Evidence-based enhanced recovery after surgery(ERAS)programs aim to improve patient outcomes and shorten hospital stays.The objective of this study is to describe the development,implementation,and evolution of an ERA...Evidence-based enhanced recovery after surgery(ERAS)programs aim to improve patient outcomes and shorten hospital stays.The objective of this study is to describe the development,implementation,and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors.A systematic review of the literature was performed,best practices were discussed with stakeholders,and institutional guidelines were established and implemented.Key performance indicators(KPI)were measured and patient-reported outcome surveys were collected.The ERAS protocol was introduced successfully at our institution.We describe the process of initiation of the program and the perioperative management of our patients.We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement,with a particular emphasis on the use of data informatics and metrics to monitor outcomes.We expect that this approach will translate to improved quality of care for these often-complex patients.展开更多
Background:Chordomas are locally invasive neoplasms,arising from notochordal remnants and can appear anywhere along the axial skeleton.Local recurrences are common,and distant metastases may occur years after the init...Background:Chordomas are locally invasive neoplasms,arising from notochordal remnants and can appear anywhere along the axial skeleton.Local recurrences are common,and distant metastases may occur years after the initial presentation.Methods:Literature review of current treatment strategies for chordomas of the skull base.Results:Surgery is the mainstay of treatment and complete resection has paramount importance for prognosis.When complete resection is not achieved recurrent disease is common.The anatomical complexity of the skull base makes resection complex.Endonasal endoscopic approaches to the clivus has become increasingly favored in recent years although addressing reconstruction of the skull base to prevent CSF leak may be challenging.Evidence suggests that radiotherapy should not be considered as a primary single modality when trying to achieve cure of the disease.Nonetheless,immediate post-operative radiotherapy improves survival.Many strategies have been suggested to preserve sensitive vital structures in the skull base during treatment but as for survival there is no evidence of advantage when comparing adjuvant therapy with photon radiotherapy,gamma knife surgery,proton beam therapy,and carbon ion radiation therapy.There is no evidence to support cytotoxic chemotherapy in the treatment of chordomas but targeted therapies have started to show promise.Several optional molecular targets exist.Brachyury is overexpressed in 95%of chordomas but not in other mesenchymal neoplasms.However,its precise role in chordoma pathogenesis is currently unclear,and its cellular location in the nucleus makes it difficult to target.The inhibition of brachyury in chordoma cell lines induces growth arrest and apoptosis.This does not have clinical application to date.There are retrospective results with different molecular targeted therapies for advanced chordomas with some effectiveness.Conclusion:Despite improvements made in the past 10 years in our knowledge of chordoma biology,available therapies still offer a limited benefit.There is an unmet need for new therapeutic options for patients with advanced disease.Therefore,patients with advanced disease should be encouraged to participate in clinical trials when and where available.展开更多
The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery.Utility of a multi-disciplinary unit in man...The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery.Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care.Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients.The many areas of potential variability in the pre,intra and post-operative timeline of pituitary surgery are readily identifiable.Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.展开更多
Objective: To evaluate the Weill Cornell Medical CoLlege (WCMC)/New York Presbyterian Hospital (NYPH) experience with intraoperative frozen (IOF) section in the management of thyroid nodules with a fine needle aspirat...Objective: To evaluate the Weill Cornell Medical CoLlege (WCMC)/New York Presbyterian Hospital (NYPH) experience with intraoperative frozen (IOF) section in the management of thyroid nodules with a fine needle aspiration (FNA) diagnosis of Bethesda Ⅱ-Ⅵ and to analyze the cost and pathology benefit it provides.Methods: The surgical and cytopathology files at WCMC/NYPH were searched within the time period of January 2008 to May 2013.A total of 435 thyroid specimens were identified for which both an FNA and subsequent IOF section was performed.The FNA was correlated with the locations of the resected nodule and the nodule frozen for intraoperative diagnosis.The results of the FNA were compared to the IOF section diagnosis and final diagnosis (FD).Results: Among 435 cases, the FNA diagnosis was Bethesda Ⅱ:149 cases, Bethesda Ⅲ:170 cases, Bethesda Ⅳ: 91 cases, Bethesda Ⅴ: 19 cases, and Bethesda Ⅵ: 6 cases.There were a total of 83 carcinomas identified on FD, which included 69 papillary thyroid carcinomas (PTCs), 12 follicular carcinomas, and 2 poorly differentiated carcinomas.The preoperative FNA diagnosis for these carcinomas was as follows: Bethesda Ⅱ, 11/149 (7.4％), Bethesda Ⅲ, 24/170 (14％), Bethesda Ⅳ, 26/91 (29％), Bethesda Ⅴ, 16/19 (84％), and Bethesda Ⅵ, 6/6 (100％).IOF section contributed to the diagnosis of malignancy in 16/429 (4％) cases: 1/149 (0.7％) Bethesda Ⅱ, 5/170 (3％) Bethesda Ⅲ, 2/91 (1.1％) Bethesda Ⅳ, and 8/19 (42％) Bethesda Ⅴ.The diagnosis of malignancy was confirmed in the 6 Bethesda Ⅵl cases by IOF section.There were no false positives on IOF section.IOF had a sensitivity and specificity of 26％ and 100％, respectively.Conclusion: The role of IOF section is limited in the evaluation of thyroid nodules.IOF section is most useful for nodules with an FNA diagnosis of Bethesda V lesions.The diagnosis of follicular variant of PTC remains difficult on frozen section.展开更多
In the past four decades,skull base surgery has undergone dramatic paradigm shifts.Evolution in understanding of physiology and anatomy coupled with advances in technology and training have completely revolutionized m...In the past four decades,skull base surgery has undergone dramatic paradigm shifts.Evolution in understanding of physiology and anatomy coupled with advances in technology and training have completely revolutionized management of patients with benign and malignant conditions of the anterior skull base.The“Skull Base Surgeon”requires broad and deep knowledge related to pathology,surgical approach and reconstruction with open and endoscopic techniques,perioperative management,and adjuvant and neoadjuvant indications and techniques.展开更多
基金This research was funded in partthrough the NIH/NCI Cancer Center Support,Grant/Award Number:P30 CA008748。
文摘Evidence-based enhanced recovery after surgery(ERAS)programs aim to improve patient outcomes and shorten hospital stays.The objective of this study is to describe the development,implementation,and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors.A systematic review of the literature was performed,best practices were discussed with stakeholders,and institutional guidelines were established and implemented.Key performance indicators(KPI)were measured and patient-reported outcome surveys were collected.The ERAS protocol was introduced successfully at our institution.We describe the process of initiation of the program and the perioperative management of our patients.We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement,with a particular emphasis on the use of data informatics and metrics to monitor outcomes.We expect that this approach will translate to improved quality of care for these often-complex patients.
