Surgical treatment of melanoma patients with early sentinel node involvement.

Sentinel lymph node biopsy (SLNB) is a standard staging procedure for many patients with clinically node negative, invasive melanoma, providing excellent prognostic information in appropriately selected patients. The broad acceptance of SLNB into clinical practice has resulted in substantial numbers of patients found to have microscopic nodal metastases. For patients with a positive sentinel node, a completion lymph node dissection (CLND) is the current standard of care. The majority of patients who undergo CLND are found to have histologically negative non-sentinel nodes, and yet are exposed to the potential morbidity of CLND, including infection, wound complications, and lymphedema. We do not yet know if there is a survival benefit from CLND that justifies its morbidity and we are currently unable to identify clinical and pathologic factors that may be associated with the likelihood of benefit from CLND. Controversy regarding the management of melanoma patients with a positive sentinel node highlights the need for continued investigation in melanoma biology, treatment, and outcomes. Patients with minimal tumor burden in their regional nodes would especially benefit from a better understanding of the appropriate management strategies. Ongoing clinical trials are aimed at determining whether CLND is superior to nodal observation and surveillance in patients with positive sentinel nodes, and at determining the outcome of patients with minimal disease in their sentinel node who forego CLND. These studies may help to resolve the uncertainties of the management in these patients. Until we have further information, CLND for melanoma patients with positive sentinel nodes remains the preferred, standard management strategy.

Experience with dedicated geriatric surgical consult services: meeting the need for surgery in the frail elderly.

BACKGROUND: Surgeons are increasingly faced with consultation for intervention in residents of geriatric centers or in patients who suffer from end stage medical disease. We review our experience with consult services dedicated to the needs of these frail patients. STUDY DESIGN: Patients were prospectively followed after being evaluated by three different geriatric surgical consult services: Group 1 was based at a geriatric center associated with a tertiary medical center, Group 2 was based at a community geriatric center, and Group 3 was based with an hospital-based service for ambulatory patients with end stage congestive heart failure. RESULTS: A total of 256 frail elderly patients underwent of 311 general surgical procedures ranging from major abdominal and vascular procedures to minor procedures such as debridement of decubitus ulcers, long-term intravenous access, enterostomy and enteral tube placement. Almost half of the surgical volume in Group 1 and 3 were 'maintenance' (decubitus debridement, long term intravenous or stomal or tube care); all of Group 2 were for treatment of decubiti. There was minimal morbidity and mortality from surgery itself, and overall one year survival for Groups 1, 2, and 3 was 46%, 60%, and 79%, respectively. Multivariate analysis showed that each group had its own unique indicators of decreased survival: Group 1 dementia and coronary artery disease, in Group 2 gender and coronary artery disease, and Group 3, gender alone. Age, number of comorbid illnesses, and type of surgery (major vs minor) were not significant indicators. CONCLUSIONS: This is the first review of the role of dedicated surgical consult services which focused on residents of geriatric centers and frail elderly. Conditions routinely encountered in this population such as dementia, end stage disease, multiple comorbidities, polypharmacy, decreased functional and nutritional status are not frequently encountered by general surgeons. But the surgery is safe, and survival data is comparable to those in geriatric centers who did not undergo surgery. A multidisciplinary team approach gives the most effective care, with a primary goal of palliation.

Invasive amebiasis and ameboma formation presenting as a rectal mass: An uncommon case of malignant masquerade at a western medical center.

A 54-year-old man presented with rectal pain and bleeding secondary to ulcerated, necrotic rectal and cecal masses that resembled colorectal carcinoma upon colonoscopy. These masses were later determined to be benign amebomas caused by invasive Entamoeba histolytica, which regressed completely with medical therapy. In Western countries, the occurrence of invasive protozoan infection with formation of amebomas is very rare and can mistakenly masquerade as a neoplasm. Not surprisingly, there have been very few cases reported of this clinical entity within the United States. Moreover, we report a patient that had an extremely rare occurrence of two synchronous lesions, one involving the rectum and the other situated in the cecum. We review the current literature on the pathogenesis of invasive E. histolytica infection and ameboma formation, as well as management of this rare disease entity at a western medical center.

Treatment of symptomatic vascular rings in the elderly.

A 76-year-old woman presented with respiratory failure that was later determined to be a result of a right aortic arch with an aberrant left brachiocephalic artery. This vascular ring compressed the trachea, requiring operative intervention. A median sternotomy gave access for an aorta-to-left brachiocephalic artery bypass and division of the vascular ring. This is a unique case, because vascular rings rarely present in elderly patients with such acute life-threatening symptoms. To our knowledge, this is the oldest and heaviest patient ever reported with symptomatic presentation and one of only 4 patients over the age of 50. The current literature on vascular rings of the thoracic aorta in adults is reviewed.

Surgery in the elderly: the evolving role of palliative care in general surgical practice.

Palliative care will continue to be an evolving part of general surgical practices, especially with an expanding elderly population. The challenge to a surgeon remains, namely, understanding when palliation is a better alternative to aggressive therapeutic measures. The transition from curative intervention to palliative care is aided by honest communication between physician and patient and respect for dying with dignity. An intimate understanding of the multidimensional nature of palliative care will enable a surgeon to provide appropriate care for a terminal patient.