Kun Morgagni ja Caesar tapasivat

Teema : syntym

Surgically Treated Unsuspected N2-Positive NSCLC : Role of Extent and Location of Lymph Node Metastasis

The role of positive lymph node location in non-small-cell lung cancer (NSCLC) patients and effects on survival was assessed. A total of 88 operated patients with unsuspected N2 disease or station 10 lymph nodes were included. No difference was found in survival between inferior positive mediastinal N2 node patients compared to multilevel N2 disease patients. The survival of patients with positive hilar disease was similar to the inferior mediastinal positive N2 group. Background: The role of surgery in the treatment of non-small-cell lung cancer that has spread to ipsilateral mediastinal or hilar lymph nodes (LNs) is controversial. We examined whether the location of LNs positive for non-small-cell lung cancer in mediastinum or hilum influences the survival of these patients. Patients and Methods: We reviewed data from 881 patients and analyzed those with unsuspected N2 disease or hilar (station 10) LNs. The patients were stratified into the following groups: group A, positive hilar Naruke 10; group B, superior mediastinal and aortic nodes (Naruke 1, 2, 3, 4, 5, and 6); group C, inferior mediastinal nodes (Naruke 7, 8, and 9), and multilevel group D (2 or more positive N2 levels). Results: A total of 69 pN2 and 19 pN1 patients were included. Progression-free survival (PFS) was statistically significant better in group B versus group C (P = .044) and group B versus group D (P = .0086). The overall survival (OS) of group A did not differ from that of group C. A statistically significant better OS was found between groups B and D (P= .051). Conclusion: Inferior positive mediastinal N2 node patients seem to have an OS and PFS as poor as multilevel N2 disease patients. The OS and PFS of patients with positive hilar disease are similar to those in the inferior mediastinal positive N2 group. Superior positive mediastinal N2 node patients have better OS and PFS than the inferior mediastinal positive N2 group. (C) 2018 Elsevier Inc. All rights reserved.Peer reviewe

Learning curve in robotic-assisted lobectomy for non-small cell lung cancer is not steep after experience in video-assisted lobectomy; single-surgeon experience using cumulative sum analysis

Publisher Copyright: © 2021Background: Robotic assistance in lung lobectomy has been suggested to enhance the adoption of minimally invasive techniques among surgeons. However, little is known of learning curves in different minimally invasive techniques. We studied learning curves in robotic-assisted versus video- assisted lobectomies for lung cancer. Methods: A single surgeon performed his first 75 video-assisted thoracic surgery (VATS) lobectomies from April 2007 to November 2012, and his 75 first robotic-assisted thoracic surgery (RATS) lobectomies between August 2011 and May 2018. A retrospective chart review was done. Cumulative sum (CUSUM) analysis was used to identify the learning curve. Results: No operative deaths occurred for VATS patients or RATS patients. Conversion-to-open rate was significantly lower in the RATS group (2.7% vs. 13.3%, p = 0.016). Meanwhile, 90-day mortality (1.3% vs. 5.3%, p = 0.172), postoperative complications (24% vs. 24%, p = 0.999), re- operation rates (4% vs. 5.3%, p = 0.688), operation time (170±56 min vs. 178±66 min, p = 0.663) and length of stay (8.9 ± 7.9 days vs. 8.2 ± 5.8 days, p = 0.844) were similar between the two groups. Based on CUSUM analysis, learning curves were similar for both procedures, although slightly shorter for RATS (proficiency obtained with 53 VATS cases vs. 45 RATS cases, p = 0.198). Conclusions: Robotic-assisted thoracoscopic lung lobectomy can be implemented safely and efficiently in an expert center with earlier experience in VATS lobectomies. However, there seems to be a learning curve of its own despite the surgeon's previous experience in conventional thoracoscopic surgery.Peer reviewe

Thoracotomy and VATS Surgery in Local Non-Small-Cell Lung Cancer : Differences in Long-Term Health-Related Quality Of Life

