Surgery Science

Surgery not necessary for most late-stage colorectal cancers

2009-06-06T04:47:00.001-07:00

A new study shows that a large majority of patients who present with advanced colorectal cancer that has spread to other organs (stage IV) don't require immediate surgery to remove the primary tumor in the colon. Researchers from Memorial Sloan-Kettering Cancer Center (MSKCC) presented their data today at the American Society of Clinical Oncology Annual Meeting.

"For this population with metastatic disease that cannot be cured by surgery, undergoing colon surgery is not always necessary," said Philip Paty, a surgical oncologist at MSKCC and one of the study's lead authors. "If the colon tumor is not causing obstruction, perforation, or bleeding we've found these patients are best treated with chemotherapy. By moving straight to chemotherapy, patients can avoid the risk of surgical complications and can start treatment for all sites of disease without delay."

For this retrospective study, a multidisciplinary team looked at 233 metastatic colorectal cancer cases treated at MSKCC from 2000 to 2006. Their analysis showed that 217 of the 233 patients, or 93 percent, did not have complications that required resection of the primary tumor. Only 16 patients required colon surgery for symptom management.

Previously, in the conventional approach to treating stage IV disease, patients underwent colon surgery immediately following their diagnosis and would typically start chemotherapy treatments three to six weeks later. The rationale for immediate colon resection was to prevent future symptoms and complications from the primary tumor. It was assumed that the majority of colorectal cancers would have little response to chemotherapy.

But with the development of better chemotherapy treatments in the past decade, doctors at MSKCC and others within the oncology community started looking at patients with stage IV disease differently, and began to administer chemotherapy as initial treatment. Such treatments seemed to be reliable in shrinking both colon tumors and the metastases; however, there was not published data to support this approach.

"We now know that the routine use of surgery for these patients is based on old thinking, and we're beyond that. There will always be the need for individual exceptions based on the clinical situation, but our default position should be not to operate," said Dr. Paty.

Colorectal cancer is the fourth most common type of cancer and the second leading cause of cancer-related death in the United States.

Back to normal: Surgery improves outcomes for spine patients

2009-06-06T04:46:00.000-07:00

People with the spine disease called degenerative spondylolisthesis* -- who choose surgical treatment -- experience substantially greater relief from pain over time compared to those who do not have surgery, according to a study published in the June 2009 issue of The Journal of Bone and Joint Surgery (JBJS). In the past, physicians had been uncertain whether surgery provided significantly greater relief for patients, but these results help to confirm the advantages to surgery.

"There are thousands of surgeries completed each year to address degenerative spine conditions, yet, there has never been a large-scale trial to give us evidence that the surgeries really work, as compared to non-operative approaches," said study author James Weinstein, DO, MS, Third Century Professor and Chair of the departments of orthopaedics at Dartmouth Medical School and Dartmouth-Hitchcock Medical Center.

Dr. Weinstein and his colleagues collected data from 607 men and women diagnosed with spondylolisthesis who were enrolled in the Spine Patient Outcomes Research Trial (SPORT), a multi-center study that included participants from 13 medical centers in 11 states. The study was the largest ever conducted of spondylolisthesis patients.

"Until this study, our 'evidence' was anecdotal and based on patient reports. We wanted data-based, scientific evidence that we could share with patients to help them make their decisions about taking an operative vs. non-operative approach," Weinstein said.

Prior to completion of the study, SPORT looked at the three most common back conditions leading to surgery, which are:

herniated disc;
spinal stenosis; and
spinal stenosis with degenerative spondylolisthesis.

To be included in the study, all patients had to meet certain criteria, including:

nerve pain in the legs
spinal stenosis revealed on cross-sectional imaging
degenerative spondylolisthesis evident in radiograph imaging
symptoms which lasted for at least 12 weeks
physician confirmation that the patient was a surgical candidate.

"Our results indicate that in these patients, there was a clear advantage for surgery," said Dr. Weinstein. "Patients felt relief faster and at two and four years, reported better function, less pain, and higher satisfaction than those who chose to go the non-surgical route."

Approximately 80 percent of Americans suffer from back pain at some point in their lives. Back pain is the most common cause of work-related disability, as well as the most expensive in terms of workers compensation and medical costs. Degenerative spondylolisthesis is one example of this kind of painful back condition.

"Degenerative spine disease can be a debilitating condition. When well informed, surgery is a good treatment choice," said Weinstein.

SPORT investigators will be releasing additional studies focusing on cost-effectiveness and other factors in coming months.

* Degenerative spondylolisthesis occurs when laxness in the spine causes one vertebra to slide forward and press against nerves, causing pain in the back and legs. The condition often occurs as a result of the aging process.

