Open versus stereotactic breast biopsy.

BACKGROUND: Stereotactic breast biopsy has been developed as a less invasive means of performing biopsy for mammographic abnormalities. METHODS: From July 1994 through June 1995, 103 women with mammographic abnormalities requiring biopsy were prospectively evaluated. RESULTS: Fifty-one women had open biopsy, and 52 women had stereotactic biopsy. The average age in both groups was 60 years. Pathology revealed malignancy in 12% of stereotactic biopsies and 13% of open biopsies. Complications occurred in 6% of the open biopsies and 4% of the stereotactic biopsies and were limited to hematomas or seromas. The average cost was $2400 for open biopsy and $650 for stereotactic biopsy (P < 0.01). One hundred and one patients returned for a follow-up mammogram within 6 months, and 1 patient in each group required a second biopsy, which revealed benign pathology. A Patient Satisfaction Survey revealed no significant differences in patient satisfaction between the two types of procedures. CONCLUSION: There were no differences between open and stereotactic biopsies in regards to diagnostic accuracy, complications, or patient satisfaction. A significant difference was noted in charges during the time frame of our study.

A prospective randomized trial comparing open versus laparoscopic appendectomy.

OBJECTIVE: The authors determined whether there was an advantage to laparoscopic appendectomy when compared with open appendectomy. SUMMARY/BACKGROUND DATA: The advantages of laparoscopic appendectomy versus open appendectomy were questioned because the recovery from open appendectomy is brief. METHODS: From January 15, 1992 through January 15, 1993, 75 patients older than 9 years were entered into a study randomizing the choice of operation to either the open or the laparoscopic technique. Statistical comparisons were performed using the Wilcoxon test. RESULTS: Thirty-seven patients were assigned to the open appendectomy group and 38 patients were assigned to the laparoscopic appendectomy group. Two patients were converted intraoperatively from laparoscopic appendectomies to open procedures. Thirty-one patients (81%) in the open group had acute appendicitis, as did 32 patients (84%) in the laparoscopic group. Mean duration of surgery was 65 minutes for open appendectomy and 87 minutes for laparoscopic appendectomy (p < 0.001). There were no statistically significant differences in length of hospitalization, interval until resumption of a regular diet, or morbidity. Duration of both parenteral and oral analgesic use favored laparoscopic appendectomy (2.0 days versus 1.2 days, and 8.0 days versus 5.4 days, p < 0.05). All patients were instructed to return to full activities by 2 weeks postoperatively. This occurred at an average of 25 days for the open appendectomy group versus 14 days for the laparoscopic appendectomy group (p < 0.001). CONCLUSIONS: Patients who underwent laparoscopic appendectomies have a shorter duration of analgesic use and return to full activities sooner postoperatively when compared with patients who underwent open appendectomies. The authors consider laparoscopic appendectomy to be the procedure of choice in patients with acute appendicitis.

Laparoscopic-assisted bowel surgery.

The use of laparoscopic surgical techniques is now being applied to a variety of operations traditionally performed in an open fashion. Twenty patients underwent laparoscopic-guided large and small bowel surgery at our institution from March 1991 to April 1992. The indications for surgery included polyps, obstruction, bleeding, and perforation, and pathologic diagnoses included benign polyps, lipomas, inflammatory bowel disease, perforation of a jejunal diverticulum, colonic arteriovenous malformations, and adenocarcinoma. Mobilization of the colon, ligation of the mesentery, and closure of the mesenteric defect were performed using the laparoscopic equipment. One trocar site was enlarged to 3 cm to deliver the bowel through the abdominal wall. All anastomoses were hand-sewn. Postoperative hospitalization ranged from 2 to 31 days (median, five days). No mortality was noted, and morbidity was 20 percent. We conclude that laparoscopic-guided bowel surgery is technically feasible and should translate into shorter hospitalization and less patient discomfort.

Safety and efficacy of total thyroidectomy for differentiated thyroid carcinoma: a 20-year review.

