A systematic review and meta-analysis of valued obstetric and gynecologic (OB/GYN) procedures in resource-poor areas.

BACKGROUND: Obstetric and gynecologic procedures are valuable in rural settings. Data identifying common procedures may better prepare surgeons to meet patient needs in remote settings. MATERIALS AND METHODS: A literature review using key MeSH terms was performed according to methods described by the Cochrane Collaboration and PRISMA on studies that described obstetric and gynecologic surgery in rural high-income countries or any setting in middle- to low-income countries. Meta-analysis was performed using random effects modeling for odds ratios of cesarean delivery and hysterectomy as proportions of total surgical volume. RESULTS: A total of 195 studies were included for qualitative synthesis and 22 for quantitative analysis. Obstetric and gynecologic procedures made up a 19% of all surgical cases. As compared to other obstetric and gynecologic surgical procedures, cesarean delivery was the most common procedure with odds ratio of 2.39 (95% confidence interval 1.48-3.86), and hysterectomy was the second most common procedure with odds ratio of 1.60 (1.57-1.64). However, heterogeneity between the studies was extremely high and risk of bias was high, limiting quality of findings. CONCLUSION: Greater provision of surgical care can be enhanced by defining which procedures are most needed, which include many obstetric and gynecologic procedures, most commonly cesarean delivery and hysterectomy.

The Evidence against Prophylactic Nasogastric Intubation and Oral Restriction.

Evidence-based perioperative care plans after colorectal surgery serve to improve quality outcome, decrease complications, and reduce medical cost. The benefits of routine nasogastric decompression and prolonged enteral restriction after bowel resection are not supported in this new era of evidence-based surgical care. Prophylactic nasogastric decompression fails to improve bowel function, length of stay, and prevent anastomotic leak, wound complications (infection, fascial dehiscence, incisional hernia), pulmonary complications (atelectasis, aspiration, pneumonia, fever, pharyngolaryngitis), and abdominal discomfort (distension, nausea, vomiting). Patients have earlier return of bowel function without the use of a nasogastric tube (NGT). Early refeeding within 24 hours after bowel resection is well tolerated in 80 to 90% of patients, and associated with earlier hospital discharge, decreased risk of infection, and improved postoperative hyperglycemic control. Abdominal discomfort is the most common complication observed in patients treated with early feeding and without a NGT, but does not result in higher therapeutic nasogastric intubation, postoperative ileus, aspiration, or other complications. The use of multimodal adjuncts in combination with these guidelines should be considered to improve outcome. The current literature is reviewed with suggestions for achieving better outcomes after colorectal resection.

Emergency management of diverticulitis.

The most common indications for emergency operative intervention in the treatment of sigmoid diverticulitis are peritonitis and failure of medical therapy. Primary resection and diversion (Hartmann's procedure) followed by delayed colostomy closure is the current standard of emergency surgical care. Guidelines for best operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. Primary resection and anastomosis with or without proximal diversion and laparoscopic lavage are alternatives to Hartmann's procedure that may provide an improved outcome in properly selected patients. Ongoing changes in the historical paradigm of the surgical approach to this disease mandate the need for large multicentered prospective randomized trials to determine the best surgical strategy under emergent conditions for the treatment of diverticulitis. The current literature is reviewed with suggestions for a management algorithm.

Management of serrated adenomas and hyperplastic polyps.

The benign serrated architecture of the hyperplastic polyp has now been recognized in morphologically similar lesions with potential for transformation to colorectal carcinoma: the sessile serrated adenoma (SSA), traditional serrated adenoma (TSA), and mixed polyp. These represent a group of serrated polyps with potential to evolve into colorectal cancer through a different molecular pathway than the traditional adenoma-carcinoma sequence, called the serrated pathway. Genetic characteristics involve a defect in apoptosis caused by BRAF and K-ras mutations that create distinct histologic characteristics of atypia in serrated architectural distortion of the crypts. An evidence-based algorithm for the clinical management of this polyp has yet to be determined. Current recommendations suggest these lesions be managed similar to conventional adenomas. The histology of serrated polyps is reviewed, as well as the common characteristics, and implications for treatment and surveillance.

Allergic reactions to isosulfan blue in sentinel lymph node mapping.

