The effect of new inclusion criteria on patient selection for reduction mammaplasty

OBJECTIVE There is a learning curve for surgeons performing “awake” spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery. METHODS The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution. RESULTS A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8. CONCLUSIONS The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.

Download Full-text

Pre-operative breast magnetic resonance imaging (MRI) influences patient selection for partial breast irradiation

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.604 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 604-604 ◽

Cited By ~ 2

Author(s):

L. A. Vallow ◽

S. Packianathan ◽

E. R. Deperi ◽

M. D. McDonough ◽

J. D. Earle ◽

...

Keyword(s):

Breast Cancer ◽

Patient Selection ◽

Breast Mri ◽

Partial Breast Irradiation ◽

Breast Irradiation ◽

Inclusion Criteria ◽

Mri Findings ◽

Local Disease ◽

Selection For ◽

Pathological Assessment

604 Background: Many patients with localized breast cancer undergo breast conservation therapy. Partial breast irradiation (PBI) is a technique that reduces irradiated tissue volume and decreases treatment time. Appropriate patient selection for this technique is critical. We studied the influence of pre-operative breast MRI on patient selection for PBI. Methods: Between 05/04 and 05/05, 231 women with newly diagnosed breast cancer underwent pre-operative bilateral breast MRI (median age = 64, range 34 to 89). Following initial clinico-pathologic review, patients were deemed to be eligible for PBI based on the NSABP B39 protocol if they satisfied its inclusion criteria (tumor size ≤3 cm, ≤3 positive nodes, negative surgical margins, lack of multicentric disease), derived through physical examination, mammography and/or ultrasonography. Breast MRI scans of all patients deemed eligible for PBI by these criteria were then reviewed to determine the impact of the MRI findings on their eligibility for PBI. Only patients who had pathological assessment to correlate with the MRI findings were included in the analysis. Results: Based on the NSABP B39 inclusion criteria, 186 patients (81%) were considered to be appropriate candidates for PBI without influence from MRI findings. Of these 186 women, MRI findings led to pathologically proven additional disease that altered the recommendations for PBI in 26 patients (14%). Mammographically occult, biopsy proven multicentic disease was detected in the ipsilateral breast in 13 patients (7%), whereas 5 women (2.7%) had mammographically occult, biopsy proven multicentric disease in the contralateral breast. In 8 patients (4.3%), pathological assessment confirmed more extensive local disease than was detected by breast MRI. Conclusions: Up to 14% of patients initially deemed eligible for PBI were later found to be ineligible because of breast MRI findings. Ipsilateral multicentric disease was identified in 7%, contralateral disease was discovered in 2.7%, and more extensive local disease was noted in 4.3%. Bilateral breast MRI complements other imaging modalities in determining eligibility for PBI by identifying mammographically occult disease in patients for whom PBI may be inappropriate. No significant financial relationships to disclose.

Download Full-text