Advances in surgery
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Robotic pancreatic resections have been established as safe alternatives to the open and laparoscopic approaches. The platform has proven to be versatile, and discriminable, allowing an increasing number of surgeons to perform complex pancreatic resections in minimally invasive fashion. To date, the realized advantages of the robotic technique are decreased blood loss, and fewer conversions to laparotomy. Although these are 2 very important metrics, larger experiences comparing robotics to open and/or laparoscopic surgery are ultimately needed if the true potential of robotic pancreatic resections are to be realized.
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The rising use of antiplatelet therapy for primary prevention and secondary prevention of cardiovascular and cerebrovascular events poses a dilemma for physicians in the perioperative period. The proven benefits of aspirin in preventing further thrombotic events in patients with prior ACS or stroke make it difficult to withdraw this therapy. The risk of hypercoagulability associated with surgery is also independent of antiplatelet withdrawal, but adds to the rebound effect of platelet responsiveness. ⋯ It is recognized that maintaining antiplatelet therapy is also not without risk, as bleeding complications have been well documented. Unfortunately, current perioperative guidelines do not often provide a simple solution for management. Therefore, the risk of bleeding has to be weighed against the risk of thrombosis, and decisions should be made with all providers caring for the patient on an individual basis.
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Advances in surgery · Jan 2014
ReviewDoes close temperature regulation affect surgical site infection rates?
The argument for close temperature control, to which regulatory bodies have held health systems in an effort to reduce the burden of hospital-acquired infections, is not fully supported by current evidence. The literature is complex on the topic, and overinterpretation of historical data supporting close temperature regulation does not preclude an important recognition of these early works' contribution to high-quality surgical care. Avoidance of hypothermia through the regular use of active rewarming should be a routine part of safe surgical care. ⋯ Clinicians, researchers, and policymakers must be careful in how they apply these well-supported findings to process metrics in an era of limited resources with increasingly stringent quality guidelines and outcomes measures. Discrete temperature targets in current measures are not supported by the existing literature. Not only do these targets artificially anchor clinicians to temperature values with an inadequate scientific basis but they demand intensive resources from health institutions that could potentially be better used on quality requirements with stronger evidence of their ultimate effect on patient care.
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Laparoscopic cholecystectomy is widely established as the standard operation in acute cholecystectomy. Valid data from several prospective studies, including a recent large randomized multicenter trial, are available, demonstrating that early cholecystectomy is associated with less morbidity, a shorter length of hospital stay, and lower total hospital costs compared with delayed cholecystectomy after a conservative treatment period with antibiotics. Early cholecystectomy within 24 hours of hospital admission is the therapy of choice in patients fit for surgery and should be implemented as the standard treatment algorithm for this condition.