Very long-term health-related quality of life (HRQoL) is an important end point in operated early stage non-small-cell lung cancer with good prognosis. The results for very long-term HRQoL after minimally invasive video-assisted thoracoscopic surgery (VATS) has not been evaluated and compared to thoracotomy. Surprisingly, inferior overall HRQoL was evident for patients operated with VATS, independent of preoperative factors including age, comorbidities, and pulmonary function tests. Background: As a result of routine low-dose computed tomographic screening, lung cancer is more frequently diagnosed at earlier, operable stages of disease. In treating local non-small-cell lung cancer, video-assisted thoracoscopic surgery (VATS), a minimally invasive surgical approach, has replaced thoracotomy as the standard of care. While short-term quality-of-life outcomes favor the use of VATS, the impact of VATS on long-term health-related quality of life (HRQoL) is unknown. Patients and Methods: We studied patients who underwent lobectomy for the treatment of non-small-cell lung cancer from January 2006 to January 2013 at a single institution (n = 456). Patients who underwent segmentectomy (n = 27), who received neoadjuvant therapy (n = 13), or who were found to have clinical stage > T2 or > NO disease (n = 45) were excluded from analysis. At time of HRQoL assessment, 199 patients were eligible for study and were mailed the generic HRQoL instrument 15D. Results: A total of 180 patients (90.5%) replied; 92 respondents underwent VATS while 88 underwent open thoracotomy. The VATS group more often had adenocarcinoma (P = .006), and lymph node stations were sampled to a lesser extent (P = .004); additionally, hospital length of stay was shorter among patients undergoing VATS (P = .001). No other clinical or pathologic differences were observed between the 2 groups. Surprisingly, patients who underwent VATS scored significantly lower on HRQoL on the dimensions of breathing, speaking, usual activities, mental function, and vitality, and they reported a lower total 15D score, which reflects overall quality of life (P <.05). Conclusion: In contrast to earlier short-term reports, long-term quality-of-life measures are worse among patients who underwent VATS compared to thoracotomy. (C) 2019 Elsevier Inc. All rights reserved.Peer reviewe

Health-related quality of life after laparoscopic repair of giant paraesophageal hernia : how does recurrence in CT scan compare to clinical success?

Background Computed tomography (CT) is widely used in the diagnosis of giant paraesophageal hernias (GPEH) but has not been utilised systematically for follow-up. We performed a cross-sectional observational study to assess mid-term outcomes of elective laparoscopic GPEH repair. The primary objective of the study was to evaluate the radiological hernia recurrence rate by CT and to determine its association with current symptoms and quality of life. Methods All non-emergent laparoscopic GPEH repairs between 2010 to 2015 were identified from hospital medical records. Each patient was offered non-contrast CT and sent questionnaires for disease-specific symptoms and health-related quality of life. Results The inclusion criteria were met by 165 patients (74% female, mean age 67 years). Total recurrence rate was 29.3%. Major recurrent hernia (> 5 cm) was revealed by CT in 4 patients (4.3%). Radiological findings did not correlate with symptom-related quality of life. Perioperative mortality occurred in 1 patient (0.6%). Complications were reported in 27 patients (16.4%). Conclusions Successful laparoscopic repair of GPEH requires both expertise and experience. It appears to lead to effective symptom relief with high patient satisfaction. However, small radiological recurrences are common but do not affect postoperative symptom-related patient wellbeing.Peer reviewe

