Thoracic surgery clinics
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Thoracic surgery clinics · Nov 2005
ReviewPostoperative futile care: stopping the train when the family says "keep going".
All surgeons must take risks when providing medical care. No guarantees of protection from a lawsuit exist in any guise. Concerning postoperative futile care, the stakes are high when withdrawal of support seems to be indicated but the surrogate believes in sanctity-of-life and demands continued aggressive care. ⋯ If so, "do what's right" is not just to "stop the train." It also consists of a range of clinical activities, including effective communication, emotional care, and pursuing a fair and open negotiation process established by the institution. Properly conducted, "stopping the train" should incur no greater risk for professional liability than any other challenging procedure that surgeons perform. Withdrawal of futile care should be considered as a procedure, and as such, the skills to deliver it should be mastered like any other.
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Higher standards of evidence for surgical procedures are likely to be demanded in the future by health insurance providers. Consequently, more formal and rigorous surgical research, including RCTs, will become more prevalent. Facing the ethical challenges of surgical research requires understanding of the ethically significant differences between surgical practice and research and the ways in which the ethical standards appropriate for the design and conduct of clinical research differ from the ethics of clinical care.
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The causal relationship between GERD and esophageal adenocarcinoma, although unclear just a few decades ago, now is established fairly well. The physiologic changes and the biocellular alterations of the damaged esophageal mucosa are documented better. Despite this knowledge, the dramatic increase in the incidence of esophageal cancer cannot be explained. ⋯ During regular endoscopic follow-up, multilevel circumferential biopsies should document the evolution of the histologic changes in the lower esophagus and at the gastroesophageal junction of these patients. It is the only method available to document the appearance of dysplasia. It still is unclear if medicine or surgery provides the best quality of life and the best protection against the development of dysplasia and the possible progression toward adenocarcinoma formation when intestinal metaplasia is present in the esophagus.
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Smokers have a significantly greater risk of complications during and after operations. Cigarette smoke has significant effects on cardiac function, circulation, and respiratory function. ⋯ Smoking cessation programs that employ advice, support groups, nicotine replacement therapy, or some anti-depressants have been used successfully in many situations and should be used to discourage smoking preoperatively. Further research is needed, however, to clarify the best approach to smoking cessation for surgical patients.
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Although data are limited for preoperative pulmonary rehabilitation, benefit can be inferred largely from studies done on COPD and pulmonary rehabilitation because of the similarity of patient populations. Although underlying lung function is unchanged, patients who undergo preoperative pulmonary rehabilitation seem to experience an enhanced quality of life and increased functional capacity. ⋯ Although pulmonary rehabilitation works to benefit patients anticipating surgery, it also represents a valuable treatment alternative to patients who are poor surgical candidates. Pulmonary rehabilitation seems to be a cost-effective, benign intervention with no adverse effects and should remain an essential component of patient management before lung transplantation, LVRS, lung resection, and potentially any other elective thoracic surgical procedure.