| 1. |
- Björck, Martin, et al.
(författare)
-
Closure of the Open Abdomen
- 2011
-
Ingår i: The American surgeon. - 0003-1348 .- 1555-9823. ; 77:7, s. S58-S61
-
Tidskriftsartikel (refereegranskat)abstract
- The open abdomen is a valuable tool in the management of patients with intra-abdominal hypertension and abdominal compartment syndrome. The longer an abdomen is left open, the greater the potential morbidity, however. From the very start, specific measures should be considered to increase the likelihood of definitive closure and prevent the development of visceral adhesions, lateralization, and/or loss of skin and fascia, ileus, fistulae, and malnutrition. Early definitive closure of all abdominal wall layers is the short-term goal of management once the need for the open abdomen has resolved. Several devices and strategies improve the chances for definitive closure. If a frozen abdomen develops, split-thickness skin grafting of a granulating open abdominal wound base is an alternative. Early coverage of the exposed viscera and acceptance of a large abdominal hernia permit earlier reversal of the catabolic state and lower the risk of fistula formation. When a stoma is required, sealing and separation can become problematic. If a fistula develops, a more complex situation prevails, requiring specific techniques to isolate its output and a longer-term strategy to restore intestinal continuity. Planning the closure of an open abdomen is a process that starts on the first day that the abdomen is opened. Multiple factors need to be addressed, optimized, and controlled to achieve the best outcome.
|
|
| 2. |
- Björck, Martin, et al.
(författare)
-
Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Non trauma Surgical Patients
- 2011
-
Ingår i: The American surgeon. - 0003-1348 .- 1555-9823. ; 77:7, s. S62-S66
-
Tidskriftsartikel (refereegranskat)abstract
- Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are commonly encountered in nontrauma surgical patients. Depending on the etiology of the patient's surgical illness (ruptured abdominal aortic aneurysm, acute pancreatitis, burns, etc.), both the incidence and mortality of IAH/ACS may be quite high. Recent advances in both the diagnosis and resuscitation of these surgical patients have resulted in significantly improved survival over that seen in years past. Intra-abdominal pressure measurements should be performed in any surgical patient who demonstrates risk factors for IAH/ACS.
|
|
| 3. |
- Ivanics, Tommy, et al.
(författare)
-
Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines
- 2020
-
Ingår i: The American surgeon. - : SAGE Publications. - 0003-1348 .- 1555-9823. ; 87:7, s. 1039-1047
-
Tidskriftsartikel (refereegranskat)abstract
- The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. Methods This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). Results Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). Conclusions Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.
|
|
| 4. |
- Khoury, L, et al.
(författare)
-
Management of Thoracic and Lumbar Spine Fractures: Is MRI Necessary in Patients without Neurological Deficits?
- 2019
-
Ingår i: The American surgeon. - : SAGE Publications. - 1555-9823 .- 0003-1348. ; 85:3, s. 306-311
-
Tidskriftsartikel (refereegranskat)abstract
- MRI after a CTscan for thoracolumbar spine (TLS) trauma has become commonplace because of the concerns for detection of posterior ligamentous complex injuries in the absence of substantial scientific evidence to support its use. We hypothesized that MRI scans were not necessary in the clinical management of TLS fractures. A prospective study was conducted at our Level I trauma center. A total of 39 neurologically intact patients with TLS fracture on CT were enrolled. The patients’ CT scan and neurological examination were reviewed by a senior neurosurgeon, who determined clinical management based on these data. Assessment was repeated after an MRI of the spine was performed, and a second clinical plan was devised. The two treatment schemes were then compared. MRI resulted in a change in clinical management in 15 per cent of patients. Ten per cent of patients changed from requiring a brace to no brace and merely observation alone. In no patient planned for nonoperative care was surgery deemed necessary after completion of MRI. Among five patients with initial plans for operative intervention, two avoided surgery after the MRI. MRI has little impact on the management of patients with CT-proven thoracic and lumbar spine fractures. Only when surgery is planned based on CT studies does an MRI seem to assist with determining optimal care.
|
|
| 5. |
- Leonard-Murali, Shravan, et al.
