Journal of the American College of Surgeons
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Clinical Trial
Perioperative Bundle to Reduce Surgical Site Infection after Pancreaticoduodenectomy: A Prospective Cohort Study.
Pancreaticoduodenectomy is historically associated with incisional surgical site infection (iSSI) rates between 15% and 20%. Prospective studies have been mixed with respect to the benefit of individual interventions directed at decreasing iSSI. We hypothesized that the application of a perioperative bundle during pancreaticoduodenectomy would decrease the rate of iSSIs significantly. ⋯ In this cohort study of 300 consecutive patients who underwent pancreaticoduodenectomy, the implementation of a 4-part bundle decreased iSSI rate from 22% to 11%.
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Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures. ⋯ No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.
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Observational Study
Development of Diabetes after Pancreaticoduodenectomy: Results of a 10-Year Series Using Prospective Endocrine Evaluation.
Limited literature is available on the development of impaired glucose tolerance and diabetes mellitus after pancreaticoduodenectomy. The primary aim was to define the diabetic phenotype and correlate preoperative glycemic laboratory results to new-onset diabetes after pancreaticoduodenectomy. ⋯ Diabetes will develop after pancreaticoduodenectomy in approximately 16.6% of patients. A preoperative glycated hemoglobin >5.4% independently predicts new-onset diabetes. Pre- and postoperative endocrine analysis remains paramount for proper patient risk stratification.
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Recent studies on postoperative pancreatic fistula (POPF) prevention suggest that omission of perioperative drains is safe for negligible- or low-risk patients undergoing pancreatoduodenectomy (PD). However, this proposed pathway has not been validated in a nationwide cohort. ⋯ In this population-based cohort, the mFRS was unable to stratify patients relative to the need for selective drain placement during PD. For both high- and low-risk patients, perioperative drain placement was associated with increased rates of POPF, CR-POPF, and extended LOS, but decreased incidence of serious morbidity.
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In 2017, our hospital was identified as a high outlier for postoperative Clostridium difficile infections (CDIs) in the American College of Surgeons NSQIP semi-annual report. The Department of Surgery initiated a CDI task force with representation from Surgery, Infectious Disease, Pharmacy, and Performance Services to analyze available data, identify opportunities for improvement, and implement strategies to reduce CDIs. ⋯ Our multidisciplinary CDI reduction program has demonstrated significant reductions in CDIs. It is effective, straightforward to implement and monitor, and can be generalized to high-outlier institutions.