Journal of the American College of Surgeons
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The Blalock-Taussig shunt (BTS) was introduced 68 years ago before open repair of cyanotic congenital heart disease (CHD) was possible. The originally described technique has undergone many modifications but remains an integral component of the management of cyanotic CHD. We report our contemporary, single institution experience with the BTS. ⋯ Although the BTS remains an important component of the surgical treatment of cyanotic congenital heart disease, patients with single ventricle circulation still face significant ongoing risk of mortality.
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Variability in flow of patients through operating rooms has a dramatic impact on a hospital's performance and finances. Natural variation (uncontrollable) and artificial variation (controllable) differ and require different resources and management. The aim of this study was to use variability methodology for a hospital's surgical services to improve operational performance. ⋯ Variability management results in improvement in operating room operational and financial performance. This optimization may have a significant impact on a hospital's ability to adapt to health care reform.
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Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem with redo myotomy and preserve the esophagus. We examined the results of this approach. ⋯ The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy.
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The hypercoagulable state associated with cancer imparts considerable risk for venous thromboembolism. Surgical resection of malignancies should theoretically reverse tumor-induced hypercoagulability. However, coagulation changes in cancer patients postresection have not been described thoroughly. Conventional coagulation tests are unable to detect hypercoagulable states. In contrast, rotational thromboelastography (ROTEM) can detect hypo- or hypercoagulable conditions. We hypothesized that the cancer-induced hypercoagulable state would improve after surgical resection. ⋯ Rotational thromboelastography identifies baseline hypercoagulability in more than one third of patients with intra-abdominal malignancies. This is among the first studies to demonstrate progressive hypercoagulability that persists for at least 1 month after resection. These data support postdischarge thromboprophylaxis regimens in high-risk cancer patients.
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Comparative Study
Impact of chronic renal insufficiency using serum creatinine vs glomerular filtration rate on perioperative clinical outcomes of carotid endarterectomy.
Several studies have reported conflicting results after carotid endarterectomy in patients with chronic renal insufficiency (CRI). However, only a few used glomerular filtration rate (GFR) (Modification of Diet in Renal Disease) in their analysis. ⋯ Glomerular filtration rate (Modification of Diet in Renal Disease) was more sensitive in detecting perioperative stroke/death after carotid endarterectomy in patients with CRI. Patients with moderate/severe CRI had more major adverse events than normal patients.