Journal of the American College of Surgeons
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Multicenter Study Comparative Study
Hospital surgical volume and cost of inpatient surgery in the elderly.
Strong relationships between hospital volume and quality with inpatient surgery have prompted calls for volume-based referral. However, many are concerned that such policies would steer patients toward higher-cost hospitals. ⋯ Volume-based referral policies would not steer patients toward hospitals with high mean costs around episodes of inpatient surgery in the elderly. Minimizing the use of very low-volume hospitals has the potential to reduce costs as well as improve outcomes, particularly for operations with strong volume-outcomes associations.
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Comparative Study
Deciding laparoscopic approaches for wedge resection in gastric submucosal tumors: a suggestive flow chart using three major determinants.
The aim of this study was to determine the optimal laparoscopic approach for wedge resection of gastric submucosal tumors (SMTs) based on tumor characteristics. ⋯ These data suggest a strategy for selection of appropriate laparoscopic wedge resection strategies based on tumor characteristics. This decision is affected by tumor size, location, and growth pattern.
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Comparative Study
Modified hernia grading scale to stratify surgical site occurrence after open ventral hernia repairs.
The lack of a universally accepted classification system for incisional hernia repair has led to inconsistent reporting of ventral hernia repairs, the inability to compare various series, and the lack of appropriate risk adjusted stratification systems to evaluate surgical outcomes. This study evaluates the Ventral Hernia Working Group's (VHWG) grading scale to accurately predict surgical site occurrence (SSO) after open ventral hernia repair. ⋯ Modification of the VHWG grading scale into a 3-level grading system would significantly improve the accuracy of predicting SSO after open ventral hernia repair. Grade 2 patients should include those with comorbidities and previous wound infections. Grade 3 patients should be stratified based on CDC definitions of wound contamination. This modified grading scale would significantly improve outcomes reporting after open ventral hernia repair.
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Comparative Study
In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy.
Although percutaneous endoscopic gastrostomy (PEG) is widely performed for nutrition or palliation, PEG-associated outcomes in cancer patients remain poorly described. We examined the safety and benefits of PEG placement in this population at our institution. ⋯ Percutaneous endoscopic gastrostomy placement in this study population was associated with major procedure-related complications. The majority of patients failed to achieve total parenteral nutrition independence or advancement of diet. Nearly 25% of patients declined aggressive resuscitation strategies after undergoing surgery for PEG. This study cautions to carefully weigh the risks and benefits of PEG placement in this patient population. Prospective studies are needed to uncover factors affecting the decision process and patient selection.
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Comparative Study
A histopathologic basis for surgical debridement to promote healing of venous ulcers.
Pathologic analysis of deep tissue obtained during debridement of venous ulcers is often unnoticed in its importance. We previously reported pathologic findings on 139 patients with venous ulcers. The objective of this study was to correlate the pathologic findings in venous ulcers with wound healing to establish a negative margin for debridement. ⋯ Presence of dense fibrosis and high levels of mature collagen in deep tissue specimens are significant correlative factors in nonhealing of venous ulcers. We recommend deep debridement on all venous ulcers that are refractory to healing until the level of absence of dense fibrosis and mature collagen is reached to promote venous ulcer healing.