Annals of surgery
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial.
This study was designed to evaluate intra-arterial thrombolytic therapy as part of a treatment strategy for patients requiring revascularization for lower limb ischemia caused by nonembolic arterial and graft occlusion. ⋯ Surgical revascularization of patients with < 6 months of ischemia is more effective and safer than catheter-directed thrombolysis. Although ongoing/recurrent ischemia is greater in the patients undergoing thrombolysis, 30-day clinical outcomes are similar, probably because of cross-over treatment to surgery. There is no difference in efficacy or safety between rt-PA and UK, although bleeding occurs in patients with greater fibrinogen depletion. A significant reduction in planned surgical procedure is observed after thrombolysis. Patients with acute ischemia (0-14 days) who were treated with thrombolysis had improved amputation-free survival and shorter hospital stays. However, for patients with chronic ischemia (> 14 days), surgical revascularization was more effective and safer than thrombolysis. Combining a treatment strategy of catheter-directed thrombolysis for acute limb ischemia with surgical revascularization for chronic limb ischemia offers the best overall results.
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Review Comparative Study
Forty-six years of patient ductus arteriosus division at Children's Memorial Hospital of Chicago. Standards for comparison.
The authors reviewed a large surgical experience (during five decades) with ligation and division of patent ductus arteriosus (PDA) in light of previously reported historical standards and present-day alternatives. ⋯ Recurrence rates for PTDC are high with as yet unknown consequences of large catheter vascular access, endocarditis, or left pulmonary artery stenosis. Video-assisted thoracotomy for PDA interruption has the potential for uncontrolled exsanguinating hemorrhage. Open thoracotomy for PDA ligation and division can be performed safely and without recurrence through a muscle-sparing incision with short LOS. All other therapeutic interventions must be compared to these standards.
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The authors reviewed their experience with extracorporeal life support (ECLS) in neonatal respiratory failure; they define changes in patient population, technique, and outcomes. ⋯ Extracorporeal life support has become standard treatment for severe neonatal respiratory failure in our center (460 cases; 87% survival), and worldwide (8913 cases; 81% survival). The availability of ECLS makes the evaluation of other innovative methods of treatment, such as late elective repair of diaphragmatic hernia and new pulmonary vasodilators, possible. The application of ECLS is now being extended to premature and low-birth weight infants as well as older children and adults.
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Missense germ-line mutations in the RET protooncogene are associated with multiple endocrine neoplasia type 2A (MEN 2A). Detection of these mutant alleles in kindred members predicts disease inheritance and provides the basis for preventative thyroidectomy. ⋯ The PCR-based direct DNA test for RET mutations is accurate, rapid, and reproducible. For all 132 individuals evaluated, the results of direct DNA analysis were consistent with haplotype studies. The direct test for mutations in the RET protooncogene is the preferred method for screening MEN 2A kindreds. In family members who have inherited a RET mutation, total thyroidectomy is indicated, regardless of the plasma CT values.
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The authors collected, analyzed, and interpreted baseline data concerning academic surgical group practices as they function in the contemporary medical marketplace. ⋯ Academic surgical group practices are vulnerable in the current marketplace. Revenue growth will be limited in the future because of weak payer mix and broad support of academic programs, including GME, using clinical income.