Akalasia

Vertaisarvioitu.Akalasia on harvinainen ruokatorven sairaus, joka aiheuttaa ruokatorven alasulkijan relaksaatiohäiriön ja runko-osan motiliteettihäiriön. Nämä johtavat ruuan nielemisvaikeuteen, käänteisvirtaukseen, rintakipuihin ja joskus painon vähenemiseen. Diagnoosiin päästään tarkkuusmanometrialla. Parantavaa hoitoa ei ole, mutta oireita voidaan lievittää löystyttämällä ruokatorven alasulkijaa joko endoskooppisella pallolaajennnuksella tai leikkaamalla sulkijalihas poikki joko laparoskopiassa (Heller-Dorin leikkaus) tai endoskopiassa (peroraalinen endoskooppinen myotomia, POEM). Monisairaiden potilaiden hoidossa voidaan joskus turvautua farmakologisiin hoitokeinoihin eli suun kautta otettaviin nitraatteihin tai kalsiumin estäjiin taikka botuliinitoksiiniruiskeisiin, mutta niiden teho on rajallinen. Pieni osa potilaista päätyy ruokatorviresektioon taudin edettyä.Peer reviewe

Non-small cell lung cancer : studies on surgical treatment outcomes and prognostic factors

In 2016, 1742 men and 992 women were diagnosed with lung cancer in Finland (Finnish Cancer Registry, 2016). The 5-year survival of LC ranges from 8% to 20%. The aims of this study were to 1) evaluate surgical results and very long-term quality of life in patients operated on for central non-small cell lung cancer (NSCLC) using either pneumonectomy (PN) or sleeve lobectomy (SL); 2) examine whether the location of lymph-node positive NSCLC in mediastinum or hilum influences the survival of these patients, 3) the impact of video-assisted thoracic surgery (VATS) on very long-term health-related quality of life (HRQoL) and 4) investigate the learning curve of an experienced VATS surgeon when institutional robotic-assisted lobectomy was programmed. Study I included 641 NSCLC patients operated between 2000 to 2010. 67 had PN and 40 patients had SL. In 2011, all surviving patients were sent a 15D Quality-of-Life questionnaire. Propensity-score-matching analysis was utilized to compare the groups and overall 5-year survival, distant and locoregional recurrence pattern, and very-long term quality of life. In study II, we reviewed data of 881 operated NSCLC patients with R0 resection combined with mediastinal lymphadenectomy. Patients with unsuspected positive lymph node metastasis in hilar (N10) or mediastinal (N2) were analyzed. In study III, we evaluated 456 patients who underwent lobectomy for the treatment of NSCLC in VATS or conventional thoracotomy between 2006 and 2013. 199 patients were mailed the generic HRQoL instrument 15D. Very-long term quality of life was analyzed. For study IV, a retrospective comparison of a single surgeon that performed the first 75 VATS lobectomies between 2007 to 2012 and 75 robotic-assisted (RATS) lobectomies between 2011 to 2018. The data from the initial cases were evaluated and a cumulative sum (CUSUM) analysis was applied to the duration of the operations. In Study I, the 5-year survival, rate of distant metastasis or locoregional recurrence did not differ between groups. Very long-term quality of life measured by 15D did not reveal significant differences in separate dimensions or total score. In Study II, PFS was statistically significant better in superior mediastinal and aortic nodes versus inferior mediastinal nodes. The overall survival (OS) of positive hilar Naruke 10 did not differ from that of inferior mediastinal nodes. In Study III, patients that had lobectomy performed by VATS had significantly lower very-long term quality of life in the dimensions of breathing, speaking, usual activities, mental function, and vitality. In Study IV, the operative outcomes were similar between RATS and VATS groups. The analysis of the surgeon learning curves for VATS and RATS based on operative time reached proficiency at 53 VATS and 45 RATS. Sleeve operations have fewer major operative complications. PN should be considered in suitable patients if SL does not seem to be oncologically sufficiently radical. Inferior positive mediastinal N2 node