Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer

PURPOSE: During radical prostatectomy for prostate cancer tumor at the surgical margin is a relatively frequent finding. We summarize the literature on the incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy. MATERIALS AND METHODS: The literature was reviewed for data on positive margins during radical prostatectomy for prostate cancer. RESULTS: Positive surgical margins may result from artifacts induced by tissue processing, incising inadvertently into the prostate or incising into extraprostatic tumor that has extended beyond the limits of resection. Patients with 10 ng./ml. or greater preoperative prostate specific antigen, biopsy Gleason score 7, multiple positive biopsies, or clinical stage T2b, T2c or T3 cancer have a higher risk of positive margins. Preoperative endorectal magnetic resonance imaging may be useful in staging a select group of patients. Neoadjuvant androgen deprivation reduces the incidence of positive margins but does not appear to delay progression or improve survival. The surgical approach, retropubic or perineal, may influence the location and etiology of positive margins. In general, nerve and bladder neck sparing procedures do not compromise tumor removal in appropriately selected patients. Positive margins increase the risk of progression and correlate with decreased cancer specific and overall survival. There is no consensus on the management of positive margins. External beam radiation and androgen deprivation may be administered as adjuvant therapy or at the time of recurrence. CONCLUSIONS: Tumor at the specimen edge is an adverse prognostic factor. With appropriate patient selection and meticulous surgical technique some positive margins can be prevented. Controlled prospective randomized studies of postoperative therapy are needed before definitive recommendations can be made for treating positive margins.     

The LAST operation: techniques and results before and after the stabilization era

BACKGROUND: Left anterior descending artery stabilization allows performance of left internal mammary artery grafting via a left anterior small thoracotomy on a beating heart. Our surgical experience was reviewed to assess if surgical results have improved as result of specialized instrumentation. METHODS: Of 545 patients who had the left anterior small thoracotomy operation, 261 underwent this procedure for single left anterior descending artery disease. Two groups were considered, before and after the use of specialized instrumentation: group A (n = 93), operated on from November 21, 1994, to April 20, 1996; and group B (n = 168), operated on from April 21, 1996, to December 1997. RESULTS: Early mortality was similar in the two groups. The further revascularization (operation or percutaneous transluminal coronary angioplasty) and the rate of occlusion of the conduit were higher in group A, whereas anastomotic or conduit malfunction was not. Cumulating angiography and Doppler flow evaluation, 92.5% of the anastomoses in group A and 98.8% in group B (p = 0.026) were patent, and 90.3% in group A and 97.6% in group B (p = 0.031) were patent and not restrictive. At 19 months, survival was similar, but the event-free survival was higher in group B. CONCLUSIONS: Both left anterior descending artery stabilization and safer left internal mammary artery harvesting contributed to improve angiographic and clinical results after the left anterior small thoracotomy operation.     

Intramural hematoma of the thoracic aorta: precursor sign to thoracic aortic dissection

A 60-year-old man was admitted at his local hospital for persistent chest pain and suspicion of aortic dissection. No evidence of aortic dissection or intimal disruption was noted by means of computed tomography and transesophageal echocardiography. A localized intramural hematoma of the ascending aorta was found. He was first treated medically and remained asymptomatic for 8 days when he developed a new episode of chest pain. He was found to have an acute type A dissection by computed tomography. He underwent graft replacement of the ascending aorta and had an uneventful post-operative course. This case report describes the development of true aortic dissection in a patient who previously had a localized intramural hematoma.     

Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results

A polymorphism in the UL42-UL43 region of the human cytomegalovirus genome has been characterized by nucleotide sequence analysis, revealing a 929-bp insertion following nt 54,612 relative to the published strain AD169-UK genome sequence (M.S. Chee et al., 1990, Curr. Top. Microbiol Immunol. 154, 125-170). Although AD169-UK exhibited polymorphism in this genomic region, other CMV strains (Towne, Toledo, and AD169-ATCC) carried only the newly characterized longer form. The additional sequence altered the assignment of UL42 and UL43 open reading frames. UL42 decreased in size from 157 to 125 codons, retaining 76 of the previously reported carboxyl terminal codons, and UL43 increased in size from 187 to 423 codons, retaining 185 of the previously reported amino terminal codons. This additional sequence makes UL43 a more conserved betaherpesvirus US22 family member. Only AD169-UK exhibited restriction fragment length polymorphism in this region, suggesting that a deletion occurred during the propagation of this strain in cell culture. The additional sequence should be considered a bona fide part of the cytomegalovirus genome and the AD169 genome size should be corrected to 230,283 bp.     