BACKGROUND: Sentinel lymph node (SLN) biopsy is often used in the assessment of lymph node status in melanoma and early stage breast cancer. With the rapidly increasing use of the technique, we can now better characterize and assess the rate of adverse reactions to the dye. METHODS: A retrospective review of all patients undergoing SLN mapping at the Columbia-Presbyterian Breast Center were identified from June 2000 to July 2002. All patients who experienced allergic reactions were documented and records examined. RESULTS: In total, three out of 351 patients had allergic complications from the procedure. All three patients developed "blue hives" after injection with isosulfan blue. The incidence at our Breast Center was 0.9%. All were treated with intravenous corticosteroids and diphenhydramine and recovered within twenty-four hours. CONCLUSIONS: The increasing utilization of the sentinel lymph node technique will make these complications more common. A high index of suspicion and appropriate clinical management are recommended to minimize the potential morbidity of these reactions.

Interpectoral nodes as the initial site of recurrence in breast cancer.

HYPOTHESIS: Interpectoral nodes can be the initial site of recurrent breast cancer. DESIGN: Retrospective review. SETTING: Comprehensive breast center, located in a university-based tertiary care center. PATIENTS: All patients undergoing operations for breast cancer at our breast center from 1995 to 2002 were reviewed. MAIN OUTCOME MEASURES: Patients with interpectoral node recurrence as the initial site of recurrent breast cancer were identified. RESULTS: During the 8-year period, 4097 patients underwent surgical management for breast cancer. During this time, 4 patients (0.1%) had recurrence at the interpectoral nodes. Three of the 4 patients were node-negative at the original operation. All lesions were mammographically occult. Preoperative needle biopsy was effective in the confirmation of malignancy. All 4 underwent excision without complications. CONCLUSIONS: Recurrence at the interpectoral nodes can be the initial site of surgical failure. These nodes may represent the site of primary drainage in a percentage of patients. The sentinel node identification technique, therefore, should diminish the number of patients affected by recurrence at this site. In patients with a palpable mass in the infraclavicular location, however, a high index of suspicion should be maintained. Workup should include additional breast imaging and needle biopsy prior to operation.

The management of lobular neoplasia identified on percutaneous core breast biopsy.

The management of lobular neoplasia (LN) found on percutaneous core biopsy remains a clinical dilemma. The purpose of this study was to establish guidelines for the management of LN when obtained on percutaneous core needle biopsy. A retrospective review of the Breast Imaging Tissue Sampling Database at New York Presbyterian Hospital-Columbia Comprehensive Breast Center was performed from 1998 to 2000. A total of 1460 percutaneous core breast biopsies were performed using 11- or 14-gauge needles with LN identified in 43 biopsies from 34 patients. Eleven biopsies were ultrasound guided for nonpalpable masses and 32 were stereotactically guided for mammographically detected densities (10) and microcalcifications (22). The 43 LN biopsies were divided into three groups based on additional findings associated with LN on core biopsy: group I (n = 19), LN with invasive cancer or ductal carcinoma in situ (DCIS); group II (n = 11), LN plus a second indication for open surgical biopsy, such as atypical ductal hyperplasia (ADH), radial scar, phyllodes tumor, or intraductal papilloma; and group III (n = 13), LN plus benign fibrocystic changes. In group I, 19 of 19 biopsies (100%) yielded invasive cancer or DCIS on surgical biopsy versus 3 of 11 (27%) for group II, and 1 of 13 (8%) for group III. Outcomes in group III are described as follows: three patients were lost to follow-up, three patients did not undergo surgical biopsy but demonstrated more than 1 year of mammographic stability following core biopsy. Of the remaining seven patients, two had LN and ADH on surgical biopsy (one had a contralateral cancer), one had atypical lobular hyperplasia (with a contralateral cancer), two had LN and benign fibrocystic changes, one had LN and intraductal papilloma, and one had LN and invasive ductal carcinoma (IDC) with DCIS (with a contralateral cancer). These results suggest that surgical biopsy is indicated for patients with LN when found on core biopsy and when the biopsy demonstrates invasive cancer, DCIS, or other indications for surgical biopsy such as ADH, or in the examination of a patient with a synchronous contralateral breast cancer. The diagnosis of LN alone without these indications on percutaneous biopsy may not warrant routine surgical biopsy.