Controversy continues to exist regarding the optimal extent of resection for differentiated thyroid carcinoma (DTC). Subtotal thyroidectomy has been advocated by some authors in expectation of lower complication rates, while others advocate total thyroidectomy to achieve better cure rates. To examine this issue, the medical records of 124 patients who underwent total thyroidectomy for DTC were retrospectively reviewed. Total thyroidectomy was the initial procedure in 115 patients, while nine patients had complete thyroidectomy following some type of subtotal resection. Concomitant procedures were performed in 47 patients. Ninety papillary, 20 mixed papillary-follicular variant, one Hürthle cell type, and 13 follicular carcinomas were performed. Tumors were bilateral or multicentric in 40 patients, with metastases present in one-third of patients at the same time of initial operation. Permanent hypoparathyroidism developed in two patients, and permanent ipsilateral recurrent laryngeal nerve palsy occurred in one patient, for an overall significant complication rate of 2.4 per cent. Tumor recurrence was noted at a mean of 19 months postoperatively in 14 patients. Ninety-six patients received adjuvant postoperative radioiodine therapy to ablate residual functioning thyroid tissue or suspected metastases. We conclude that total thyroidectomy as treatment for differentiated thyroid carcinoma carries a low rate of morbidity, treats occult contralateral disease, and should facilitate radioiodine scanning and ablation of residual functioning thyroid tissue or metastatic disease.

Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function.

Upper abdominal surgery is associated with characteristic changes in pulmonary function which increase the risk of lower lobe atelectasis. Sixteen patients undergoing open cholecystectomy and 20 patients undergoing laparoscopic cholecystectomy were prospectively evaluated by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume [FEV-1], and forced expiratory flow [FEF] 25% to 75%) before operation and on the morning after surgery to determine if the laparoscopic technique lessens the pulmonary risk. Fraction of the baseline pulmonary function was calculated by dividing the postoperative pulmonary function by the preoperative pulmonary function and multiplying by 100%. Postoperative FVC measured 52% of preoperative function for open cholecystectomy and 73% for laparoscopic cholecystectomy (p = 0.002). Postoperative FEV-1 measured 53% of baseline function for open cholecystectomy and 72% for laparoscopic cholecystectomy (p = 0.006). Postoperative FEF 25% to 75% measured 53% for open cholecystectomy and 81% for laparoscopic cholecystectomy (p = 0.07). It is concluded that laparoscopic cholecystectomy offers improved pulmonary function compared to the open technique.

Current status of genitourinary fistula.

From 1970-1985, 303 women with genitourinary fistulas were seen at the Mayo Clinic. The fistula formed after treatment for benign conditions in 74% of the patients and malignant conditions in 14%; in 12%, we were unable to establish the nature of the condition. Gynecologic surgery was responsible for 82% of the fistulas, obstetric procedures for 8%, various forms of irradiation for 6%, and trauma or fulguration for 4%. In the nonirradiated patient, the ideal time for operative repair was eight to 12 weeks after fistula formation or failed repair. With ureterovaginal fistulas, the patient's general condition and the degree of obstruction of the ureter influenced the time and method of repair. We used a vaginal approach for urethral fistulas and an abdominal one for ureteral repairs. Because of difficulty with adequate exposure and the proximity of the ureter, an abdominal approach was used in 20% of the patients with vesicovaginal fistulas; the remaining 80% were approached vaginally, regardless of size, number, or history of previous repairs. Ninety-two percent of the urethrovaginal fistulas were corrected on the first attempt; the four failures were managed successfully at the second attempt. Ninety-eight percent of the vesicovaginal fistulas were corrected on the first attempt when approached vaginally, and all were managed successfully when approached abdominally, regardless of the number, size, or previous operative attempts.

Presacral tumors in the female: clinical presentation, surgical management, and results.

A relatively infrequent and heterogeneous group of tumors with similar clinical presentation may arise in the presacral space. From 1965-1980, 70 female patients with primary presacral tumors underwent surgical management at the Mayo Clinic. Twenty-three percent had no symptoms, and their tumors were found on routine pelvic examination. Most of the symptoms resulted from compression or obstruction of adjacent organs or from pressure on pelvic nerves or bone. A palpable tumor was found in 65 (93%) of the patients. Computed tomography scan has proved valuable in determining the extent and degree of tumor invasion. The abdominal approach was selected in 39 (56%), transsacral in 20 (28%), abdominal/perineal in six (9%), and transperineal in five (7%). Complications occurred in 22 patients (31%). However, there were no operative deaths. Seventy percent of the tumors were benign, and 30% were malignant. The prognosis for patients with benign tumors was excellent and their symptoms were relieved. All 21 patients with malignant tumors died between three months and four years after surgery. Survival was not prolonged by the use of radiation or chemotherapy.

Management of nonpalpable breast abnormalities.

