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PubMed2005

Prospective randomized study on asymptomatic severe carotid stenosis and perioperative stroke risk in patients undergoing major vascular surgery: prophylactic or deferred carotid endarterectomy?

We compared the perioperative (30-day) stroke risk in asymptomatic patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) before or after major vascular surgery. Seventy-nine patients with asymptomatic severe carotid lesion were randomly assigned to group I (n = 40) or group II (n = 39) to receive prophylactic CEA (within 1 week before major surgery) or deferred CEA (between 30 days and 6 months after major surgery), respectively. All procedures were eversion CEAs performed under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. There were no perioperative deaths or strokes relating to the major surgical procedure in either group. All group II patients underwent deferred CEA as planned (median 47 days, range 38-94) with no subsequent perioperative deaths or strokes. Two of these patients (5.1%) suffered a minor stroke, however, 65 and 78 days after their major surgical procedure, while awaiting carotid revascularization. Although data emerging from this analysis indicate that severe asymptomatic carotid disease may be safely postponed in patients undergoing major noncarotid vascular surgery, only a multicenter prospective study could determine the most appropriate management of this subset of patients.

Aged↗
PubMed2002

Minidose lidocaine-fentanyl spinal anesthesia in ambulatory surgery: prophylactic nalbuphine versus nalbuphine plus droperidol.

UNLABELLED: Minidose lidocaine-fentanyl spinal anesthesia (SAB(MLF)) is a safe, effective, and efficient anesthetic for ambulatory surgery. Unfortunately, it has a frequent incidence of pruritus and a substantial incidence of nausea and vomiting. Nalbuphine is effective in treating or preventing pruritus after intrathecal or epidural morphine but may or may not have a beneficial effect on nausea and vomiting. Droperidol has demonstrated antiemetic efficacy with neuraxial opiates. In this study, we examined the prophylactic use of nalbuphine alone compared with nalbuphine with droperidol after SAB(MLF). One-hundred-twenty-four patients having outpatient knee arthroscopy under SAB(MLF) with 20 mg of lidocaine 0.5% and 20 micro g of fentanyl were randomized to receive IV at the end of surgery either 4 mg of nalbuphine (Group N) or droperidol 0.625 mg plus nalbuphine 4 mg (Group ND). The incidences of early (before discharge) and late onset nausea were, respectively, 18% versus 5% and 32% versus 13%. The postoperative incidences of pruritus were 61% versus 40%, whereas 19% of patients in Group N compared with 2% of patients in Group ND requested treatment for this. Group ND had lower pain scores and had a longer delay until first use of analgesic. There were no differences in average times to discharge. The only side effect of the medications was an increased drowsiness in Group ND. In conclusion, as prophylactic medication for use in conjunction with SAB(MLF), the addition of droperidol 0.625 mg to nalbuphine 4 mg was superior to nalbuphine alone. The combination provided for reduced postoperative nausea, pruritus, and pain-benefits that persisted after discharge home. The combination also avoided isolated cases of extreme delay in discharge. IMPLICATIONS: Droperidol in combination with nalbuphine enhances analgesia and is more effective than nalbuphine alone in preventing pruritus, nausea, and vomiting after minidose lidocaine-fentanyl spinal anesthesia.

Adult↗
PubMed2003

Acceptable age for prophylactic surgery in children with multiple endocrine neoplasia type 2a.

AIMS: Germline mutated RET proto-oncogene, causing multiple endocrine neoplasia (MEN)-2a syndrome is the indication for prophylactic total thyroidectomy. Literature regarding the risk and the extent of early surgical intervention is scarce and the optimum age for surgery is still controversial. To optimize management in these young children we evaluate our experience and results. PATIENTS AND METHODS: From 1990 to 2001 preventive total thyroidectomy was performed in 13 MEN-2a gene carriers (4 boys and 9 girls; median age 7 (4-14) years). Preoperative assessment, surgical procedure, pathological examination, postoperative complications and treatment results were studied. RESULTS: Surgery existed of a total thyroidectomy alone (n=3) in children with normal basal calcitonin and in combination with tracheo-esophageal exploration (n=6) or central compartment dissection (n=4) in case of abnormal calcitonin levels. Eight children presented with medullary thyroid cancer (MTC), three (median: 5 (4-12) years) with microscopic MTC and five (median 6 (4-14) years) with frank invasive MTC. Four of these five patients were younger than 6 years. Except for long-lasting hypoparathyroidism in one patient there were no complications. At a median follow-up of 6.5 years all patients are disease free. CONCLUSION: MTC in RET mutated MEN-2a gene carriers in childhood are found at the age of 4 years. Therefore, DNA testing should be done preferably before that age. Preventive surgery can be performed safely at that age and may be limited to total thyroidectomy when baseline calcitonin levels are normal.

