Journal of the American College of Surgeons
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Inhalation injury, which is among the causes of acute lung injury and acute respiratory distress syndrome (ARDS), continues to represent a significant source of mortality in burned patients. Inhalation injury often requires mechanical ventilation, but the ideal tidal volume strategy is not clearly defined in burned pediatric patients. The aim of this study was to determine the effects of low and high tidal volume on the number of ventilator days, ventilation pressures, and incidence of atelectasis, pneumonia, and ARDS in pediatric burned patients with inhalation injury within 1 year post burn injury. ⋯ High tidal volume significantly decreases ventilator days and the incidence of both atelectasis and ARDS compared with low tidal volume in pediatric burned patients with inhalation injury. Therefore, the use of HTV may interrupt sequences leading to lung injury in our patient population.
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Multicenter Study
Value of primary operative drain placement after major hepatectomy: a multi-institutional analysis of 1,041 patients.
The value of routine primary (intraoperative) drain placement after major hepatectomy remains unclear. We sought to determine if primary drainage led to decreased rates of complications, specifically, intra-abdominal biloma or infection requiring a secondary (postoperative) drainage procedure. ⋯ Primary intraoperative drain placement after major hepatectomy does not decrease the need for secondary drainage procedures and may be associated with increased bile leaks and 30-day readmissions. Routine drain placement is not warranted.
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Mesh repair of incisional hernias has been consistently shown to diminish recurrence rates after repair, with an increased risk of infectious complications. We present a consecutive series of elective, retrorectus mesh repairs of the abdominal wall and attempt to determine predictors of wound events and recurrence. ⋯ Wound events are common after open mesh repairs of complex incisional hernias. Previous mesh infections and recurrent repairs increase the likelihood of an SSI, which significantly increases the risk of recurrence. Recurrences after retrorectus mesh repairs are significantly higher with lightweight compared with mid-weight meshes.
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Multicenter Study
Use of radioiodine after thyroid lobectomy in patients with differentiated thyroid cancer: does it change outcomes?
Radioiodine (RAI) lobe ablation in lieu of completion thyroidectomy is not recommended. This study describes RAI use patterns and outcomes in patients with well-differentiated thyroid cancer (DTC) after thyroid lobectomy (TL). ⋯ A total of 32,119 patients (20%) underwent TL as the definitive procedure. Mean age at diagnosis was 48 years, median tumor size was 1 cm, 4% had extrathyroidal extension, 4% had positive lymph nodes, and <1% distant metastases. Radioiodine was administered to 24% of patients in the TL cohort and represented 10% of the overall RAI use. In multivariate analysis, RAI use was associated with age younger than 45 years (odds ratio [OR] = 1.51), community facilities (OR = 1.26), ≥ 1 cm tumors (OR = 5.67), stage II (OR = 1.54) or III (OR = 2.05), positive lymph nodes (OR = 1.78), and extrathyroidal extension (OR = 1.36). On both univariate and multivariate analysis, RAI after TL was associated with improved survival at both 5 and 10 years follow-up (97% vs 95% and 91% vs 89%, respectively; hazard ratio = 0.53; 95% CI, 0.38-0.72; p < 0.001) CONCLUSIONS: Nearly one quarter of TL patients received RAI. The strongest predictors of RAI use were larger cancers and advanced stage. Use of RAI in these patients was associated with improved overall survival. Future studies and guidelines will need to more clearly address this practice and educate providers about the appropriate use of RAI in TL patients.
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Multicenter Study
Surgical treatment of hepatocellular carcinoma in North America: can hepatic resection still be justified?
The incidence of hepatocellular cancer (HCC) is increasing dramatically worldwide. Optimal management remains undefined, especially for well-compensated cirrhosis and HCC. ⋯ The increasing incidence of HCC stresses limited resources. Although transplantation results in better long-term survival, limited donor availability precludes widespread application. Hepatic resection will likely remain a standard therapy in selected patients with HCC. In this large series, only about 10% of patients with cirrhosis were transplant-eligible based on tumor status. Although liver transplantation results are significantly improved compared with resection, transplantation is available only for a minority of patients with HCC.