Impact on regional recurrence and survival of axillary surgery in women with node-negative primary breast cancer.

BACKGROUND: This study examined whether axillary lymph node dissection (ALND) with removal of many normal lymph nodes resulted in a reduced rate of axillary recurrence and better survival, as reported in recent studies. METHODS: The follow-up analyses were based on 8657 patients with node-negative primary breast cancer treated solely by surgery. Median follow-up was 9 years. RESULTS: The number of lymph nodes removed correlated with a reduction in the rate of subsequent axillary recurrence (from 2.1 to 0.4 per cent; P = 0.037), local recurrence (from 7.4 to 3.8 per cent; P < 0.001) distant metastases (from 15.0 to 10.3 per cent; P < 0.001) and death as first event (from 7.5 to 5.5 per cent; P = 0.012). CONCLUSION: When ALND is indicated, at least ten axillary lymph nodes should be retrieved. The role of ALND as primary treatment has decreased significantly during the past decade. The findings leave the concept of the sentinel node biopsy intact, as a highly specific procedure compared to ALND.

Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease.

BACKGROUND: It is not known whether initial endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A cost-effectiveness analysis of EUS, MRCP and ERCP was performed on 163 patients. The effectiveness of an investigation was defined as the percentage of patients with no need for further evaluation after the investigation in question had been performed. Costs were assumed from the budget-holder's point of view. RESULTS: MRCP, EUS and ERCP had a total accuracy of 0.91, 0.93 and 0.92, respectively. Eighty-four (52%) patients needed endoscopic therapy in combination with ERCP, giving an effectiveness of MRCP, EUS, and ERCP of 0.44, 0.45 and 0.92, respectively. The cost-effectiveness of MRCP, EUS, and ERCP was 6622, 7353 and 4246 Danish Kroner (DKK) per fully investigated and treated patient (1 DKK=0.14 EUR). CONCLUSION: Within a patient population with a probability of therapeutic ERCP in 50% of the patients, ERCP was the most cost-effective strategy.

Is there a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography and magnetic resonance cholangiopancreatography?

BACKGROUND AND STUDY AIMS: It is still unknown whether there is a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP). PATIENTS AND METHODS: The test performance and potential clinical impact of EUS and MRCP, had each investigation been performed as the first examination method, were compared prospectively in 163 patients admitted for and examined by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The accuracies of EUS and MRCP were 0.93 and 0.91, respectively (no significant difference, P > 0.05). Had EUS or MRCP been performed as the first investigation in the 75 patients who had a presumed high probability for needing therapeutic ERCP, only 15 and nine patients, respectively, would have avoided ERCP. In this group of patients, one patient needed other diagnostic investigations following EUS compared with 11 patients following MRCP ( P = 0.004). For the 57 patients with an intermediate probability of needing endoscopic therapy, EUS and MRCP would have spared 37 and 38 patients, respectively, from the need to have an ERCP. In 31 patients with a presumed low risk of needing endoscopic therapy, 30 and 29 patients would have been spared from ERCP had EUS and MRCP, respectively, been performed initially. CONCLUSIONS: There was no difference in the diagnostic accuracy and clinical impact between EUS and MRCP in the majority of the patients. The impact of EUS or MRCP on the ERCP workload was highly dependent on the presumed probability of needing endoscopic therapy.

Is the 'Trondsen Discriminant Function' useful in patients referred for endoscopic retrograde cholangiopancreatography?

BACKGROUND: Ideally, patients should only be referred to endoscopic retrograde cholangiopancreatography (ERCP) if therapy is indicated. The aim of this study was to evaluate whether or not the 'Trondsen Discriminant Function' (DF) could be used for selecting patients directly for ERCP. METHODS: The DF was calculated in 163 patients referred for ERCP with the DF value being unknown to the endoscopist. Compared to the final diagnoses of the patients, the sensitivity and specificity of a positive DF value for predicting biliary obstruction and need of endoscopic therapy were calculated. RESULTS: Ninety-three (57%) patients had obstruction of the bile duct and 84 (52%) needed endoscopic therapy. A positive DF value had a sensitivity, specificity, positive predictive value and negative predictive value for predicting biliary obstruction of 81%, 72%, 79% and 73%, respectively. If only patients with a positive DF value had been examined by ERCP, 50 (31%) patients would have been saved from this investigation. Had a negative DF value stopped the patients from further diagnostic evaluation, 18 (11%) would have had undiagnosed pathological conditions. CONCLUSION: A positive DF value is useful for selecting which patients should be referred directly for ERCP because of a high probability that they will need endoscopic therapy. A negative DF value cannot be used to stop the patient from further diagnostic evaluation.

Clinical impact of endoscopic ultrasonography at a county hospital.