patients seem to have OS and PFS as poor as multilevel N2 patients. The OS and PFS of patients with positive hilar disease are similar to those in the inferior mediastinal positive N2 group. Very long-term quality-of-life measures are poorer among patients who were treated with VATS compared to thoracotomy patients. In the treatment of local NSCLC, the perioperative results of RATS and VATS lobectomies of the same surgeon were equally good. Even if the surgeon is experienced, a long learning curve for robotic surgery implementation is required.Keuhkosyöpä on yksi Suomen yleisimmistä syövistä. Vuosittain 1742 miestä ja 992 naista sairastuu keuhkosyöpään (Suomen syöpärekisteri, 2016). Viiden vuoden ajanjaksolla kokonaiseloonjääminen vaihtelee 8–13 %. Tämän tutkimuksen tavoitteena oli 1) arvioida kirurgisia hoitotuloksia sekä pitkäaikaista elämänlaatua potilailla, joilta leikattiin sentraalinen ei-pienisoluinen keuhkosyöpä (NSCLC) joko keuhkonpoistoa (PN) tai hiharesektiota käyttämällä, 2) tutkia, onko positiivisen imusolmukkeen sijainnilla välikarsinassa tai keuhkon portissa vaikutuksia ei- pienisoluista keuhkosyöpää sairastavan potilaan eloonjäämiseen 3) selvittää videoavusteisen rintakirurgian (VATS) vaikutusta pitkäaikaiseen elämänlaatuun sekä 4) tutkia kokeneen VATS-kirurgin oppimiskäyrää robottiavusteisessa lohkonpoistossa. Ensimmäisessä osatyössä potilasaineistona oli Helsingin yliopistollisessa keskussairaalassa (HYKS) vuosina 2000–2010 leikatut 641 ei-pienisoluista keuhkosyöpäpotilasta. Näistä potilasta 67:lle oli tehty keuhkonpoisto (PN) ja 40:lle potilaalle keuhkon hiharesektio (SL). Vuonna 2011 kaikille elossa oleville potilaille lähetettiin 15D -elämänlaatukysely. Toisessa osatyössä analysoimme 881 HYKS:ssä leikattua ei-pienisoluista keuhkosyöpäpotilasta, joilla oli paikallinen välikarsinan imusolmukkeisiin levinnyt tauti (N2-tauti) tai keuhkoportin (aseman 10) imusolmukkeeseen levinnyt tauti. Kolmannessa osatyössä oli 456 potilasta, joille tehtiin torakoskooppinen tai avoin keuhkolohkonpoisto ei-pienisoluisen keuhkosyövän vuoksi HYKS:ssä vuosina 2006–2013. Potilaista 199 henkilöä täytti tutkimuksen kriteerit ja heille postitettiin yleinen 15D -elämänlaatukysely. Neljännessä osatyössä selvitettiin oppimiskäyrää vertailemalla takautuvasti yhden kirurgin suorittamia 75:ä torakoskooppista (VATS) keuhkolohkonpoistoa vuosina 2007–2012 ja 75:ä robottiavusteista (RATS)-lobektomiaa vuosina 2011–2018. Ryhmien oppimiskäyrä määritettiin kumulatiivista summa-analyysiä (CUSUM) käyttämällä. Johtopäätökset Hiharesektiolla leikatuilla potilailla on vähemmän merkittäviä haittatapahtumia ja pitkäaikainen eloonjääminen on parempi keuhkonpoistoryhmään verrattuna. Hiharesektiota tulisi suosia ensisijaisena tekniikkana sentraalista ei-pienisoluista keuhkosyöpää sairastavilla potilailla. Mikäli potilaan arvioidaan sietävän koko keuhkon poiston, sitä tulisi harkita, mikäli hiharesektiolla ei saavuteta riittävää onkologista radikaliteettia. Välikarsinan alaosan yksittäisellä imusolmukemetastaasipotilasryhmällä (N2) kokonaiseloonjääminen sekä mediaani OS ennen taudin etenemistä vaikuttaa olevan samanlainen kuin monitasoisilla N2-potilailla. Potilailla, joilla on positiivinen keuhkon portin solmuke N10, ei kokonaiseloonjääminen poikkea välikarsinan alaosan imusolmukemetastaasien kokonaiseloonjäämisestä. Välikarsinan yläosan yksittäisillä imusolmukemetastaasipotilasryhmillä kokonaiseloonjääminen sekä mediaani OS ennen taudin etenemistä on parempi kuin välikarsinan alaosan imusolmukemetastaasiryhmällä. Pitkän aikavälin elämänlaatu on huonompi VATS-leikatuilla potilailla verrattuna torakotomiapotilaisiin. Paikallisen ei-pienisoluisen keuhkosyövän hoidossa yhden kirurgin suorittamissa robotti- ja torakoskooppisissa lohkonpoistoissa ei perioperatiivisissa tuloksissa havaittu eroa. Robottiavusteisessa lohkonpoistossa on alhaisempi konversioaste ja sitä voidaan pitää turvallisena leikkaustekniikkana. Oppimiskäyrä on kuitenkin varsin pitkä jopa kokeneella kirurgilla