Psychological research and the prevention, etiology, and treatment of AIDS.

An overview of some of the issues and problems related to psychological research on AIDS and human immunodeficiency virus (HIV) infection is presented. Behavioral, cognitive, psychobiological, and neuropsychological issues are examined in relation to the development of a scientific research agenda on AIDS. The role of psychobiological variables in the etiology, treatment, and prevention of infection and disease are reviewed as they pertain to the fight against AIDS. The relation between AIDS and basic scientific processes is bidirectional in that AIDS may provide important insight into various basic processes and these same processes may also yield information useful to efforts to halt the spread of the disease. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Apico-aortic shunt: a support technique during surgery on the descending thoracic aorta

Although colloid cysts of the third ventricle are unusual in children, we have recently encountered six examples. Histologically they were lined by cuboidal, pseudostratified or columnar ciliated and mucous-secreting epithelial cells. Two cases showed small microcysts within the fibrovascular stroma surrounding the main cyst. The outermost layer consisted of a glial-ependymal envelope, in keeping with the postulated supraventricular origin of colloid cysts. Scanning electron microscopy showed 10-40% ciliated cells, and no ballooning of non-ciliated cells. Aspiration of cyst contents was performed in three patients, two of whom subsequently required surgical resection 4 months and 8 years after drainage, respectively. In adults colloid cysts may be asymptomatic, whereas in children they have not been documented as incidental findings at autopsy. Two of our six cases died, both before a diagnosis was established. A colloid cyst of the third ventricle must be included in the evaluation of acute neurological deterioration in children, in whom they are more frequently lethal.     

Video-assisted thoracic surgical procedures: the Mayo experience

In neurodegenerative disorders, hyperphosphorylated tau proteins aggregate into abnormal filaments. In the present study, tau protein alterations were studied in one corticobasal degeneration and seven Pick's disease cases using specific immunological probes. The typical lesions of corticobasal degeneration and Pick's disease were revealed by immunohistochemistry, including the presence of Pick bodies and achromatic swollen neurons, neuritic alterations, and neurofibrillary tangles. Tau-immunoreactive glial tangles were also observed. By immunoblotting, the case of corticobasal degeneration was characterized by the tau profile previously reported to occur in progressive supranuclear palsy with an intense labeling of the two tau 64 and 69 bands, while tau 55 was not visualized. In Pick's disease cases with Pick bodies and neurofibrillary tangles, a tau triplet similar to that encountered in Alzheimer's disease (tau 55, 64 and 69) was detected. Furthermore, a particular tau profile was found in four Pick's disease cases showing only Pick bodies and no neurofibrillary tangles. In these cases, tau 55 and 64 were strongly immunoreactive, whereas tau 69 was almost unlabeled. These differences are likely to be related to particular pools of tau isoforms present within the degenerating neurons. Since there is a great diversity of neurodegenerative disorders with substantial clinical and neuropathological overlap, the electrophoretic profile of tau proteins could represent a useful marker for the type of neurodegeneration.     

Endovascular stent graft repair for aneurysms on the descending thoracic aorta

BACKGROUND: The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair. METHODS: Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients. RESULTS: The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients. CONCLUSIONS: These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.     

Intravascular coagulation in surgical procedures on the abdominal aorta

A prospective study was performed on 32 consecutive patients undergoing elective operations on the abdominal aorta. Dacron prosthetic grafts were used to replace resected abdominal aortic aneurysms or to bypass aorta-iliac occlusive disease. Complete coagulation studies were performed preoperatively, immediately postoperatively and 24 hours postoperatively. Twenty to 30 per cent of the patients had significant postoperative alterations in prothrombin time, partial thromboplastin time and platelet count. Fibrin monomer, fibrin split products and plasminogen were abnormal in 40 to 80 per cent of the patients postoperatively. Results of preoperative studies showed no significant abnormalities. One of the 32 patients had mild clinical evidence of disseminated intravascular coagulation postoperatively, which was treated with 5 units of heparin per kilogram per hour. Results of the study indicate that aortic grafting procedures frequently produce intravascular coagulation, either local or disseminated. In most patients, this is offset by activation of the fibrinolytic system. However, clinically significant sequelae may result, requiring prompt recognition and treatment.     

Implant placement: surgical techniques and considerations

Successful implant surgery largely depends on good planning and meticulous technique. The former requires an appreciation of the restorative requirements and visualization of the desired end result. This may be easier for the clinician who is delivering both aspects of treatment, but in other circumstances requires close collaboration between prosthodontist and surgeon. This paper focuses on the surgical techniques involved in implant surgery, because successful osseointegration is achievable only with careful surgical preparation.     

