTC. RESULTS: There were 4402 (81%) low-risk and 1030 (19%) high-risk patients; 84.9% underwent total thyroidectomy. The 5- and 10-year survival were 95% and 89% in the low-risk patients and 84% and 73% in the high-risk patients, respectively (P = .001). In the low-risk patients, 10-year survival after total thyroidectomy was 89%, compared with 91% after partial thyroidectomy (adjusted hazard ratio for death, 1.73; 95% confidence interval, 1.28-2.33; P < .001); older age, male sex, larger tumor, lymph node metastases, and lack of radioactive iodine were associated with higher mortality. In the high-risk patients, 10-year survival after total thyroidectomy was 72%, compared with 78% after partial thyroidectomy (adjusted hazard ratio for death, 1.46; 95% confidence interval, .89-2.40; P = .14); older age, distant metastases, larger tumors, and lack of radioactive iodine were associated with higher mortality. CONCLUSIONS: Survival of patients with PTC was not significantly influenced by the extent of thyroidectomy. The survival after partial thyroidectomy was similar to total thyroidectomy within both the low- and high-risk prognostic groups.
Adult↗
AMES prognostic index and extent of thyroidectomy for well-differentiated thyroid cancer in the United States.
BACKGROUND: The optimal extent of thyroidectomy for well-differentiated thyroid cancer is controversial. It has been suggested that surgeons use the Age, Metastases, Extent and Size (AMES) risk classification to decide between partial thyroidectomy (PT) or total thyroidectomy (TT). METHODS: The Surveillance, Epidemiology and End Results database was used to identify patients who underwent PT or TT for well-differentiated thyroid cancer between 1992 and 1997. Age, distant metastases, extrathyroidal extension, tumor size, AMES risk group, gender, histologic subtype, and lymph node metastases were analyzed by using logistic regression models to evaluate whether surgeons use these factors to determine extent of thyroidectomy. RESULTS: Of 9,226 patients, most patients had small cancers confined to the thyroid gland. Of these, 79.9% were AMES low-risk, and 83% underwent TT. Age 40 years or older (40 to 49 years: odds ratio [OR], 0.75, 95% confidence interval [CI], 0.65 to 0.86; 50 years or older: OR, 0.66; 95% CI, 0.58 to 0.75) was associated with a lower likelihood of TT, as were female gender (OR, 0.80; 95% CI, 0.70 to 0.92) and follicular histology (OR, 0.65; 95% CI, 0.55 to 0.78). Extrathyroidal extension (OR, 3.85; 95% CI, 3.09 to 4.80), regional lymph node metastases (OR, 6.98; 95% CI, 5.45 to 8.93), distant metastases (OR, 7.29; 95% CI, 2.69 to 19.8), AMES high-risk group (OR, 2.82; 95% CI, 2.36 to 3.38), and larger tumor size (OR, 1.27; 95% CI, 1.01 to 1.59) were associated with greater likelihood of TT. In multivariable analyses, only age, extrathyroidal extension, and regional and distant metastases were associated with extent of thyroidectomy; AMES risk group and tumor size were no longer significant. CONCLUSIONS: Most patients undergo TT for well-differentiated thyroid cancer regardless of AMES risk grouping. In contrast to AMES risk-group classification, younger patients are more likely to undergo TT compared with older patients. Although extrathyroidal extension and distant metastases were associated with TT in accordance with AMES criteria, tumor size had no independent influence. Regional lymph node metastasis, not an AMES criterion, increased the likelihood of TT. Some components of AMES risk-group classification are used by surgeons to choose the extent of thyroidectomy.
Adenocarcinoma, Follicular↗
Lymphatic mapping improves staging and reduces morbidity in women undergoing total mastectomy for breast carcinoma.
Lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) have become widely accepted in the setting of breast conservation surgery. We hypothesized that LM can be extended to women undergoing total mastectomy, being technically feasible, yielding highly accurate and sensitive results, improving axillary staging, and reducing postoperative morbidity. Between 1995 and 2003, 99 women (mean age 59 years, range 34-87) underwent 100 mastectomies with LM using blue dye alone. Fifty-nine operations (60%) were followed by a completion axillary lymph node dissection (ALND). Ninety per cent of patients had invasive carcinoma; 10 per cent had in situ carcinoma. Mean tumor size was 2.5 cm (range 0.3-8 cm). One hundred fifty-nine sentinel nodes (SNs) (mean 1.65, range 1-5) were successfully identified in 96 (96%) axillae. Twenty-five (25%) sentinel nodes revealed nodal metastases. Five of 25 (20%) SNs had micrometasteses. Three patients had a false-negative SN, yielding a sensitivity of 91 per cent. The accuracy of LM was 97 per cent. No patient who underwent SLNB alone developed lymphedema, axillary seroma formation, infection, or restricted arm movement. This was contrasted with patients undergoing ALND, where 10 (16%) developed lymphedema and 2 (3%) developed an infection. Ten (25%) patients developed axillary paresthesias after SNB compared with 47 (78%) patients after ALND (P < 0.0001). LM in the setting of mastectomy is accurate and sensitive. This technique improves axillary staging and decreases morbidity. Patients who are not candidates for breast conservation should be offered LM and SLNB at the time of mastectomy.
Adult↗
Ex vivo lymphatic mapping: a technique to improve pathologic staging in colorectal cancer.