基金This research was funded in part through the NIH/NCI Cancer Center Support Grant,P30 CA008748.
文摘Background:Chordomas are locally invasive neoplasms,arising from notochordal remnants and can appear anywhere along the axial skeleton.Local recurrences are common,and distant metastases may occur years after the initial presentation.Methods:Literature review of current treatment strategies for chordomas of the skull base.Results:Surgery is the mainstay of treatment and complete resection has paramount importance for prognosis.When complete resection is not achieved recurrent disease is common.The anatomical complexity of the skull base makes resection complex.Endonasal endoscopic approaches to the clivus has become increasingly favored in recent years although addressing reconstruction of the skull base to prevent CSF leak may be challenging.Evidence suggests that radiotherapy should not be considered as a primary single modality when trying to achieve cure of the disease.Nonetheless,immediate post-operative radiotherapy improves survival.Many strategies have been suggested to preserve sensitive vital structures in the skull base during treatment but as for survival there is no evidence of advantage when comparing adjuvant therapy with photon radiotherapy,gamma knife surgery,proton beam therapy,and carbon ion radiation therapy.There is no evidence to support cytotoxic chemotherapy in the treatment of chordomas but targeted therapies have started to show promise.Several optional molecular targets exist.Brachyury is overexpressed in 95%of chordomas but not in other mesenchymal neoplasms.However,its precise role in chordoma pathogenesis is currently unclear,and its cellular location in the nucleus makes it difficult to target.The inhibition of brachyury in chordoma cell lines induces growth arrest and apoptosis.This does not have clinical application to date.There are retrospective results with different molecular targeted therapies for advanced chordomas with some effectiveness.Conclusion:Despite improvements made in the past 10 years in our knowledge of chordoma biology,available therapies still offer a limited benefit.There is an unmet need for new therapeutic options for patients with advanced disease.Therefore,patients with advanced disease should be encouraged to participate in clinical trials when and where available.
文摘The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery.Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care.Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients.The many areas of potential variability in the pre,intra and post-operative timeline of pituitary surgery are readily identifiable.Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.
文摘Objective: To evaluate the Weill Cornell Medical CoLlege (WCMC)/New York Presbyterian Hospital (NYPH) experience with intraoperative frozen (IOF) section in the management of thyroid nodules with a fine needle aspiration (FNA) diagnosis of Bethesda Ⅱ-Ⅵ and to analyze the cost and pathology benefit it provides.Methods: The surgical and cytopathology files at WCMC/NYPH were searched within the time period of January 2008 to May 2013.A total of 435 thyroid specimens were identified for which both an FNA and subsequent IOF section was performed.The FNA was correlated with the locations of the resected nodule and the nodule frozen for intraoperative diagnosis.The results of the FNA were compared to the IOF section diagnosis and final diagnosis (FD).Results: Among 435 cases, the FNA diagnosis was Bethesda Ⅱ:149 cases, Bethesda Ⅲ:170 cases, Bethesda Ⅳ: 91 cases, Bethesda Ⅴ: 19 cases, and Bethesda Ⅵ: 6 cases.There were a total of 83 carcinomas identified on FD, which included 69 papillary thyroid carcinomas (PTCs), 12 follicular carcinomas, and 2 poorly differentiated carcinomas.The preoperative FNA diagnosis for these carcinomas was as follows: Bethesda Ⅱ, 11/149 (7.4％), Bethesda Ⅲ, 24/170 (14％), Bethesda Ⅳ, 26/91 (29％), Bethesda Ⅴ, 16/19 (84％), and Bethesda Ⅵ, 6/6 (100％).IOF section contributed to the diagnosis of malignancy in 16/429 (4％) cases: 1/149 (0.7％) Bethesda Ⅱ, 5/170 (3％) Bethesda Ⅲ, 2/91 (1.1％) Bethesda Ⅳ, and 8/19 (42％) Bethesda Ⅴ.The diagnosis of malignancy was confirmed in the 6 Bethesda Ⅵl cases by IOF section.There were no false positives on IOF section.IOF had a sensitivity and specificity of 26％ and 100％, respectively.Conclusion: The role of IOF section is limited in the evaluation of thyroid nodules.IOF section is most useful for nodules with an FNA diagnosis of Bethesda V lesions.The diagnosis of follicular variant of PTC remains difficult on frozen section.
文摘In the past four decades,skull base surgery has undergone dramatic paradigm shifts.Evolution in understanding of physiology and anatomy coupled with advances in technology and training have completely revolutionized management of patients with benign and malignant conditions of the anterior skull base.The“Skull Base Surgeon”requires broad and deep knowledge related to pathology,surgical approach and reconstruction with open and endoscopic techniques,perioperative management,and adjuvant and neoadjuvant indications and techniques.