Adolescent↗
PubMed2000

Prophylactic surgery in women with a hereditary predisposition to breast and ovarian cancer.

PURPOSE: To review the published literature on the efficacy and adverse effects of prophylactic mastectomy (PM) and prophylactic oophorectomy (PO) in women with a hereditary predisposition to breast and ovarian cancer and to provide management recommendations for these women. METHODS: Using the terms "prophylactic," "preventive," "bilateral," "mastectomy," "oophorectomy," and "ovariectomy," a MEDLINE search of the English-language literature for articles related to PM and PO was performed. The bibliographies of these articles were reviewed to identify additional relevant references. RESULTS: There have been no prospective trials of PM or PO for the reduction of breast cancer or ovarian cancer incidence or mortality. Most of the available retrospective studies are composed of women who had surgery for a variety of indications and in whom genetic risk was not well characterized. However, some reports in women at increased risk of breast or ovarian cancer have shown that PM and PO can reduce cancer incidence. CONCLUSION: Interest in and use of PM and PO are high among physicians and high-risk women. PM and PO seem to be associated with considerable reduction in the risk of breast and ovarian cancer, albeit incomplete. The surgical morbidity of PM and PO is low, but the complications of premature menopause may be significant, and few studies address quality-of-life issues in women who have opted for PM and PO. Management recommendations for high-risk individuals are presented on the basis of the available evidence.

Breast Neoplasms↗
PubMed1982

[Enlightenment of patients prior to prophylactic surgery ].

To give his consent for diagnostic or therapeutic procedures a patient needs information on the nature of the disease, its course and possible complications. Additionally, he needs to be informed about the necessary diagnostic and therapeutic procedures themselves and the possible consequences of omitting them. All the typical risks have to be explained, even though they may be extremely rare. If a procedure is not immediately necessary, the information given has to be more comprehensive than in emergency cases. Therefore, comprehensive information has to be provided for prophylactic procedures (including information leaflets for patients, especially in cases of cataract, glaucoma and retinal detachment surgery, photocoagulation for equatorial degeneration and diabetic retinopathy, as well as vitrectomy and fluorescein angiography). The information must be given by the physician himself and should be as comprehensive as is necessary to enable the patient to decide for himself whether he wants to undergo the procedure. The majority of patients accept the enlightenment is necessary, consider the information supplied adequate and are thus reassured.

Anesthesia↗
PubMed1996

Prophylactic surgery for multiple endocrine neoplasia type IIa after genetic diagnosis: is parathyroid transplantation indicated?

Identification of germline mutations in the RET proto-oncogene predisposing to multiple endocrine neoplasia type IIa (MEN-IIa) has allowed a DNA-based approach to diagnosis and treatment by prophylactic thyroidectomy in children testing genetically positive. Although total thyroidectomy is the accepted operation for C cell disease, the necessity of routine total parathyroidectomy and autotransplantation as previously described in these asymptomatic children is questionable, particularly given the low occurrence of hyperparathyroidism in MEN-IIa (10-20%). Thirty-six children (ages 1 month to 12 years) from four MEN-IIa kindreds at risk for disease underwent genetic testing. Mutational analysis was done using a highly sensitive PCR-based denaturing gradient gel electrophoresis technique. Parathyroid or serum calcium concentrations were determined preoperatively. Of the 36 children at risk, 18 were found to have a MEN-IIa mutation; 11 have undergone prophylactic thyroidectomy at ages ranging from 2 to 12 years (mean 7.5 years). In each case, there was no biochemical evidence of hypercalcemia preoperatively, and all parathyroid glands were identified and were found to be grossly normal at exploration. Glands were carefully dissected and left in situ. Postoperatively, 10 of the 11 children maintained normocalcemia, allowing discharge within 24 to 36 hours. Resected thyroid glands contained C cell hyperplasia in nine, medullary carcinoma in one, and normal histology in one. We conclude that an alternative to routine parathyroidectomy may be desirable for prophylactic treatment of MEN-IIa. In situ parathyroid preservation can be safely achieved without compromising the completeness of the thyroid resection. This conservative approach obviates the potential morbidity associated with total parathyroidectomy and autotransplantation.

Calcium↗
PubMed2001

[Hereditary thyroid cancer can be cured by prophylactic surgery].