Sentinel lymph node (SLN) biopsy is widely used for solid tumors and has been proposed for use in staging colorectal cancer (CRC). Few studies have examined the ex vivo lymphatic mapping (EVLM) technique for staging CRC. We hypothesized that EVLM is technically feasible, sensitive, accurate, and improves the staging of CRC. After standard resection for colorectal cancer, 1 mL of isosulfan blue dye was injected circumferentially around the tumor. Blue-stained nodes were dissected separately and examined by hematoxylin and eosin (H&E) and immunohistochemical (IHC) stains. Routine pathologic evaluation was performed on all other harvested lymph nodes. Forty patients underwent 43 cancer resections with EVLM from July 2000 to December 2003. SLN were identified in 39 of 43 (91%) specimens. The mean number of SLN obtained was 1.9 (range, 0-5). Pathologic evaluation demonstrated nodal metastasis in 16 of 39 (39%) specimens. The SLN was tumor-positive in 9 of these 16 (56%) patients. The overall accuracy of EVLM was 82%. Two patients (9%) with H&E node negative disease were upstaged when found to have micrometastases by IHC staining. In conclusion, EVLM is technically possible in 90 per cent of patients with CRC. Although overall accuracy was high, the SLN status correlated poorly with the true nodal status of the CRC. However, EVLM improves pathologic staging in 9 per cent of patients and therefore may be of value in CRC.
Adenocarcinoma↗
Underuse of wide excision for primary cutaneous melanoma in the United States.
Three randomized trials support wide excision (WEX) for primary cutaneous melanoma. The objective was to evaluate WEX use for melanoma in the United States. Patients with localized melanoma were identified from the Surveillance, Epidemiology and End Results database between 1988 and 1997. Associations between predictor variables and WEX compared to biopsy alone were evaluated using logistic regression. Of 8,268 patients identified, 74.9 per cent had WEX, whereas 25.1 per cent had biopsy alone. WEX use peaked in 1990 at 81.6 per cent and was lowest in 1995 at 69.8 per cent. Overall, WEX use decreased over time. WEX use was independently associated with Breslow thickness (odds ratio [OR] per 1-mm depth of invasion 1.4, 95 per cent confidence interval [CI] 1.3, 1.5), and was inversely related to patient age (OR per 10 years of age 0.93; 95% CI 0.90, 0.96). As compared with the time period 1988 to 1990, WEX use declined during 1991 to 1993 (OR 0.71, 95% CI 0.60-0.83) and from 1994 to 1997 (OR 0.65; 95% CI 0.57-0.75). Many patients with localized melanoma undergo biopsy alone without a WEX. Use of WEX is associated with thicker melanomas and younger patients. Use of WEX has decreased over time, despite results from three randomized trials supporting its use.
Adult↗
Optimal excision margins for primary cutaneous melanoma: a systematic review and meta-analysis.
OBJECTIVE: To determine in patients with localized primary melanoma of the trunk or extremities the optimal excision margin that achieves the highest disease-free survival and overall survival and the lowest local recurrence rate. DATA SOURCES: Trials comparing 2 different excision margins were identified by searching MEDLINE from 1966 to May 2002 using the term "melanoma," subheading "surgery," and limiting the search to human studies and randomized controlled trials (RCTs). Additional studies were found using the MeSH term "surgical procedures, operative," combining with "melanoma," and limiting to human studies. We searched EMBASE and the Cochrane Library in May 2002 using similar terminology. No language restriction was applied. STUDY SELECTION: We selected studies for the overview using the following inclusion criteria: design--an RCT with wide excision versus narrower excision (margin width was not specified a priori); population--adult patients (> 18 yr) with cutaneous melanoma of the trunk or extremities without evidence of metastasis; intervention--surgical excision of the primary melanoma; and outcomes--at least 1 of overall survival, disease-free survival, local recurrence, wound complications and necessity for skin grafting. DATA EXTRACTION: Information was abstracted for each outcome reported in the studies, and results were pooled by consensus. Statistical analysis was performed using RevMan 4.1 (The Cochrane Collaboration) software program. Relative risk and risk difference were reported with 95% confidence intervals. The number needed to harm was calculated for the need for skin grafting by taking the inverse of the risk difference. DATA SYNTHESIS: Three trials and their follow-up studies met the inclusion criteria and included 2087 adults with localized cutaneous melanoma of the trunk or extremities. No statistically significant differences were found between wide surgical excision (margins ranging from 3-5 cm) and narrower surgical excision (margins ranging from 1-2 cm) with respect to mortality, disease-free survival or local recurrence rate. CONCLUSIONS: Surgical excision margins no more than 2 cm around a melanoma of the trunk or extremities are adequate; overall survival, disease-free survival and recurrence rate are not adversely affected compared with a wider excision. There is more data to support a 2-cm margin than a 1-cm margin as the minimum margin of excision. Surgical margins should be no less than 1 cm around the primary melanoma.
Biopsy↗
Follicular thyroid carcinoma.
Follicular carcinomas are rare thyroid malignancies that are difficult to diagnose preoperatively. Fine needle aspiration is an excellent diagnostic tool and should be the initial step in managing the solitary thyroid nodule. Follicular carcinoma cannot be diagnosed with certainty by cytologic features alone; the diagnosis rests on the histologic findings of blood vessel or tumor capsule invasion. Surgical resection is the primary option for treatment. The extent of thyroidectomy for optimal survival outcome has not been determined scientifically. The outcome is excellent in minimally invasive follicular carcinoma with lobectomy and isthmusectomy; it is difficult to argue that total thyroidectomy is necessary. In a low risk prognostic group, for tumors other than minimally invasive carcinoma, lobectomy and isthmusectomy or total thyroidectomy can be justified. However, if total thyroidectomy can be done safely with a minimum of complications, then it has definite advantages for staging, postoperative surveillance, treatment, and possibly a lower recurrence rate and better survival rate. For all patients at high risk of recurrence, total thyroidectomy is preferred.
Adenocarcinoma, Follicular↗