Zenkerin divertikkelin epidemiologia ja hoito Suomessa

Fakultet: Medicinska fakulteten Utbildningsprogram: Utbildningsprogrammet i medicin Studieinriktning: Medicine licentiat Författare: Sandra Uoti Arbetets titel: Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System Arbetets art: Artikel Månad och år: 12/2021 Sidantal: 27 Nyckelord: Zenkers divertikel; Dysfagi; Epidemiologi Handledare: Ilkka Ilonen, Saana Andersson, Ville Kytö Förvaringsställe: https://pubmed.ncbi.nlm.nih.gov/34913965/ Övriga uppgifter: Sammandrag: Zenkers divertikel uppstår i gränsen mellan svalget och matstrupen. Vanliga symptom är bland annat dysfagi och regurgitation av födoämnen, samt problem relaterade till aspiration. Enligt nuvarande uppfattning är den enda definitiva vården kirurgisk intervention. Tidigare estimat av Zenkers divertikels epidemiologi baserar sig på små kohortstudier. Bakgrundsmaterialet i forskningen är data samlad i vårdanmälningssystemet (HILMO) under åren 1996–2015. Inkluderade i materialet är vuxna patienter för vilka det i registret förekommer antingen diagnosen Zenkers divertikel, eller för vilka ett ingrepp indicerat för vård av divertikeln undertagits. Studien inkluderade 2736 patienter (medianålder vid diagnos 72.0 [19-106] år; 1278 kvinnor [46.7%]). Incidensen av Zenkers divertikel är 2.9/100 000 personer årligen, något som med liknande precision inte kunnat beskrivas förut. Vården av divertikeln visar sig vara fördelad över flera olika specialiteter och varje upptagningsområden för högspecialiserad vård. Vi upptäckte att det finns markanta skillnader i vårdpraxis mellan såväl operativa specialiteter som upptagningsområden. Flera olika metoder tillämpas i operativa vården av divertikeln. Valet av metod ser ut att bero på patientens ålder, kirurgens specialitet, samt av upptagningsområdet på vilket vården förverkligas. Endast 1044 (38.2%) av patienter undergick operativ, alltså definitiv vård under uppföljningstiden

Biphasic patterns of age-related differences in dopamine D1 receptors across the adult lifespan

Age-related alterations in D1-like dopamine receptor (D1DR) have distinct implications for human cognition and behavior during development and aging, but the timing of these periods remains undefined. Enabled by a large sample of in vivo assessments (n = 180, age 20 to 80 years of age, 50% female), we discover that age-related D1DR differences pivot at approximately 40 years of age in several brain regions. Focusing on the most age-sensitive dopamine-rich region, we observe opposing pre- and post-forties interrelations among caudate D1DR, cortico-striatal functional connectivity, and memory. Finally, particularly caudate D1DR differences in midlife and beyond, but not in early adulthood, associate with manifestation of white matter lesions. The present results support a model by which excessive dopamine modulation in early adulthood and insufficient modulation in aging are deleterious to brain function and cognition, thus challenging a prevailing view of monotonic D1DR function across the adult lifespan