Journal of the American College of Surgeons
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Anastomotic leak is a dreaded complication of intestinal surgery and has been associated with a high mortality rate. But it is uncertain exactly which patient populations are at risk of death from the leak. We sought to assess the impact of surgeon volume on leak rate and to better understand the relationship of a leak to postoperative mortality. ⋯ The variability in leak rate by surgeons doing similar operations suggests that many leaks may be preventable. But death after a leak is most often a surrogate for a critically ill patient and was infrequently the actual cause of death.
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The outcomes after elective surgery in patients with cirrhosis have not been well studied. ⋯ In-hospital mortality, length of stay, and total hospital charges are significantly higher after elective surgery in cirrhotic patients, even in the absence of portal hypertension. Careful decision-making about surgery in these patients is critical as the nationwide increase in hepatitis C and cirrhosis continues.
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Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective. ⋯ In patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, preoperative targeted beta blockade alone is more effective than selective cardiac stress testing and nontargeted beta blockade in preventing cardiac morbidity.
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Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs). Laparoscopic surgery should be considered for these tumors, because their biologic behavior lends them to curative resection without requiring large margins or extensive lymph-adenectomies. ⋯ Laparoscopic resection of GISTs is considered safe and effective. The longterm disease-free survival of 78% establishes this minimally invasive approach as comparable to open techniques.
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Organ donation serves a public health function but is also an important part of end-of-life care. Nearly 40% of organ donors are the victims of traumatic brain injury (TBI). We report on a series of patients with nonsurvivable TBI and severe coagulopathy or active hemorrhage who went on to successful organ donation with the use of recombinant factor VIIa (rFVIIa). ⋯ Use of rFVIIa facilitated donation in patients with multisystem injuries who otherwise might have been ineligible for organ donation. Use of rFVIIa did not affect early graft function, although longterm outcomes are unknown. Recombinant factor VIIa is expensive, but its use is justified if the donor organ supply can be increased.