American journal of surgery
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Comparative Study
Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients.
Cirrhotic patients who present for elective and emergent surgery pose a formidable challenge for the surgeon because of the high reported morbidity and mortality. The Child-Turcotte-Pugh (CTP) score previously has been used to evaluate preoperative severity of liver dysfunction and to predict postoperative outcome. Recently, a more objective scoring classification, the model for end-stage liver disease (MELD), has been shown to predict accurately the 3-month mortality for cirrhotic patients awaiting transplantation. We sought to compare the CTP and MELD scores in predicting outcomes in cirrhotic patients undergoing surgical procedures requiring general anesthesia. ⋯ Our study shows that cirrhotic patients who undergo surgery under general anesthesia have an extremely high 1- and 3-month mortality rate that progressively increases with severity of preoperative liver dysfunction. Additionally, the MELD score correlates well with the CTP score, providing a more objective predictor of postoperative mortality in cirrhotic patients undergoing surgery.
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Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility. ⋯ Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.
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Comparative Study
Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment.
It is known that smokers and patients with chronic obstructive pulmonary disease (COPD) experience a higher rate of pulmonary-related complications following abdominal surgery. The impact of anesthetic technique (regional [RA] versus general [GA] versus combination of both) on the complication rate has not been established. This study examined the outcomes of abdominal surgery performed using RA (epidural or continuous spinal) as the sole anesthetic technique in patients with severe pulmonary impairment (SPI). ⋯ Abdominal surgery can be safely performed using RA alone in selected high-risk patients, making this option an attractive alternative to GA for those with severe pulmonary impairment.
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Comparative Study
Improvements in dialysis access survival with increasing use of arteriovenous fistulas in a Veterans Administration medical center.
Native arteriovenous fistulas (AVFs) have been found to exhibit higher survival rates and lower complication rates than prosthetic grafts (AVGs). ⋯ The National Kidney Foundation-Dialysis Outcome Quality Initiative (NKF-DOQI) guidelines for dialysis access reawakened interest in maximizing the use of renal veins for AVF. AVFs created by using the patient's native vein provides the best vascular access for dialysis when compared with prosthetic grafts. AVF has better long-term patency with fewer complications.
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Comparative Study
Evaluating alternative risk-adjustment strategies for surgery.
Comparison of institutional health care outcomes requires risk adjustment. Risk-adjustment methodology may influence the results of such comparisons. ⋯ In surgical patients, different risk-adjustment methodologies afford divergent estimates of mortality risk.