Journal of the American College of Surgeons
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Randomized Controlled Trial Multicenter Study
Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial.
Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy. There have been no large prospective randomized trials evaluating PF rates comparing invagination versus duct to mucosa pancreaticojejunostomy. We tested the hypothesis that a duct to mucosa pancreaticojejunostomy would reduce the PF rate. ⋯ This dual-institution prospective randomized trial reveals considerably fewer fistulas with invagination compared with duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy. Results confirm increased PF rates in soft as compared with hard glands. Additional studies are needed to define the optimal technique of pancreatic reconstruction after pancreaticoduodenectomy.
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Randomized Controlled Trial
Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring.
The ARDS Clinical Trials Network Fluid and Catheter Treatment Trial (FACTT) addressed fluid management and central monitoring of patients with acute respiratory distress syndrome/acute lung injury (ARDS/ALI). Because surgical patients may have been fundamentally different from the overall FACTT cohort, we set out to separately analyze the surgery patients in the trial. ⋯ The risk of death did not vary with fluid management or catheter. A conservative fluid-administration strategy and central venous catheter monitoring resulted in more ventilator-free and ICU-free days in surgical patients with acute lung injury, and conservative fluid administration did not result in more renal failure.
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Emergency department (ED) crowding and delays in care represent a national problem; no large study has examined the impact of such delays in surgical patients. We sought to determine the impact of delayed transfer from the ED on outcomes in trauma/emergency general surgical patients in a center that has developed a policy to triage more critically ill/severely injured patients to earlier ICU admission. ⋯ Experienced clinicians can effectively triage more critically injured patients to earlier ICU admission and alter associations between ED length of stay and mortality. Hospitals with a large trauma/emergency general surgery caseload resulting in delays in ED throughput should institute policies and procedures for triage of more severely injured patients for early ICU admission and develop a monitoring system to ensure that delays do not adversely affect patient outcomes.
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The Institute of Medicine has urged the adoption of electronic prescribing systems in all health-care organizations by 2010. Accordingly, computerized physician order entry (CPOE) warrants detailed evaluation. Mixed results have been reported about the benefit of this system. No review of its application in surgical patients has been reported to date. We present the implementation of CPOE in the management of surgical patients within an academic multispecialty practice. ⋯ Present CPOE technology can allow major efficiency gains, but refinements will be required for improvements in patient safety.
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Determine the effect of race, socioeconomic status (SES) and other demographic variables on outcomes of patients with invasive ductal and lobular breast cancer. ⋯ Dramatic disparities by patient race and SES exist in breast cancer. Our study integrates previous smaller studies, providing comprehensive insight into African-American patients and their outcomes for breast cancer. Earlier screening programs and greater access to cancer care for the poor and African Americans are needed. Successful institution of such programs will not completely erase disparities in outcomes for breast cancer in African-American patients.