The Surgical clinics of North America
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Minimally invasive esophagectomy can be safely performed in selected cases in centers specializing in minimally invasive esophageal surgery. Potential benefits include lessened physiologic insult, with decreased hospital stay and a more rapid recovery to full activity. ⋯ Prospective trials with longer follow-up will be required to confirm any advantages of MIE over conventional approaches. Open surgical approaches should remain the standard operation for esophagectomy in most institutions.
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Surg. Clin. North Am. · Jun 2005
ReviewPartial versus complete fundoplication: is there a correct answer?
Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. ⋯ The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.
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The key points of this article are: Spirituality gives meaning and purpose to life. Spiritual issues that may lie dormant for many years often surface at the end of life. Not all people are religious, but all are spiritual. ⋯ Redefining hope: hospice can help the dying patient to redefine hope in terms of realistic goals-from a hope for cure to a hope for good symptom relief. Reconciliation is the work of the dying. Empathy is the opportunity for those who care for the dying.
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Pharmacologic therapy for neuropathic pain is based on an evolving understanding of its underlying mechanisms, and often requires a patient,methodical sequence of trials that include the "four As": analgesics,antidepressants, anticonvulsants, and antiarrhythmics. Critical for success is a willingness to stay engaged with the patient to evolve a mutually acceptable plan and goals of care with realistic outcomes that emphasize symptom control and maximization of function. Such management is within the capabilities of surgeons for most patients, whereas the use of consultation and interdisciplinary supportive interventions from comprehensive pain management centers, if available, is helpful in more difficult cases.
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Surg. Clin. North Am. · Apr 2005
ReviewEthical issues in surgical palliative care: am I killing the patient by "letting him go"?
Recent medical advances have complicated decisions regarding terminal care. Surgeons should be familiar with the ethical issues that contribute to end-of-life decision-making. ⋯ Artificial ethical distinctions between withholding versus withdrawing care or ordinary versus extraordinary treatments can confuse clinical decision-making at the end of life. An ethics of death and dying requires that the intent and the action of the moral agent be considered.