Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement.

BACKGROUND: Gastroparesis is a chronic digestive disorder with symptoms of nausea, vomiting, bloating, and abdominal pain resulting in a poor quality of life. Surgeons are increasingly asked to treat patients with gastroparesis as medical options have become limited due to safety concerns of many prokinetics. Surgical options include gastric stimulator implantation, sub-total gastrectomy, and pyloroplasty. We report our experience with minimally invasive pyloroplasty as sole surgical treatment for adult gastroparesis. MATERIALS AND METHODS: A retrospective review of prospectively collected data of 28 patients who underwent minimally invasive pyloroplasty alone as treatment for gastroparesis from Jan 2007 to Sept 2010. Pre- and postoperative symptom severity score (SSS), gastric emptying scintigraphy (GES), and medication use were reviewed. RESULTS: A laparoscopic Heineke-Mikulicz pyloroplasty was performed in 26 patients. A laparoscopic assisted, flexible trans-oral endoscopic circular stapled pyloroplasty was used in two patients. Prokinetic use was significantly reduced from 89% to 14% (p = <0.0001). The mean GES T1/2 decreased from 320 to 112 min (p = 0.001) and normalized in 71%. Significant improvements in the SSS were seen at 1 month for nausea (p = <0.0001), vomiting (p = <0.0001), bloating (p = 0.0023), abdominal pain (p = <0.0001), and gastroesophageal reflux disease (GERD) symptoms (p = 0.0143). Significant improvement persisted at 3 months for nausea (p = <0.0001), vomiting (p = <0.0001), bloating (p = 0.0004), abdominal pain (p = 0.0001) and GERD symptoms (p = 0.013). The average length of stay was 3.71 days. Overall, 83% of patients' indicated that they saw improvement at 1 month follow-up. CONCLUSION: Minimally invasive pyloroplasty provides excellent outcomes for patients with gastroparesis and should be considered as a primary treatment along with diet and medications as it is effective and does not eliminate the option for additional surgical options in the future for refractory disease. With technological advancements, a totally endoscopic pyloroplasty may be a less invasive option.

Preoperative chemotherapy for operable breast cancer is associated with better compliance with adjuvant therapy in matched stage II and IIIA patients.

INTRODUCTION: Preoperative chemotherapy (PC) for operable breast cancer has shown significant benefits in prospective trials. Many patients are treated in the community setting and some may question the applicability of PC outside the university setting. METHODS: Retrospective review was performed of stage II and IIIA breast cancer patients treated from January 2002 to July 2009. Fifty-three of 57 patients who underwent PC were matched based on age, tumor size, and hormone receptor status with 53 patients who did not undergo PC. Differences in patient compliance with physician recommendations for all types of adjuvant therapy were evaluated. Crude odds ratios and adjusted odds ratios derived from conditional logistic regression models were calculated. RESULTS: There were 106 patients included. Patient compliance with chemotherapy was better in the PC group than in the adjuvant chemotherapy (AC) group (100% versus 70%; p = .0001). Similarly, more patients in the PC group completed radiation therapy (96% versus 65%; p = .0003) and initiated hormonal therapy (100% versus 62%; p = .0001). Conditional logistic regression revealed that higher pathologic stage and current cigarette smoking were associated with poorer compliance with chemotherapy. For radiation therapy, the univariate model revealed that compliance with chemotherapy and being employed were associated with completion of radiation, whereas current cigarette smoking and larger pathologic size were associated with poorer compliance with radiation. For hormonal therapy, current cigarette smokers were more likely to be noncompliant with initiation of hormonal therapy. CONCLUSIONS: PC for operable breast cancer can improve patient compliance with chemotherapy. Current cigarette smokers were more likely to be noncompliant with all types of adjuvant therapy.

Preoperative chemotherapy for operable breast cancer improves surgical outcomes in the community hospital setting.

BACKGROUND: Preoperative chemotherapy (PC) for operable breast cancer has demonstrated significant benefits in clinical trials. Many patients are treated in the community setting and some may question the applicability of PC outside the university setting. The potential benefits of PC in terms of surgical outcomes in a community practice were examined. METHODS: A retrospective review was performed of stage II and stage IIIA breast cancer patients from January 1, 2002 to July 31, 2009. Surgical outcomes of margin status, volume of lumpectomy, rate of lumpectomy, and re-excision lumpectomy were evaluated. RESULTS: There were 212 patients included. Seventy-nine percent of patients who underwent PC had a clinical response and 25% had a pathologic complete response. For clinical stage T2 and stage T3 tumors, the PC group underwent lumpectomy more often than patients in the adjuvant chemotherapy (AC) group (78% versus 50%; p = .016 and 60% versus 29%; p = .015, respectively). The rate of close or positive margins in the PC group was half the rate in the AC group (23% versus 46%; p = .04) and this resulted in fewer re-excisions (p = .01). The volume of tissue removed was also smaller in the PC group (143.6 cm³ versus 273.9 cm³; p = .003). Conclusions. PC for operable breast cancer can significantly improve surgical outcomes in community-based practice.

Empiric, broad-spectrum antibiotic therapy with an aggressive de-escalation strategy does not induce gram-negative pathogen resistance in ventilator-associated pneumonia.

BACKGROUND: Early, empiric, broad-spectrum antibiotics followed by de-escalation to pathogen-specific therapy is the standard of care for ventilator-associated pneumonia (VAP). In our surgical intensive care unit (SICU), imipenem-cilastatin (I-C) in combination with tobramycin (TOB) or levofloxacin (LEV) has been used until quantitative bronchoalveolar lavage results are finalized, at which time de-escalation occurs to pathogen-specific agents. With this practice, however, alterations in antimicrobial resistance remain a concern. Our hypothesis was that this strict regimen does not alter antimicrobial susceptibility of common gram-negative VAP pathogens in our SICU. METHODS: After Institutional Review Board approval, a retrospective review of SICU-specific antibiograms was performed for the sensitivities of common gram-negative VAP pathogens. Time periods were defined as early (January-June 2005) and late (July-December 2006). Chart review of empiric and de-escalation antibiotic usage was obtained. Data were collated, and statistical significance was assessed with the chi-square test using the on-line Simple Interactive Statistical Analysis tool. RESULTS: Imipenem-cilastatin was used 198 times for empiric VAP coverage (811 patient-days), whereas TOB and LEV were given a total of 149 (564 patient-days) and 61 (320 patient-days) times, respectively. Collectively, the susceptibility of gram-negative organisms to I-C did not change (early 91.4%; late 97%; p = 0.33). Individually, non-significant trends to greater sensitivity to I-C were noted for both Pseudomonas aeruginosa (early 85.7%; late 90.9%; p = 0.73) and Acinetobacter baumannii (early 80%; late 100%; p = 0.13). Further, both TOB (early 77.1%; late 70.0%; p = 0.49) and LEV (early 74.3%; late 70.0%; p = 0.67) were found to maintain their susceptibility profiles. The frequency of resistant gram-positive VAPs was unchanged during the study period. Our de-escalation compliance (by 96 h) was 78% for I-C, 77.2% for TOB, and 59% for LEV. When infections requiring I-C were removed from the analysis, de-escalation compliance was improved to 92%. CONCLUSIONS: In our SICU, early, empiric broad-spectrum VAP therapy followed by de-escalation to pathogen-specific agents did not alter antimicrobial resistance and is a valid practice. Further, our compliance with de-escalation practices was higher than published rates.