Multiple endocrine neoplasia type 2 (MEN 2) is a rare syndrome in which the consequences for the patient and family members are considerable. Mutation analysis of the RET proto-oncogene is crucial for decision-making regarding each patient. Today, carriers of MEN 2 mutations should be offered prophylactic thyroidectomy with the potential to eliminate the risk for potentially lethal medullary thyroid carcinoma (MTC). Here, we present the first Swedish experience of such operations performed mainly on the basis of genetic analysis. Twenty patients underwent total thyroidectomy at a mean age of 13.5 (6-43) years. In all cases, either manifest MTC (n = 11) or C-cell hyperplasia was found. So far, no patient has any sign of recurrence or developmental insufficiency at 1-5 years follow-up. As the medical and ethical problems in this group of patients are substantial, and as the operations are performed in otherwise healthy children, they should be treated at centers with adequate multidisciplinary expertise and competence.

Adolescent↗
PubMed2000

Clear cell carcinoma of the fimbria of the fallopian tube in a BRCA1 carrier undergoing prophylactic surgery.

We report the case history of a patient with a family history of breast and ovarian cancer who was subsequently found to be a carrier of the BRCA1 gene, in whom a tiny focus of clear cell carcinoma was found at the fimbrial end of one fallopian tube when she underwent prophylactic hysterectomy and bilateral salpingoophorectomy. The implications of this finding are discussed.

Adenocarcinoma, Clear Cell↗
PubMed2003

Prophylactic surgery and other strategies for reducing the risk of familial ovarian cancer.

The goal of a cancer prevention program is to improve the mortality rates of patients. No risk-reduction strategy is proven to reduce mortality rates of women at increased risk for ovarian cancer. Methods of ovarian cancer surveillance are unproven in high-risk women. According to some studies, the use of oral contraceptives in high-risk women reduces ovarian cancer risk. Prophylactic salpingo-oophorectomy is the most effective method of cancer risk reduction in women at high risk for ovarian cancer. However, women who undergo prophylactic salpingo-oophorectomy remain at risk for primary peritoneal cancer. A minority of women with BRCA1 and BRCA2 mutations are diagnosed with occult cancer at the time of surgical prophylaxis. Surgical prophylaxis should include complete removal of the fallopian tubes and ovaries, procurement of peritoneal cytology, and thorough evaluation of the tubes and ovaries by an expert pathologist. Beginning at age 30 years, women with BRCA1 and BRCA2 germline mutations should have an annual or semiannual screening, consisting of serum CA-125 measurement and transvaginal ultrasound, until the completion of childbearing. After the completion of childbearing and by age 40 years, women should undergo prophylactic salpingo-oophorectomy.

Female↗
PubMed2002

Timing of prophylactic surgery in prevention of diverticulitis recurrence: a cost-effectiveness analysis.

Although surgery is recommended after two or more attacks of uncomplicated diverticulitis, the optimal timing for surgery in terms of cost-effectiveness is unknown. A Markov model was used to compare the costs and outcomes of performing surgery after one, two, or three uncomplicated attacks in 60-year-old hypothetical cohorts. Transition state probabilities were assigned values using published data and expert opinion. Costs were estimated from Medicare reimbursement rates. Surgery after the third attack is cost saving, yielding more years of life and quality adjusted life years at a lower cost than the other two strategies. The results were not sensitive to many of the variables tested in the model or to changes made in the discount rate (0-5%). In conclusion, performing prophylactic resection after the third attack of diverticulitis is cost saving in comparison to resection performed after the first or second attacks and remains cost-effective during sensitivity analysis.

Cohort Studies↗
PubMed1985

Time and type of prophylactic surgery for familial adenomatosis coli.

Data on 61 kinds of familial adenomatosis coli registered in Finland, including 185 affected members, were collected to evaluate the chronological evolution of carcinoma in this disease. The long-term results for 52 patients undergoing colectomy and ileorectostomy were reviewed. Colorectal carcinoma occurred in 105 patients, with cumulative percentages of 1, 6, 16, 28, and 42 at 20, 25, 30, 35, and 40 years of age. Only three out of 50 call-up patients (6%) had a carcinoma, as compared with 62% in the propositi group. No cases of rectal stump carcinomas were recorded after 52 ileorectostomies in a follow-up period of up to 21 years (mean 6 +/- 5 S.D. years). It was concluded that prophylactic colectomy must usually be performed at 20 to 25 years of age, at the latest. Despite conflicting earlier evidence, colectomy and ileorectal anastomosis may still be a viable alternative, providing that the rectal stump is very short (5 to 10 cm) and the surveillance and treatment of all new adenomas is effective.

Adenoma↗
PubMed2003

Genetic testing for a BRCA1 mutation: prophylactic surgery and screening behavior in women 2 years post testing.