From January 1982 to June 1986, 444 patients had localization of 500 nonpalpable mammographically suspicious lesions using the Kopans hook wire technique. Four hundred ninety-nine biopsies were performed in 443 patients. Cancer was identified in 12% of the biopsies performed for a suspicious mass or density and in 20% of biopsies performed for suspicious calcifications. Carcinoma was identified in a total of 72 biopsies (14%) performed in 65 patients; 82% of the malignant lesions were invasive. All lesions were small; 76% of the cancers were 1.0 cm or less in diameter. Sixty-two axillary dissections were performed of which seven (11%) had positive nodes. Advantages of preoperative needle localization include precise localization of the lesion, a small incision, and removal of a small amount of breast tissue with no cosmetic deformity. Outpatient biopsy of these lesions can be easily performed under local anesthesia. Identification and treatment of these small preclinical cancers should lead to improved survival from breast cancer.

The incidence of colon carcinoma complicating ulcerative colitis.

The tendency for development of cancer in patients with ulcerative colitis is well documented. Each physician must take into account the clinical presentation of the patient and the known risk factors and must adapt follow-up and consultation to the patient and family accordingly. Presently, after a 5- to 7-year history of ulcerative colitis, it is reasonable to document mucosal changes with air-contrast barium enema examination and laboratory assessment with carcinoembryonic antigen levels being obtained. If the extent of disease is more limited to the distal colon, then the surveillance should be modified accordingly because the relative risk is reduced. In the future, the addition of histochemical and immunohistologic analysis of mucosal biopsies will result in better criteria for patient selection for surgical intervention. Because of the delay in recognition of a cancerous lesion in patients with ulcerative colitis, a total proctocolectomy is recommended by some after the first decade of disease. Most prefer, however, to continue surveillance of some type. During surveillance, if moderate or severe dysplasia is found, a proctocolectomy should be performed. This mode of surveillance and treatment of patients at risk for developing colonic carcinoma subsequent to ulcerative colitis remains an evolving process. There will be further changes in management following better classification of the neoplastic changes and the discovery of the etiology of the disease process itself.

Urinary diversion with use of ileal and sigmoid conduits.

Two hundred eighteen patients underwent urinary diversion: 156 with ileal and 62 with sigmoid conduits. There were no significant differences between the two groups regarding frequency of conduit morbidity or patient survival. The ileal conduit is preferred for urinary diversion with anterior exenteration, whereas the sigmoid conduit is preferable for urinary diversion with total exenteration.

Surgical management of complicated diverticulitis.

The majority of patients with acute diverticulitis can be managed medically. Some will have a complication of diverticulitis such as free perforation with peritonitis, abscess formation, obstruction, or fistula formation. Perhaps even a larger number will develop recurrent diverticulitis, which is associated with an increased rate of complications. Although the preoperative diagnosis of these problems may be obvious in many patients, elderly or steroid-treated patients may have few manifestations of significant intra-abdominal disease. Of extreme importance in the management of these complications of diverticulitis is the preoperative resuscitation. Intravascular volume depletion is replaced with intravenous fluids, and intravenous antibiotics are given. At this time, with any of these complications, it is unusual to perform the classic three-stage operation, which includes an initial diverting colostomy and drainage followed by resection of the involved colon and, finally, a colostomy closure as the third stage. The usual treatment now is a two-stage operation with the initial operation being resection of the diseased segment and formation of a colostomy proximally and either a mucous fistula or a Hartmann's pouch distally. The second stage is the colostomy closure. This two-stage approach is indicated in patients with acute diverticulitis complicated by perforation, whether free or confined with abscess formation, and in patients with obstruction or fistula formation in whom a preoperative bowel preparation is not possible. Resection and primary anastomosis should not be performed in the elderly in the emergency setting for complicated diverticulitis. However, this is the procedure of choice in the elective treatment of diverticulitis and its complications in the elderly.

Palliative exenteration--what, when, and why?

Between 1955 and 1981, 323 pelvic exenterations were performed at the Mayo Clinic. Fifty-nine (18%) were considered retrospectively to be palliative because of pelvic or aortic nodal metastasis, pelvic peritoneal involvement, pelvic wall involvement, bone involvement, or, in two cases, distant metastasis. The survivals were 47% at 2 years and 17% at 5 years. When metastatic nodal disease was found after irradiated pelvic recurrence, the 2- and 5-year survivals were 46% and 23%, respectively. Although exenteration procedures are designed to be curative, the palliative benefits obtained in this group of patients appear to be worthwhile and comparable to those achieved in advanced epithelial ovarian carcinoma for which aggressive surgical management is now strongly advocated.

