JAMA surgery
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Multicenter Study
Epidural analgesia in laparoscopic colorectal surgery: a nationwide analysis of use and outcomes.
The use of epidural analgesia in laparoscopic colorectal surgery has demonstrated superiority over conventional analgesia in controlling pain. Controversy exists, however, regarding its cost-effectiveness and its effect on postoperative outcomes. ⋯ The perioperative use of epidural analgesia in laparoscopic colorectal surgery is limited in the United States. While epidural analgesia appears to be safe, it comes with higher hospital charges, longer hospital stay, and a higher incidence of urinary tract infections.
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Comparative Study
Locally advanced pancreatic cancer: association between prolonged preoperative treatment and lymph-node negativity and overall survival.
Treatment of patients with locally advanced/borderline resectable (LA/BR) pancreatic ductal adenocarcinoma (PDAC) is not standardized. ⋯ Our approach to patients with LA/BR PDAC, which includes prolonged preoperative chemotherapy, is associated with a high incidence of LN-negative disease and excellent OS. After surgical resection, HP treatment response, perineural invasion, and SMAD4 status should help determine who should receive adjuvant therapy in this select subset of patients.
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Comparative Study
Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.
To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality. ⋯ High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.
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An Institute of Medicine report on patient safety that cited medical errors as the 8th leading cause of death fueled demand to use quality measurement as a catalyst for improving health care quality. ⋯ In-hospital mortality rates. RESULTS Performance benchmarking was not significantly associated with lower in-hospital mortality (adjusted odds ratio [AOR], 0.89; 95% CI, 0.68-1.16; P=.39). Similar results were obtained in secondary analyses after stratifying patients by mechanism of trauma: blunt trauma (AOR, 0.91; 95% CI, 0.69-1.20; P=.51) and penetrating trauma (AOR, 0.75; 95% CI, 0.44-1.28; P=.29). We also did not find a significant association between nonpublic reporting and in-hospital mortality in either low-risk (AOR, 0.84; 95% CI, 0.57-1.25; P=.40) or high-risk (AOR, 0.88; 95% CI, 0.67-1.17; P=.38) patients. CONCLUSIONS AND RELEVANCE Nonpublic reporting of hospital risk-adjusted mortality rates does not lead to improved trauma mortality outcomes. The findings of this study may prove useful to the American College of Surgeons as it moves ahead to further develop and expand its national trauma benchmarking program.
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Review Meta Analysis
The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis.
Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. ⋯ The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.