Arch Surg Chicago
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Clinical Trial
Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery.
One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. Therefore, in up to 5% of patients, revisional surgery is necessary. ⋯ Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.
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With advances in surgical care, the occurrences of major adverse outcomes have become a rare event. The effect of a surgical service can be more comprehensively evaluated by following the Donabedian model, looking at the triad of structure, process, and outcome. It is hypothesized that the implementation of a focused program commitment at a trauma center is associated with improvements in process of care and patient outcomes. ⋯ The implementation of a full-time trauma service is associated with improved timeliness of triage and therapeutic interventions and improved patient outcomes.
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Nonoperative management (NOM) of injuries to the liver, spleen, and kidney is highly successful, as shown in retrospective studies, but needs prospective validation. Patients in whom NOM is likely to fail can be identified by specific criteria. ⋯ In a prospective study, the rate of NOM failure for solid abdominal organ injuries is higher than the rates reported in retrospective studies. Nonoperative management is less likely to fail in liver injuries than in splenic or kidney injuries. Use of NOM should be exercised with caution if blood transfusion is needed, fluid is identified on the screening ultrasonogram, or a significant quantity of blood is discovered on CT.
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Hypotheses The results of ruptured abdominal aortic aneurysm repairs from a solo community hospital-based practice are comparable to those reported from large university referral medical centers. Patients younger than 70 years, arriving in the emergency department with stable hemodynamics, and undergoing prompt operation have better outcome. ⋯ The results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers.
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Case Reports
In utero repair of myelomeningocele: experimental pathophysiology, initial clinical experience, and outcomes.
Experimental work raises the possibility that in utero repair of myelomeningocele (MMC) may improve lower extremity, bladder, and bowel function, ameliorate the Arnold-Chiari malformation, and decrease the need for postnatal shunting. ⋯ Fetoscopic repair, although feasible, does not yet yield optimal surgical results. Open surgical repair before 22 weeks' gestation is physiologically sound and technically feasible. One third of patients appear to be spared the need for a shunt at age 1 year, but improvement in distal neurologic function is less clear. Additionally, fetal mortality is associated with this procedure. Our results complement the data published by groups at Children's Hospital of Philadelphia, in Pennsylvania, and Vanderbilt University, Nashville, Tenn. A National Institutes of Health-sponsored prospective randomized trial is now underway at these 3 centers to compare fetal repair with postnatal repair.