(författare)
-
Esophagectomies for Malignancy Among General and Thoracic Surgeons: A Propensity Score Matched National Surgical Quality Improvement Program Analysis Stratified by Surgical Approach
- 2021
-
Ingår i: The American surgeon. - : SAGE Publications. - 0003-1348 .- 1555-9823.
-
Tidskriftsartikel (refereegranskat)abstract
- Previous studies of esophagectomy outcomes by surgical specialty do not address malignancy or surgical approach. We sought to evaluate these cases using a national database. The National Surgical Quality Improvement Program (NSQIP)–targeted esophagectomy data set was queried for esophagectomies for malignancy and grouped by surgeon specialty: thoracic surgery (TS) or general surgery (GS). 1:1 propensity score matching was performed. Associations of surgical specialty with outcomes of interest (30-day mortality, anastomotic leak, Clavien-Dindo grade ≥ 3, and positive margin rate) were assessed overall and in surgical approach subsets. 1463 patients met inclusion criteria (512 GS and 951 TS). Propensity score matching yielded matched groups of 512, with similar demographics, preoperative stage, and neoadjuvant therapy rates. All outcomes of interest were similar between TS and GS groups, both overall and when stratified by surgical approach. Esophagectomy for malignancy has a similar perioperative safety profile and positive margin rate among general and thoracic surgeons, regardless of surgical approach.
|
|
| 6. |
- Leonard-Murali, Shravan, et al.
(författare)
-
Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does it Matter?
- 2021
-
Ingår i: The American surgeon. - : SAGE Publications. - 0003-1348 .- 1555-9823.
-
Tidskriftsartikel (refereegranskat)abstract
- Recurrent laryngeal nerve (RLN) injury and postoperative hypocalcemia are potential complications of thyroidectomy, particularly in malignancy. Intraoperative nerve monitoring (IONM) remains controversial. We sought to evaluate the impact of IONM on these complications using a national data set. Methods The American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-targeted data set was queried for patients who underwent thyroidectomies from 2016 to 2017. Patients were grouped according to IONM use. Logistic regression models were constructed to evaluate associations of variables with 30-day hypocalcemic events (HCEs) and RLN injury. Associations were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). A subgroup analysis was performed of patients with malignancy. Results A total of 9527 patients were identified; 5969 (62.7%) underwent thyroidectomy with IONM and 3558 (37.3%) without. By multivariable analysis, IONM had protective associations with HCE (OR = .81, 95% CI = .68-.96; P = .013) and RLN injury (OR = .83, 95% CI = .69-.98; P = .033). Malignancy increased risk of HCE (OR = 1.21, 95% CI=1.01-1.45; P = .038) and RLN injury (OR = 1.22, 95% CI = 1.02-1.46; P = .034). A large proportion (5943/9527, 62.4%) of patients had malignancy; 3646 (61.3%) underwent thyroidectomy with IONM and 2297 (38.7%) without. In the subgroup analysis, IONM had stronger protective associations with HCE (OR = .73, 95% CI = .60-.90; P = .003) and RLN injury (OR = .76, 95% CI = .62-.94; P = .012). Discussion Malignancy was associated with increased risk of HCE and RLN injury. Intraoperative nerve monitoring had a protective association with HCE and RLN injury, both overall, and in the malignant subgroup. Intraoperative nerve monitoring was correlated with improved thyroidectomy outcomes, especially if the indication was malignancy. This warrants further study to clarify cause and effect.
|
|
| 7. |
|
|
| 8. |
|
|
| 9. |
- Zebley, James A., et al.
(författare)
-
Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries
- 2023
-
Ingår i: The American surgeon. - : Southeastern Surgical Congress. - 0003-1348 .- 1555-9823. ; 89:11, s. 4696-4706
-
Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients.METHODS: We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders.RESULTS: A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed.DISCUSSION: While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.
|
|
