Journal of the American College of Surgeons
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Comparative Study
Pancreas transplantation in C-peptide positive patients: does "type" of diabetes really matter?
In the past, type 2 (C-peptide positive) diabetes mellitus (DM) was a contraindication for simultaneous pancreas-kidney transplantation (SPKT). ⋯ Patients with higher pretransplantion C-peptide levels appear to have a type 2 DM phenotype compared to insulinopenic patients undergoing SPKT. However, survival and functional outcomes were similar, suggesting that pretransplantation C-peptide levels should not be used exclusively to determine candidacy for SPKT.
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Preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography (IOC) are standard procedures in evaluating patients with suspected choledocholithiasis. This study evaluates the changing practice patterns over time of these 3 procedures in a large cohort of patients undergoing laparoscopic cholecystectomy (LC) at a single tertiary care center. ⋯ Despite a shift from IOC and preoperative ERCP to preoperative MRCP alone or with ERCP, a significant percentage (7.6%) of patients still underwent IOC in 2013. Use of IOC during LC has decreased but is not considered obsolete, rather, it remains a valuable tool for the evaluation of bile duct anatomy, bile duct injury, or suspected choledocholithiasis. Intraoperative cholangiography during uncomplicated LC should be emphasized in teaching programs to insure general surgery resident competency with the procedure.
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Liver resection is used to treat primary and secondary malignancies. Historically, these procedures were associated with significant complications, which may affect cancer-specific outcomes. This study analyzed the changes in morbidity and mortality after hepatic resection over time. ⋯ Morbidity and mortality rates after partial hepatectomy for cancer have decreased substantially as the major hepatectomy rate has dropped. Encouraging parenchymal preservation and preventing abdominal infections are vital for continued improvement of liver resection outcomes.
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Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for all patients undergoing elective colorectal surgery at an academic institution. ⋯ Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.
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Category 1 guidelines emphasize multimodality therapy (MMT) for patients with gastric cardia cancer (GCC). These patients are often referred to thoracic surgeons for "esophagogastric junction" cancers rather than to abdominal surgeons for "proximal gastric" cancers. This study sought to determine the ideal surgical approach using national datasets evaluating morbidity/mortality (M/M) and overall survival (OS). ⋯ Tumor biology and MMT, rather than surgical approach, dictate oncologic outcomes for GCC. Therefore, the decision of esophagectomy vs gastrectomy for GCC should be based on proximal and distal tumor extent and the multidisciplinary strategy with the lower rate of complications and the higher rate of MMT completion.