More Information: SPORT is the first comprehensive study to look at different ways of treating low back and leg pain and how effective they are for patients. The trial was funded by the National Institutes of Health (NIH) in recognition of how prevalent back problems are, and how disabling they can be. The research is meant to give patients and their physicians solid information to help guide them as they make decisions about how to treat their conditions. Approximately 2500 patients took part in the 5-year study.

Surgery in patients with RA is often 'too little, too late'

2009-06-06T04:45:00.000-07:00

A new study published by the American Society of Plastic Surgeons reveals that one of the most common conditions caused by Rheumatoid Arthritis (RA) is best treated surgically, sooner rather than later. Patients with RA frequently experience a debilitating condition known as metacarpophalangeal joint disease, which is usually treated by replacing the knuckle joints with solid silicone joints. However, this treatment (and others like it) has spurred great disagreement between hand surgeons and rheumatologists regarding the indications, timing and perceived outcomes of the procedure; rheumatologists tend to refer late-stage patients for surgery whereas hand surgeons believe that earlier intervention can yield more positive outcomes.

In the largest cohort study of its kind, researchers from Michigan, Maryland, and the United Kingdom evaluated the surgical outcomes of 70 RA patients who suffered from varying degrees of hand deformities. Following reconstruction, patients were separated into two groups based on the degree of deformity, and the outcomes of the reconstruction were assessed at 6 months and at years 1, 2 and 3. After reconstruction, both groups had positive self-reported hand outcomes and showed statistically significant improvement from baseline. However, researchers found that the more severe group still had significant deformities - showing that the more serious the malformation, the more difficult it is to correct.

This study acknowledges that the management of rheumatoid hand and wrist problems is challenging because of the lack of evidenced-based research regarding the management of these difficult patients. Findings from this study support the general view of hand surgeons that surgery is beneficial to both the early stage and late stage patients. Both specialties agree that working together in a team approach will enhance the quality of life for the RA population. This study appears in the June issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

NOTES advances suggest promising future for scarless surgery

2009-06-06T04:44:00.000-07:00

Researchers will present the latest advances in a technology that continues to change the face of gastroenterology and surgery, known as Natural Orifice Translumenal Endoscopic Surgery®, or NOTES®, today at Digestive Disease Week® 2009 (DDW®). NOTES eliminates the need for incisions and allows for less pain and scarring associated with traditional laparoscopic surgery along with a much faster recovery time for the patient. Study findings and video demonstration will illustrate the most recent NOTES applications including cholecystectomy, appendectomy and gastrectomy. DDW is the largest international gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery.

"The potential of NOTES and near-NOTES procedures is being demonstrated," said Michael L. Kochman, MD, FASGE, AGAF, Hospital of the University of Pennsylvania and NOSCAR® Research Subcommittee co-chair. "These latest studies show that surgeries that once subjected patients to significant pain and recovery time may become a thing of the past."

NOTES is performed by passing an endoscope through a natural orifice, or opening, then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.

Transoral Gastroplasty. A Novel Technique For Incisionless Weight Loss Surgery (Abstract #1016)

Researchers will present for the first time early results and a video demonstration of a promising new technique for incisionless weight loss surgery known as Transoral Gastroplasty.

The novel procedure, aimed at patients in need of intermediate weight loss, involves placing a device into the stomach that uses a vacuum to bring the sides of the stomach together and stapling them without the necessity of making incisions in the abdominal wall. The video presented by the researchers, Edward Phillips, MD, and Kai Nishi, MD, of the Comprehensive Weight Loss Center at Cedars-Sinai Medical Center, is the first demonstration of the instrument being used in a procedure involving humans.

Because the study is part of an FDA clinical trial, researchers cannot yet share the findings of their study, but are confident that the weight loss results will prove to be as effective as more traditional weight loss surgeries without the complicated recovery involved in those methods.

"Any time you can avoid making an incision in a patient, you dramatically improve their recovery," said Dr. Phillips. "This procedure holds tremendous promise not only for weight loss, but for any procedure that currently requires abdominal incisions."

Drs. Phillips and Nishi will present their video on Wednesday, June 3 at 9:45 a.m. CDT in S504, McCormick Place.

NOTES Transvaginal Sleeve Gastrectomy -- Initial Human Experience in the United States (Abstract #527)

The first uses of Natural Orifice Translumenal Endoscopic Surgery (or NOTES) to perform transvaginal sleeve gastrectomy in morbidly obese patients show promise, according to researchers at the University of California San Diego (UCSD) who say this could be a far less painful and dangerous surgical weight loss option.

The transvaginal sleeve gastrectomy requires surgeons to make two small incisions in the abdomen and one in the vagina to remove 70 percent of the patient's stomach. By contrast, laparoscopic gastrectomy requires five to seven larger incisions in the abdomen that can cause significant scarring and put patients at risk for infections and hernias.

