The American surgeon
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The American surgeon · Nov 2019
Risk of Perforation in the Era of Nonemergent Management for Acute Appendicitis.
Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to perforation. Recently, studies have suggested nonemergent management of acute appendicitis. Our study aimed to determine changes in risk of rupture and complications in patients with appendicitis, with increasing time from symptom onset to treatment. ⋯ Furthermore, for each day delay, there is an 8% increased risk of postoperative abscess (RR 1.08, P = 0.027). The relative risk for appendiceal perforation is 9 per cent per day delay with a resultant 8 per cent increased risk of postoperative abscess. Thus, appendectomy for acute appendicitis should remain an emergent procedure, given that delays in operative management lead to complications and increases in cost of care.
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The American surgeon · Oct 2019
Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection.
Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. ⋯ Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.
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The American surgeon · Sep 2019
Human Acellular Dermal Matrix Is a Viable Alternative to Autologous Skin Graft in Patients with Cutaneous Malignancy.
Skin substitutes have shown success in complex wound reconstruction. We evaluate the use of a human acellular dermal matrix (ADM) as a viable alternative to autologous skin grafting for defects secondary to skin cancer excision. An institutional review board-approved, retrospective review of ADM-reconstructed defects secondary to skin cancer excision between 2012 and 2018 was conducted. ⋯ The median interval to complete epidermal coverage was 42 days, with graft failure evident in six patients (2.6%). ADM is a viable, low-morbid alternative for reconstruction of defects secondary to skin cancer excision, with no donor site morbidity. With exception to complete healing time, outcomes are similar to those of autologous grafting.
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The American surgeon · Sep 2019
Failure to Rescue: A Quality Improvement Imperative in Achieving Zero Death in Damage Control Laparotomy Patients.
Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. ⋯ This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.