Surgery for morbid obesity. Appraisal of old and new techniques.

Morbid obesity is a serious and sometimes lethal disease of unknown etiology. Nonsurgical treatment has not been successful in producing permanent weight loss. Surgical treatment does reliably result in weight loss but is not a cure and is not indicated for all morbidly obese patients. Jejunoileal bypass, the first operation devised for morbid obesity, usually produces excellent weight loss but has high rates of morbidity and mortality. For this reason, it is not currently advised by most surgeons. Gastric bypass reduces morbidity and mortality without compromising weight loss; however, it is technically more difficult than jejunoileal bypass. The newest operations for morbid obesity are variations of gastroplasty. If correctly performed, they will produce satisfactory weight loss with the lowest morbidity rates of all the operations for morbid obesity. However, long-term results for these procedures are not yet available. Therefore, the ideal operative procedure for morbid obesity has yet to be identified.

Melanoma of the vulva: an update.

During the time interval 1950 through 1980, 48 patients having a mean age of 60.2 years were treated primarily for melanoma of the vulva. In all but one patient, a surgical therapeutic approach was selected, including 40 modified Basset procedures and 23 pelvic lymphadenectomies. The 5-year survival rate of the eligible population was 54%. Although surgical staging according to the classification established by the International Federation of Gynecology and Obstetrics (FIGO) was of minimal value, microstaging, using Clark's and Breslow's stratifications for assessing dermal penetration, was of prognostic significance. Ten-year survival rates associated with Clark's level II, III, IV, and V tumors were 100, 83, 65, and 23%, respectively. Histologic growth patterns (5-year survival rates of 71 and 38% for superficial spreading and nodular melanomas, respectively) and groin nodal metastasis were cogent prognostic factors and indirectly were related to depth of local tumor invasion. Likewise, assessment of treatment failures demonstrated a positive correlation between recurrences (specifically at distant sites) and Clark's level of melanocytic penetration. Because of the unacceptably high (32%) local treatment failure rate despite radical vulvar resection, treatment modifications for vulvar melanoma are imperative.

Carcinoma of the vulva: analysis of treatment and survival.

The treatment of 224 patients with invasive squamous cell carcinoma of the vulva over a 20-year interval at the Mayo Clinic resulted in an overall survival rate of 75%, compared with 89% for age-matched controls. For patients with stage I disease, 5-year survival was 90%; for those with stages II, III, and IV, it was 81, 68, and 20%, respectively. A precipitous decline in survival rates was noted when metastases to regional nodes were encountered, when lesion size was more than 3 cm, and when histologic dedifferentiation exceeded grade 2. Incorrect clinical staging efforts were observed in 25% of the cases, so the necessity for surgical staging was apparent.

Carcinoma of the vulva: analysis of treatment failures.

Continuous follow-up of 224 patients treated for primary invasive squamous cell carcinoma of the vulva in a 20-year period (1955 to 1975) at the Mayo Clinic resulted in the detection of recurrent (or persistent) neoplasia in 59 (26%). Rates of treatment failure increased with advancing stage of disease-from 14% for Stage I to 71% for Stage IV. The rate of local vulvar recurrence was 18%, which was about three times greater than the recurrence rates for the groin, pelvis, and distant sites. However, the 1- and 5-year survival rates of 73% and 50%, respectively, after vulvar recurrence were in sharp contrast to the corresponding rates of 34% and 10% for regional or distant recurrence. When 35 patients with central vulvar extension of disease were evaluated, groups at excessive risk for treatment failure (lesions 4 cm or larger inguinal node involvement, or both) were identified and modifications in conventional therapy applicable to these groups were considered.

Nutritional support of the surgical patient.

Malnutrition, unfortunately, is not uncommon and malnourished patients suffer increased morbidity and mortality from surgery. Identification of protein-calorie deficient patients can be performed rapidly and inexpensively through standard techniques of nutritional assessment. If the gastrointestinal tract is available, safe and economic nutritional support may be provided by mouth or by tube feeding. If the gastrointestinal tract cannot be utilized, total parenteral nutrition (TPN) may be instituted via a central vein, or in selected instances peripheral amino acids, fat emulsions, or both may suffice. When failure of various organs (heart, kidneys, liver) complicates malnutrition and the underlying surgical condition, adequate nutritional support can and should be provided by adjustment of the amount and content of commercially available nutritional formulations. Optimal surgical care demands the identification and appropriate nutritional support of malnourished patients.