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This Month in Archives of Surgery
Arch Surg. 2003;138:1172.
Dr Veronesi and his group at the European Institute of Oncology attempted to shorten the period of irradiation for patients undergoing breast conservation surgery and determine whether full-dose intraoperative radiation therapy with a linear accelerator to the local area (without irradiating the axilla, supraclavicular area, or other parts of the surgically treated breast) is as effective as whole-breast radiotherapy after local excision with or without positive margins. After a 19-month follow-up, the rate of posttreatment complications was very low. Three patients (1.4%) developed ipsilateral breast cancer; 1 (0.5%), supraclavicular node metastasis; and 1 (0.5%), distant metastases. This type of treatment, performed in 237 patients with breast cancer, looks extremely promising.
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The other important aspect of breast cancer research deals with pulse oximeter changes with the use of isosulfan blue for sentinel lymph node identification. Examining the anesthesia records of 92 patients who underwent a sentinel lymph node biopsy with intraparenchymal injection of isosulfan blue, the Columbia-Presbyterian Medical Center group found interference with pulse oximeter readings for up to 3 hours. Although these changes can be significant, the course appears predictable. In most otherwise healthy patients with normal pulmonary function, invasive monitoring is not necessary.
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Greenfield and Proctor from the University of Michigan examined 175 patients with septicemia who had vena caval filters. No adverse events were related to sepsis, and no filter was removed. Follow-up data were available for 56 patients with a combined recurrent pulmonary embolus and caval occlusion rate of 1.7%. The Greenfield filter appears to be a safe method of prophylaxis for patients with septicemia.
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Laparoscopic vs Open Colectomy: Outcomes Comparison Based on Large Nationwide Databases
On the issues of length of hospital stay, in-hospital complications, and rate of routine discharge, this group from Duke University Medical Center found that laparoscopic sigmoid resection in patients with diverticular disease had statistically and clinically significant advantages compared with open sigmoid resection.
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One Thousand Fifty-Six Hepatectomies Without Mortality in 8 Years
Congratulations are due to this team from the University of Tokyo that performed 1056 consecutive hepatic resections: 532 for hepatocellular carcinoma, 262 for other primary and secondary liver malignancies, 57 for biliary tract malignancy, 174 for living donor liver transplantation, and 31 for other benign disease. There was no mortality, and major complications occurred in only 3% of patients with hepatocellular carcinoma, 8% with other liver malignancy, 28% with biliary tract malignancy, and 5% of donors. Independent factors for major complications included an operative time greater than 6 hours, a total bilirubin level of 1.0 mg/dL or higher ( 17 µmol/L), and blood loss of more than 1000 mL. Meticulous attention to the balance between liver functional reserve and the volume of liver to be removed proved invaluable. Please also see the Invited Critique.
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Causalgia: A Meta-analysis of the Literature
Employing a database for English-language articles up to the year 2000, the authors noted that cases of causalgia were easy to recognize and treat, with excellent results. Causalgia always follows a somatic nerve injury, usually partial, and is associated with near-constant, severe pain (predominantly a burning quality) distal to the injury in the extremity. An effective anesthetic block of the appropriate part of the sympathetic chain often immediately relieves the pain, and the majority of patients are cured by sympathectomy.
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SECTION EDITOR: GERALD W. PESKIN, MD
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