Thoracic surgery clinics
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Pulmonary complications are the major source of morbidity and mortality after esophageal resection, and numerous studies have identified various associated with these complications. This article discusses preoperative, intraoperative, and postoperative factors affecting pulmonary complications and strategies to reduce these complications after esophagectomy.
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In conclusion, chylothorax after esophagectomy is a devastating complication with high mortality rates if not corrected. A heightened awareness of this complication with early diagnosis and aggressive reoperation leads to excellent outcome. Reoperation is not indicated only when medical therapy significantly slows the daily loss of chyle and there are no metabolic consequences. ⋯ Reoperation should be based on the approach initially used for the esophagectomy, the location of the leak, and the side that has the chylothorax. The conduit should be handled carefully at the time of reoperation, the leak identified, the duct or the leaking nodal basin clipped and glued, and a pleurodesis performed. Following these principles minimizes the morbidity of a serious postoperative complication.
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HIPAA regulations have been seen by many physicians as providing innumerable administrative hoops that require jumping through with no clear benefit for individual patients. Although this article has not comprehensively explored the requirements of HIPAA regulations, it has focused on the issues of "incidental disclosures" that are so important to the daily interactions of physicians and patients. Through the use of illustrative cases, it has been shown that HIPAA regulations frequently are based on well-accepted ethical principles. ⋯ As Lo and colleagues have very appropriately pointed out: In the context of inadvertent disclosure, the legal risks of good practice are very low. Physicians should work with risk managers and practice administrators to develop policies that promote good communication in patient care, while taking appropriate steps to protect patient privacy. By adopting such an approach to HIPAA, physicians can abide by the regulations while maintaining high ethical standards and minimizing the impact of the new requirements on physician-patient relationships.
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Informed consent plays a major role in forming a therapeutic alliance with the patient. The informed consent process has evolved from simple consent, in which the surgeon needed only to obtain the patient's permission for a procedure, into informed consent, in which the surgeon provides the patient with information about clinically salient features of a procedure, the patient understands this information adequately, and the patient voluntarily authorizes the surgeon to perform the procedure. Special circumstances of informed consent include conflicting professional opinions, consent with multiple physicians, patients who are undecided or refuse surgery, patients with diminished decision-making capacity, surrogate decision making, pediatric assent, and consent for the involvement of trainees.
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Thoracic surgery clinics · Nov 2005
ReviewWithdrawing life-sustaining treatment: ethical considerations.
In the community of caregivers, there is a general consensus that some heroic measures are not obligatory in certain circumstances that are defined by professional norms. For example, cardiopulmonary resuscitation in terminal cancer patients is not endorsed because of its violation of the dignity of the irremediably ill, and its unproductive cost to society. Moving back from this extreme, the availability and effectiveness of life-prolonging treatments, such as ventilators, dialysis, and implantable mechanical hearts, moves into a domain where the boundary limit of the obligation to preserve life is less clearly defined. ⋯ Neglecting this part of the duty to provide appropriate care brings moral anguish to all participants in the peculiar circumstances that have come to surround death in the ICUs of developed countries. It is helpful to accept the inevitable reality that death is, in Shakespeare's words, a "necessary end" to all mortal life, and to recognize that defying death with technology can sometimes become an unnatural and degrading activity, however well motivated. The withdrawal of life-sustaining treatment, when conducted expertly, is a shared human experience that can be gratifying, although difficult for all concerned.