Mutations in the BRCA1 gene are associated with an increased risk of breast and ovarian cancer in carrier women. An understanding of behavioral responses to BRCA1 mutation testing by mutation carriers and non-carriers is important to guide the clinical application of this new technology. This study examined the utilization of genetic testing for a BRCA1 mutation in high-risk individuals and the response of tested women with respect to interventions for early cancer detection and prevention. This study assessed the utilization of genetic testing for both men and women in a large kindred and the behavioral responses by women with respect to use of health care interventions during the 2 years following testing. Participants were offered BRCA1 mutation testing. Surveillance behaviors related to breast and ovarian cancer were assessed by computer-assisted telephone interviews at baseline (prior to genetic counseling and testing), 1-2 weeks, 4-6 months, 1 and 2 years after the provision of test results. Mutation carriers, non-carriers, and individuals of unknown mutation status were compared to determine the impact of test results. Utilization of genetic testing for both men and women are reported and, for women, mammography, breast self-exam, clinical breast exam, mastectomy, oophorectomy, transvaginal ultrasound, and CA125 screening were assessed. Of those fully informed of the opportunity for testing, 55% of the women and 52% of the men pursued genetic testing. With respect to mammography for women 40 years and older, 82% of mutation carriers obtained a mammogram in each year following testing compared to 72% of non-carrier women the first year and 67% the second year. This mammography utilization represents a significant increase over baseline for both mutation carriers and non-carriers. Younger carrier women also significantly increased their mammography utilization from baseline. Overall, 29% of the carrier women did not obtain a single mammogram by 2 years post-testing. At 2 years, 83% of the carrier women and 74% of the non-carriers reported adherence to recommendations for breast self-exam and over 80% of carrier women had obtained a clinical breast examination each year following testing. None of the carrier women had obtained a prophylactic mastectomy by 2 years after testing, although 11% were considering this procedure. Of carrier women 25 years of age and older who had at least one intact ovary at the time of testing, 46% of carriers had obtained an oophorectomy 2 years after testing, including 78% of women 40 years of age and older. The majority of carrier women (73%) had discussed their genetic test results with a medical doctor or health care provider. Our results indicate utilization of genetic testing by a majority of high-risk individuals who received information about testing. Both carriers and non-carriers increased their utilization of mammography and breast self-exam following testing. Oophorectomy was obtained by a large proportion of carrier women in contrast to mastectomy which was not utilized within the first 2 years following testing.

Adult↗
PubMed2002

Congenital lumbosacral lipomas: pitfalls in analysing the results of prophylactic surgery.

OBJECTIVES: Our objectives were to examine the assumption that the natural history of congenital lumbosacral lipomas in children presenting early and those presenting late is the same, and to determine whether there are factors that might predict the post-operative outcome of surgery among the presenting features of children with lumbosacral lipomas. METHODS: The authors present a clinical series of 50 consecutive cases of congenital lumbosacral lipoma that had been treated surgically. All patients underwent both pre- and post-operative urological assessment and pre-operative imaging with MRI. The case notes, urology assessments and MRI films were studied to provide data on the clinical presentation, follow-up history and urological outcome of the children, as well as on the anatomical features of their lipomas. RESULTS: Analysis of the data revealed a predominance in girls and a bimodal distribution of age at presentation with peaks at 0-2 and 7-8 years. Skin stigmata were more frequent in children below 6 years of age than in older children (P=0.035). The MRI scans demonstrated that the conus lay within the sacral canal more often in girls than boys (P=0.025). Severe bladder dysfunction was significantly more frequent in those presenting at =3 years of age (P=0.017) and there were more normal outcomes in patients operated upon before the age of 3 than in those operated upon at or after this age ( P<0.0001). Eight patients who had been operated upon had severe urological problems at the time of their last assessment (median age of 8 years and 2 months). They were predominantly girls with major pre-operative urological dysfunction. CONCLUSIONS: Formal pre-operative urological assessment proved to be the strongest determinant of final urological outcome. Other predictors of poor urological outcome were large lipoma size and sacral position for the lipoma. This series demonstrates how early and late presenting children may represent different patient groups, follow different natural histories and may therefore not be reliable for comparison purposes. Future studies of prophylactic untethering need to follow cohorts beyond the age of deterioration found in untreated cases (8 years) and must report the salient MRI features that we suggest are predictive of poor outcome.

Adolescent↗
PubMed1996

Choice of prophylactic surgery for the large bowel component of familial adenomatous polyposis.

The surgical options for treating the large bowel component of familial adenomatous polyposis are total proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy, with or without mucosectomy. Although the first of these eradicates all mucosa at risk, it carries several disadvantages, not least of which is a permanent ileostomy. There is little to choose functionally between the other two operations. The choice should be based on the perceived risk of cancer developing in any residual rectum; the factors influencing this risk are discussed.

Adenomatous Polyposis Coli↗