Surgery
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The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis. ⋯ Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.
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Major bile duct injuries remain a potentially devastating complication after laparoscopic cholecystectomy. A retrospective review was conducted of patients who underwent a biliary-enteric reconstruction of a biliary injury to assess their long-term outcome. ⋯ Bile duct injuries that require a biliary-enteric repair are commonly associated with long-term complications. Level of injury and likely timing of repair predict risk of postoperative stricture.
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The National Surgical Quality Improvement Program (NSQIP) has reduced complications for surgery patients in the Department of Veterans Affairs Healthcare System. The American College of Surgeons Committee on Trauma maintains the National Trauma Data Bank (NTDB) to track injured patient comorbidities, complications, and mortality. We sought to apply the NSQIP methodology to collect comorbidity and outcome data for trauma patients. Data were compared to the NTDB to determine the benefit and validity of using the NSQIP methodology for trauma. ⋯ Complications occurred more frequently in trauma patients than general surgery patients. The UM NSQIP Trauma patients had higher rates of complications than reported in the NTDB. The NTDB data potentially underreport important comorbidity and outcome data. Application of the NSQIP methodology to trauma may present an improved means of effectively tracking and reducing adverse outcomes in a risk-adjusted manner.
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Hemorrhage-induced activation of endothelial cell Na+/H+ -exchanger results in cellular swelling, which physically impedes capillary filling and compromises gut perfusion. We hypothesized that correction of the vascular volume deficit by conventional resuscitation does not improve capillary filling unless cellular swelling is prevented. Also, we hypothesized that adjunctive direct peritoneal resuscitation (DPR) with topical peritoneal dialysis solution (Delflex; Fresenius USA, Inc., Ogden, Ut) enhances capillary filling and gut perfusion by mechanisms that are independent of the Na+/H+ function. ⋯ Paradoxical endothelial cell swelling occurs early during hemorrhagic shock because of activation of the Na+/H+ exchanger. This cellular edema, which is not resolved by correction of the vascular volume deficit, explains the persistent postresuscitation endothelial cell dysfunction and gut hypoperfusion. Simulated adjunctive DPR in this study reversed endothelial cell swelling and enhanced gut perfusion by mechanisms that are independent of the Na+/H+ exchanger activity.
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The field of postgraduate minimally invasive surgery/gastrointestinal surgery (MIS/GIS) training has undergone substantial growth and change. To determine whether fellowships are meeting a strategic need in training, we conducted a survey to assess the current status and trends of change in MIS/GIS fellowships. ⋯ It seems that the MIS/GIS Fellowship is meeting a real need among graduating surgical residents; fellows felt unprepared for clinical practice at the completion of residency. It is encouraging to note the improvements in fellowship structure, standards, and overall experience, brought by the efforts of the FC. It is hoped that this report of the state of MIS fellowship with a comprehensive review of current data will aid in further evaluation and improvement.