Minimally invasive cardiac surgery in the adult: surgical instruments, equipment, and techniques

To clarify the special instruments and equipment used for minimally invasive cardiac surgery (MICS), we examined the initial experiences with MICS operations with ministernotomy or minithoracotomy at our institution. Fifty adult patients with congenital, valvular, and/or ischemic heart diseases underwent MICS operations, and all surgical procedures were completed without conversion to full sternotomy. The length of the skin incision was about 10 cm or less in all patients. Postoperative recovery was favorable, and the majority of the patients were discharged from the hospital around the end of the second postoperative week. In this series of patients, an oscillating bone saw, lifting type retractor, 2 blade spreader, cannula with a balloon, and right-angled aortic clamp among other items, were very useful for successfully performing various operations with MICS approaches and techniques. The associated results suggest that MICS with ministernotomy or minithoracotomy was feasible using special instruments and equipment and could be encouraged for adult patients with various cardiovascular diseases.     

In vivo morphology of woven, collagen-sealed Dacron prostheses in the thoracic aorta

BACKGROUND: Long-term changes in knitted Dacron grafts inserted into the infrarenal aorta have been addressed by a number of studies indicating their potential for postoperative dilatation. In contrast, the behavior of woven, collagen-presealed, double-velour Dacron grafts used to replace the thoracic aorta is not known. METHODS: Forty-five patients were examined at a mean of 32.4 +/- 14.8 months after insertion of woven, collagen-coated, Dacron double-velour prostheses (Meadox woven with Hemashield, Meadox, Oakland, NJ) in the thoracic position under highly standardized conditions using spiral computed tomography. RESULTS: Compared with a manufactured diameter of 26 mm, all grafts showed an increase of 1 to 5 mm (mean, 3.0 +/- 1.2 mm [11.6% +/- 4.4%]; p < 0.0001) with greater enlargement of the ascending than of the descending aortic portions (p = not significant). A further statistically significant progressive dilatation failed to occur. Degenerative changes, including false aneurysm formation, could be excluded. CONCLUSIONS: Woven, collagen-coated Dacron prostheses are considered a safe replacement material for the thoracic aorta.     

Video-assisted thoracic surgical resection with the neodymium:yttrium-aluminum-garnet laser

Since January 1991, we have performed 79 video-assisted neodymium: yttrium-aluminum-garnet laser resections for pulmonary nodular or interstitial disease. Pathologic examination demonstrated malignancy in 59 patients (32 primary and 27 metastatic), benign nodules in 11, interstitial processes in seven, and granulomatous disease in two. There were 39 men and 40 women with a mean age of 63.4 +/- 12.5 years. Thirty-nine patients underwent resection with the neodymium:yttrium-aluminum-garnet laser alone and 40 had lesions resected with a combination of laser and endoscopic stapling. Laser excision was performed for lesions deep in the substance of the lung or on its effaced surface; both are locations that make stapling alone difficult. Fifteen of 32 patients with a diagnosis of primary lung malignancy underwent open anatomic resections. Pulmonary reserves of the other 17 patients were inadequate for further resection. Operative time, duration of chest tube placement, length of hospital stay, and complication rate were compared with those for 72 patients undergoing video-assisted thoracic surgical resection of nodules with staplers alone. Although operative time for laser-assisted procedures was longer (p < 0.05), there were no differences in duration of chest tube placement or hospital stay compared with stapled resections. The complication rate for laser-treated cases was not higher than for stapled resections and consisted primarily of air leaks lasting 2 to 7 days. The neodymium:yttrium-aluminum-garnet laser is a safe and precise primary or adjunctive tool for video-assisted thoracic surgical pulmonary resection.     

Blunt traumatic disruption of the thoracic aorta: a rare injury in children

Rupture of the thoracic aorta secondary to blunt chest trauma is an exceedingly uncommon injury in pediatric patients. We present a case of blunt traumatic aortic disruption in a 10-year-old child who was successfully managed by primary aortic repair using partial cardiopulmonary bypass. The epidemiology and pathophysiology of this injury, with particular reference to children, is reviewed. The ongoing controversies regarding the diagnosis and operative management of this injury are summarized.     

Left hemothorax, a complication of a dissecting aneurysm of the descending thoracic aorta

A woman of 93 was admitted to hospital with a left pleural effusion. The presence of an unrecognised aneurysm of the descending thoracic aorta, lying posteriorly, led to an inadvertent puncture of the aorta. The diagnosis of a haemothorax due to dissection of the aneurysm was supported by echocardiography, and confirmed by angio-scanning.