Advances in surgery
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PD continues to be associated with a high rate of failed discharges, despite significant improvements in techniques and postoperative care at high-volume centers. Even in the best hands, 1 in 5 patients undergoing PD can be expected to require readmission in the early postoperative period. Efforts to minimize readmissions must be aimed at identifying high-risk patients, addressing patient expectations, establishing patient care plans, and using outpatient resources to address anticipated problems and complications.
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Advances in surgery · Jan 2013
ReviewReadmission after abdominal aortic aneurysm repair: what does it mean?
Thirty-day readmission is common after AAA repair, an d postoperative events are strong predictors of readmission after adjusting for comorbidity. In addition, readmission is strongly associated with 1-year mortality. Considering the current evidence for readmission after AAA repair, improved coordination of care across the inpatient, transitional care, and outpatient settings, with active surveillance for procedure-specific (EVAR vs open) postoperative complications, may prevent some early readmissions. Given the pending financial implications and the striking association with 1-year mortality, developing interventions that target readmission after AAA repair is of paramount importance in the landscape of vascular surgery practice.
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Advances in surgery · Jan 2013
ReviewThe effect of do-not-resuscitate status on postoperative mortality in the elderly following emergency surgery.
Elderly patients who have preexisting DNR orders experience a high incidence of mortality and major morbidity within 30 days after emergency general surgery. Although not a risk factor for major morbidity, preoperative DNR status does represent an independent risk factor for mortality after emergency general surgery. The most plausible reason for the excess mortality in DNR patients is their decreased willingness to undergo aggressive treatment of major postoperative complications. Whether patient-driven failure-to-pursue-rescue also explains to some extent the high mortality of non-DNR elderly emergency general surgery patients deserves further investigation.
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Current recommendations from the 2002 ASA Task Force on Preanesthesia Evaluation are not specific to ambulatory surgery and are not based on strongly designed and adequately powered studies. Furthermore, although the ASA does not advocate routine testing or testing without indication, the guidelines for "selective" or "indicated" testing are unclear. As a result, preoperative testing in the United States is overused relative to the current ASA Task Force recommendations. ⋯ Identification of reasons for overuse of testing is the first step toward changing practice. Once clear guidelines are developed, the creation of preoperative clinics that centralize preoperative care, or promoting the use of clinical pathways and/or checklists for determining appropriate tests, may improve the adequate use of preoperative tests. It will be critical for quality improvement measures to include surgeons, anesthesiologists, hospital administrators, and governing bodies such as the ASA and American College of Surgeons to achieve success.