Journal of the American College of Surgeons
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Little is known about the outcomes of patients with microscopically positive (R1) resections for primary gastrointestinal stromal tumors (GIST) because existing retrospective series contain small numbers of patients. The objective of this study was to analyze factors associated with R1 resection and assess the risk of recurrence with and without imatinib. ⋯ Approximately 9% of 819 GIST patients had an R1 resection. Significant factors associated with R1 resection include tumor size ≥ 10 cm, location, and rupture. The difference in recurrence-free survival with or without imatinib therapy in those undergoing an R1 vs R0 resection was not statistically significant at a median follow-up of 4 years.
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Several prospective randomized controlled trials show equal effectiveness of surgical fundoplication and proton pump inhibitor therapy for the treatment of gastroesophageal reflux disease. Despite this compelling evidence of its efficacy, surgical antireflux therapy is underused, occurring in a very small proportion of patients with gastroesophageal reflux disease. An important reason for this is the perceived morbidity and mortality associated with surgical intervention. Published data report perioperative morbidity between 3% and 21% and mortality of 0.2% and 0.5%, and current data are uncommon, largely from previous decades, and almost exclusively single institutional. ⋯ Analysis of this large cohort demonstrates remarkably low 30-day morbidity and mortality of laparoscopic fundoplication. This is particularly true in patients younger than 70 years, who are likely undergoing fundoplication for gastroesophageal reflux disease. These data suggest that surgical therapy carries an acceptable risk profile.
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The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce. ⋯ Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.
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Many laparoscopic procedures are currently performed on an outpatient basis. Laparoscopic appendectomy, however, continues to require postoperative hospitalization at most institutions. A treatment protocol for outpatient laparoscopic appendectomy was developed to determine if this could be successfully performed without increasing postoperative complications. We hypothesized that adopting an outpatient protocol for laparoscopic appendectomy will significantly increase the rate of outpatient management for uncomplicated appendicitis, without an increase in morbidity or mortality. ⋯ An outpatient protocol for laparoscopic appendectomy significantly increased the rate of outpatient management with no increase in morbidity or mortality. This practice has now become standard of care at our institution.
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The surgical treatment of metastatic, nonfunctional pancreatic neuroendocrine carcinoma (nPNEC) is not well defined. Existing series are confounded by inclusion of patients with metastatic functional tumors or gastrointestinal carcinoid. Our hypothesis was that the surgical treatment of metastatic nPNEC provides favorable perioperative and oncologic outcomes. ⋯ Surgical treatment of metastatic nPNEC to the liver with curative intent or for palliative ≥ 90% debulking provides favorable oncologic outcomes. Despite a high incidence of tumor recurrence, 5-year survival rates are encouraging and appear to justify an aggressive surgical approach in these patients.