"Compared to traditional laparoscopic techniques in which patients experience a high incidence of infections and hernias, the results so far indicate this procedure accelerates weight loss while minimizing adverse events," said Santiago Horgan, MD, professor of surgery at UCSD.

In the first two patients to undergo the procedure, no infection was reported. Horgan said he and his colleagues are optimistic that transvaginal sleeve gastrectomy is a viable option for weight loss in morbidly obese patients, but they caution that more patients need to undergo the procedure under IRB protocols to demonstrate its efficacy.

Dr. Horgan will present these data on Tuesday, June 2 at 7:45 a.m. CDT in S504, McCormick Place.

NOTES Transvaginal Appendectomy (Abstract #639)

Appendectomies are the latest, successful use of NOTES according to researchers at the University of California, San Diego (UCSD). Initial results suggest transvaginal appendectomy is a promising, emerging technique for acute appendicitis.

Under IRB protocol, a team of surgeons at UCSD performed transvaginal appendectomies in two patients. Surgeons removed the appendix using the vagina as the port of entry to the peritoneal cavity. Unlike in standard laparoscopic transabdominal appendectomy, which requires several abdominal incisions, transvaginal appendectomy requires only two small incisions, one in the abdomen and one in the vagina.

Santiago Horgan, MD, professor of surgery at UCSD, and his colleagues are the first to perform appendectomies transvaginally. Previous NOTES research has demonstrated the efficacy of transvaginal removal of other organs including the gallbladder and pancreas. Similar to those studies, initial results show the benefits of NOTES over transabdominal laparoscopic surgery including less pain, scarring and incidence of infection and hernia, as well as quicker recovery time.

"Our initial results suggest when appendectomies are performed transvaginally, patients experience less pain, fewer complications and are on their feet in three to four days," said Dr. Horgan. "While we have enough data to prove that the procedure is safe, the question now is to see if it can be duplicated successfully in a larger sample of patients."

'Non-surgical' method for chronic tendinosis of the Achilles tendon

2009-06-06T04:37:00.000-07:00

Researchers have found an alternative, "non-surgical" method to treat chronic tendinosis (tendinitis) of the Achilles tendon that fails conservative treatment, according to a study performed at the Feinberg School of Medicine, Northwestern University in Chicago, IL.

Seventeen patients underwent sonographically-guided Achilles tendon debridement, a procedure that helps to break up any scar tissue within the tendon that might cause it to become stiffer than normal and to encourage the body's own repair process to heal the tendon damage. All patients had at least six months of failed conservative treatment (rest and ice, heel lifts, orthotics and non-steroidal anti-inflammatory drugs, such as ibuprofen and physical therapy). "Out of the 17 patients surveyed after the procedure, approximately 60% of patients reported their symptoms had either completely resolved or were markedly improved," said Thomas Grant, DO, lead author of the study.

"We believe this procedure will be a treatment option before performing surgery for patients suffering from Achilles tendinosis that have failed conservative measures. Traditionally surgery was the only treatment available to patients failing conservative management," said Dr. Grant.

"The true incidence of Achilles tendinosis is uncertain. Studies in runners suggest about 10-15% incidence in this higher risk group. Achilles tendinosis is also relatively common in non-athletes. Men and women of all age groups are affected," he said.

"Although most patients respond to conservative management, a significant number do not respond and have chronic symptoms that limit their activities. Ultrasound-guided Achilles debridement is a viable non-surgical option for these patients with no adverse effects that we have seen," said Dr. Grant.

Eyelid Surgery (Blepharoplasty)

2009-06-06T04:36:00.001-07:00

As we age, the muscles around our eyes tend to weaken and our skin begins to sag. Blepharoplasty or eyelid surgery (as it is commonly referred to) corrects droopy, puffy, or wrinkled upper and/or lower eyelids by removing excess fat, skin, and muscle. The remaining skin is smoothed to create a more rested and youthful appearance.

If you're considering blepharoplasty surgery, one of the first things a plastic surgeon will determine at your consultation is if both your upper and lower lids need to be treated, or one or the other. As you can imagine, the cost of blepharoplasty surgery will vary depending on the extent of your surgery, so the average price range we offer takes into account one or both lids, with the upper bound pricing implying both.

Sometimes, to achieve the desired results the surgeon will only have to work on your upper lids; however, with more extensive cases, he or she may need to improve the look of both lids to have them appear symmetrical and balanced. In older patients, eyelid surgery often becomes a necessity as excess skin can block their field of vision. In such cases, insurance may apply and you would need to check with your insurance provider to learn if you're covered. Your plastic surgeon can often help you submit your claim, deeming the procedure as medically necessary.

What Are The Most Popular Cosmetic Surgery Procedures?

