Journal of the American College of Surgeons
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The ACGME instituted duty hour restrictions in 2003. This presents a challenge for surgical residents who must acquire a medical and technical knowledge base during their training. Although the effect of work hour limitations on operative volume has been examined, no study has examined whether duty hour reform has had an effect on operative volume variability. ⋯ After the implementation of the 80-hour workweek, we found a significant increase in operative variability. This might suggest a growing disparity in the operative experience among surgical residents and, consequently, a varying quality of graduating residents. Programs should therefore consider using learning styles and developing competency-based training curricula to ensure equitable training among all trainees.
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The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist. ⋯ Although the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.
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The ACGME requires general surgery residents (GSR) to perform 20 pediatric surgery cases as part of the total 750 cases before graduation. ⋯ Total pediatric surgery cases and PSF operative volume have increased, while GSR operative volume has decreased. Opportunities may exist to increase resident participation while providing further teaching opportunities for GSR, improving the quality of both resident and fellow training.
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Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone. ⋯ In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.
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Use of Enhanced Recovery After Surgery (ERAS) pathways have evidenced improved outcomes in several surgical specialties. The effectiveness of ERAS pathways specific to hernia surgery, however, has not yet been investigated. We hypothesized that our ERAS pathway would accelerate functional recovery and shorten hospitalization in patients undergoing open ventral hernia repair (VHR). ⋯ A comprehensive ERAS pathway for major open VHR was implemented safely. Multimodal perioperative pain management, oral opioid-receptor blockade, and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations, and fewer readmissions. Use of our ERAS pathway appears to result in improved outcomes in patients undergoing open VHR.