Journal of the American College of Surgeons
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Multicenter Study
Global Outcomes Benchmarks in Laparoscopic Liver Surgery for Segments 7 and 8: International Multicenter Analysis.
In recent years, there has been growing interest in laparoscopic liver resection (LLR) and the audit of the results of surgical procedures. The aim of this study was to define reference values for LLR in segments 7 and 8. ⋯ This study shows the need to establish standards for the postoperative outcomes in LLR based on the complexity of the resection and the location of the lesions.
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As the principle of respect for patient autonomy has gained salience over the past 75 years, surgeons now struggle to resolve conflicts between autonomy and beneficence in certain clinical scenarios. One such conflict occurs when a patient desires a surgical intervention, but the surgeon concludes that the patient is "too sick for surgery" and hence would not benefit from the operation. We provide historical context for the principle of respect for patient autonomy and review recent qualitative data that demonstrate surgeons experience significant moral distress when asked to perform nonbeneficial surgery. ⋯ Third, we use the centuries-old notion of medicine as a profession to show that surgeons have a fiduciary responsibility to act in the best interests of their patients, including and especially when patients request interventions that are not beneficial. Finally, we draw on virtue ethics to give surgeons character-based resources for fulfilling their professional obligations to patients. We contend that surgeons owe their patients the ability to trust that they will always use their knowledge and skills for patients' benefit, even if surgeons must limit patients' autonomy in certain ways to do so.
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Gastric electrical stimulation (GES) is an intervention used in the treatment of medically refractory gastroparesis. There are few large series demonstrating efficacy over a long-term follow-up period. This study reports clinical outcomes for patients from a single institution for up to 5 years. ⋯ GES is associated with sustained symptomatic relief, reduced reliance on medications, and reduced hospitalizations in gastroparesis patients selected using our institutional protocol.
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Laparoscopic paraesophageal hernia (PEH) repair has a high hernia recurrence rate. The aim of this study was to assess the 5-year hernia recurrence rate after PEH repair using a combination of bioresorbable mesh and advanced surgical techniques to address tension as needed in a prospective group of patients. ⋯ The combination of Phasix ST Mesh and tension-reducing techniques during PEH repair led to a 25% hernia recurrence rate at 5 years. The addition of a Collis gastroplasty led to significantly fewer hernia recurrences and is indicative of the potential for esophageal shortening in many patients with a PEH. The long-term safety and efficacy of Phasix ST Mesh in combination with surgical technique for PEH repair is confirmed.
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Mild traumatic brain injury (mTBI) encompasses a spectrum of disability including early cognitive impairment (ECI). The Brain Injury Guidelines suggest that patients with mTBI can be safely discharged from the emergency department. Although half of patients with mTBI with intracranial hemorrhage (ICH) have evidence of ECI, it is unclear what percentage of these patients' ECI persists after discharge. We hypothesize a significant proportion of trauma patients with mTBI and ECI at presentation have persistent ECI at 30-day follow-up. ⋯ More than one-third of mTBI patients with ICH had ECI. At 30-day postdischarge follow-up, more than one-fourth of these patients had persistent ECI and 33% had concussion symptoms. This highlights the importance of identifying ECI before discharge as a significant portion may have ongoing difficulties reintegrating into work and society.