BACKGROUND AND STUDY AIMS: Although endoscopic ultrasonography (EUS) is a well-described examination method, there have been few reports concerning its clinical impact. The aim of this study was to describe EUS as it is performed at a county hospital, with an emphasis on the indications and clinical outcome. PATIENTS AND METHODS: Patients examined using EUS between December 1997 and November 2000 were recorded prospectively. Follow-up was conducted by examining each patient's medical records at least 3 months after the investigation. The EUS findings were compared with the patient's final diagnosis, and the decisions made by the referring department on the basis of each investigation were recorded. RESULTS: A total of 344 EUS procedures were performed. In the third year, the distribution of patients relative to the various referral diagnoses was: 78 with suspected benign pancreaticobiliary disease, 33 for staging of known upper gastrointestinal tract malignancy, 15 with suspected mediastinal disease or for staging of lung cancer, 13 with suspected submucosal lesions, and five with unclassified disease. Follow-up was possible in 340 patients (99 %). Compared to the final diagnosis in each patient, the sensitivity, specificity, and accuracy rates of EUS were 86 %, 90 %, and 88 %, respectively. The EUS findings made more invasive procedures unnecessary in 199 patients (58 %). EUS led to a switch to less invasive procedures in 61 patients (18 %), and it had no influence on the further management strategy in 80 patients (24 %). CONCLUSIONS: EUS has a high level of accuracy and a substantial clinical impact when performed in an unselected population. The estimated numbers of investigations needed appear to justify setting up an EUS center at institutions with a catchment population of 350 000 inhabitants.

Does interpleural bupivacaine blockade reduce arterial hypoxemia and pain in endoscopic retrograde cholangiopancreatography? A prospective randomized trial.

BACKGROUND AND STUDY AIMS: Interpleural blockade with bupivacaine has been used in operations and for the treatment of pain with promising results. Endoscopy may be followed by serious complications associated with the use of intravenous drugs. Drug-induced hypoxemia has an important role in the pathophysiology. PATIENTS AND METHODS: A randomized study to assess whether interpleural bupivacaine blockade compared with a standard procedure reduced the risk of hypoxemia and the need of medication in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Other variables studied were its acceptability to patients and morbidity. RESULTS: Ninety patients were included. Interpleural blockade (n = 43) was followed by minor complications. The blockade itself induced mild hypoxemia in four patients (9%). Overall, eight patients (27%) developed hypoxemia. There were correlations between age, drugs given and hypoxemia in the total series and in the two study groups individually. During ERCP eight (19%) in the blockade group and 16 (34%) in the standard procedure group developed hypoxemia. During the recovery period the opposite pattern was observed: (26%) compared with four (9%) (p = 0.05). Drug requirements did not differ. Procedure-related discomfort did not differ. More patients in the blockade group would prefer another sedative procedure. CONCLUSIONS: Interpleural bupivacaine blockade did not contribute to patients' comfort or safety during ERCP.

[Thyroid gland surgery in a teaching department of parenchymal surgery. Quality control and perspectives based on a 10-year material]. / Thyreoideaoperationer i en organkirurgisk uddannelsesafdeling. Kvalitetskontrol og perspektiver på basis af et tiårsmateriale.

The complications after surgery for benign thyroid disease in a non-specialized department were evaluated in a retrospective study. Furthermore it was evaluated whether the new recommendations of The National Board of Health for referral of patients in need of thyroid surgery would influence the rate of operations and complications in the ward. Three hundred and seventy-four patients were operated on. The complication rate was at the same level as in earlier Danish reports. Permanent unilateral palsy of the recurrent laryngeal nerve was registered in 2.1% of the patients (i.e. in 1.4% of "nerves at risk") in patients with primary benign goitre. The complication rate was slightly, but not significantly, higher after operations for recurrent goitre. Hypoparathyroidism occurred in 1.8%, infection in 3% and haemorrhage in 5.3% of the patients. If the recommendations of The National Board of Health for referral of patients were applied the complication rate would decrease, but not to a level of statistical significance. The number of operations would decrease by 20%. From the findings it is argued that not more than one or two hospitals in a county should perform thyroid operations and that not every surgeon should be trained in thyroid surgery.

Ureterorenoscopy in the management of renal and ureteric calculi.

A total of 172 ureterorenoscopies were performed in 112 patients with 131 ureteric and renal calculi. The success rates for retrieval were 65, 59 and 79% in the upper, middle and lower third of the ureter, respectively. 32% of renal calculi were removed by ureterorenoscopy. By combined endourological techniques 89% of all stones were removed. Few complications occurred, and no late sequelae were recorded. It is concluded that ureterorenoscopic stone retrieval is an efficient and safe procedure, especially for lower ureteric stones. In the hand of a trained endourologist it might be attempted for upper ureteric calculi as well, and for certain renal stones in selected patients.