Journal of the American College of Surgeons
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Ischemia-reperfusion injury (IRI) can occur during hepatic surgery and transplantation. IRI causes hepatic mitochondrial and microcirculatory impairment, resulting in acute liver dysfunction and failure. We proposed a novel strategy of regulated hepatic reperfusion (RHR) to reverse the cellular metabolic deficit that incurred during organ ischemia by using a substrate-enriched, oxygen-saturated, and leukocyte-depleted perfusate delivered under regulated reperfusion pressure, temperature, and pH. We investigate the use of RHR in mitigating IRI after a prolonged period of warm ischemia. ⋯ Regulated hepatic reperfusion mitigates IRI, facilitates liver function recovery, and improves survival after a prolonged period of hepatic warm ischemia. This novel strategy has potential applicability to clinical hepatic surgery and liver transplantation when marginal grafts are used.
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Comparative Study
Mortality after elective colon resection: the search for outcomes that define quality in surgical practice.
Process measures constitute the focal point of surgical quality studies. High levels of compliance with such processes have not correlated with improved outcomes. Wide ranges of reported hospital death rates led us to hypothesize that survival after elective colon resection would be a legitimate outcomes measure for quality of surgical practice. ⋯ Elective colon resection is a safe procedure in both teaching hospitals and nonteaching hospitals, with an impressively homogenous mean mortality rate of 1.56% in teaching hospitals, and 1.38% in nonteaching hospitals. We reject our original hypothesis because the data do not sufficiently discriminate to permit the use of death after elective colon resection as a differentiating quality measure; however, the data do identify individual poor performers. Poor performing institutions/surgeons should seek extramural guidance to improve their outcomes or discontinue performing such operations.
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Comparative Study
Adherence to a simplified management algorithm reduces morbidity and mortality after penetrating colon injuries: a 15-year experience.
Our previous experience with colon injuries suggested that operative decisions based on a defined algorithm improve outcomes. The purpose of this study was to evaluate the validity of this algorithm in the face of an increased incidence of destructive injuries observed in recent years. ⋯ Despite an increase in the incidence of destructive colon injuries, our management algorithm remains valid. Destructive injuries associated with pre- or intraoperative transfusion requirements of more than 6 units packed RBCs and/or significant comorbidities are best managed with diversion. By managing the majority of other destructive injuries with resection plus anastomosis, acceptably low morbidity and mortality can be achieved.
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Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. ⋯ Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.
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The influence of minimally invasive options has led to the application of new evolving techniques in thyroid surgery to eliminate visible neck scars. Here, we describe one author's experience with transaxillary robotic thyroidectomy and examine the effect of experience on determining the learning curve and improvements over time in operative performance. ⋯ Here we report the largest experience of robotic gasless thyroid surgery in the United States. This novel technique provides excellent cosmetic results and can be performed as an outpatient procedure in selected group of patients. It is feasible and safe, however, has a lengthy learning curve.