2009-06-06T04:34:00.000-07:00

Liposuction, formerly the top cosmetic procedure in the U.S., has dropped in rank. The ASAPS first began conducting their yearly studies in 1997, and liposuction has reigned every year since then. Now, the new ASAPS study shows that breast augmentation has knocked liposuction down to second place and grabbed the number one spot. The ASAPS recorded that over 350,000 breast augmentation procedures were performed in 2008. Liposuction ranked second, with 341,144 procedures performed in 2008. The third most popular cosmetic surgery procedure last year was blepharoplasty eyelid surgery, followed by rhinoplasty in fourth, and abdominoplasty, or tummy tucks, ranked fifth.

When separating the ASAPS procedure rankings by men and women, we see that liposuction is still holding strong for both genders. The top five cosmetic surgery procedures for men and women are ranked as such by the ASAPS:

Top five plastic surgery procedures for women

Breast augmentation
Lipoplasty (liposuction)
Eyelid surgery (blepharoplasty)
Abdominoplasty (tummy tuck)
Breast reduction

Top five plastic surgery procedures for men

Liposuction
Rhinoplasty (nose job)
Eyelid surgery (blepharoplasty)
Gynecomastia (male breast reduction)
Hair transplantation

How Do We Really Feel About Cosmetic Surgery?

2009-06-06T04:33:00.000-07:00

As our culture becomes more accustomed to plastic surgery as a novelty or a necessity, general acceptance concerning its appropriateness or popularity increases, right? Well, not quite. According to a recent survey by the ASAPS, 20% of men and women are "more favorable" to cosmetic surgery than they were five years ago, and 7% said they were "less favorable" now than they were before. However, a hefty 73% of the study's participants said their stance hasn't changed from what it was 5 years ago. While the number of individuals who would consider having cosmetic surgery has increased to 30%, the overall number of people who approve of plastic surgery hasn't significantly changed.

That being said, the same survey stated that 56%, or "more than half of all Americans approve of cosmetic plastic surgery". This survey and the ASAPS 2008 statistics also mention that women undergo cosmetic surgery more than men do (men accounted for only 8% of total cosmetic procedures performed in 2008).

Also worth pointing out is that, although ASPS noted a positive increase in the general opinion of plastic surgery, the percentages of total cosmetic procedures performed in '08, both surgical and non-surgical, actually decreased from 2007. This decrease in procedures performed, by 11% for women and by 21% for men, is most likely a result of the ongoing recession. There was a recorded decrease for both surgical and non-surgical cosmetic procedures.

Minimally invasive stroke treatment produces better patient outcomes than surgical operation

2009-06-06T04:21:00.000-07:00

While minimally invasive coil treatments for those with a ruptured brain aneurysm have proved to be a more effective technique than traditional surgical operation in selected patients, the superior procedure is drastically more expensive, according to new research from the Zeenat Qureshi Stroke Research Center at University of Minnesota Medical School.

Using outcomes from more than 2,000 patients ? half of whom underwent minimally invasive endovascular coiling for brain aneurysms ? and economic data gathered from a variety of hospitals throughout the United States, it is clear the minimally invasive procedure has better patient outcomes ? including qualify of life ? than the neurosurgical counterpart.

Minimally invasive treatments on average cost about $72,000 more than surgical treatments for each quality-adjusted life years gained (including costs stemming from disability, hospitalization, retreatment, and rebleeding) ? partly because multiple follow-up treatments are necessary within the first year of endovascular treatments, as opposed to one major surgical operation.

Coiling is a technique that involves placing a small catheter into the aneurysm and filling it with platinum coils. The catheter is introduced through a blood vessel in the groin and advanced under X-ray all the way into the brain blood vessels.

With accrual of additional years with better outcome status, the cost-effectiveness of endovascular coiling would most likely progressively improve and eventually reverse direction, said Alberto Maud, M.D., principal investigator of the study.

"The minimally invasive treatment is better tolerated in selected critically ill patients with ruptured brain aneurysms. The procedure is effective in preventing a second rupture but currently limited in terms of cost due to the need for additional follow-up procedures to treat new aneurysm growth," Maud said. "However, a new generation of devices promises to provide more permanent obliterations for aneurysms. It should be noted that despite additional treatments, patients treated with endovascular treatment continued have lower rates of death and disability than those treated with open surgery."

The research is published in the May issue of the Journal of Neurosurgery.

Other benefits of minimally invasive surgery include less time in hospital and lower chance of disability, said Adnan I. Qureshi, M.D., senior investigator of the study, who is also the director of the Minnesota Stroke Initiative. Currently about 30 to 40 percent of all patients with aneurysms are treated with minimally invasive procedures, he said.

Intracranial aneurysms impact about 2 percent of the general population worldwide and are present in 10 million people in the United States. Until recently, the predominant treatment was open operation. However, endovascular treatments have increased as the technique has improved.

Other investigators included Drs. Lakshminarayan, Suri, Vazquez, and Lanzino. The study was funded by Zeenat Qureshi Stroke Research Center.