Journal of the American College of Surgeons
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Practice guidelines for management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) are based on low-quality evidence, and there is limited literature that addresses optimal revascularization techniques. The purpose of this study was to compare outcomes of LSA coverage during TEVAR and revascularization techniques. ⋯ During TEVAR, LSA coverage without revascularization is associated with an increased risk of stroke and upper extremity ischemia. When LSA coverage is required during TEVAR, CSB and SCT are equally acceptable options.
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Liver transplantation (LTX) is curative for selected patients with hilar cholangiocarcinoma (HC) in the setting of sclerosing cholangitis. However, the outcome of LTX vs liver resection (RTX) for patients with de novo HC remains unclear. ⋯ Patients with clearly resectable de novo HC should be treated with resection because there is no evidence that they would fare better with LTX. Patients with locally unresectable de novo HC, meeting criteria for our protocol, should be treated with LTX. The decision to proceed with RTX or LTX for patients with borderline resectable de novo HC remains difficult, but our results suggest that patients with B-C type IV HC might be best treated with transplantation, if they are excellent transplant candidates.
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We sought to investigate the incidence of abdominal injuries in "found down" trauma patients to better understand the value of emergency department (ED) imaging. Found down patients are at high risk for injuries to the head or neck and low risk to the abdomen or pelvis, so imaging with CT of the abdomen/pelvis (AP) or Focused Assessment with Sonography for Trauma (FAST) is of questionable value. ⋯ Although patients found down have a high mortality, abdominal injuries identified by imaging are highly unlikely. Efforts should focus on rapidly identifying and treating other causes of mortality, especially trauma to the head and neck, or medical diagnoses such as cerebral vascular accident or sepsis.
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Stenting across the gastroesophageal (GE) junction for adenocarcinoma has historically been contraindicated secondary to the concerns for severe GE reflux (GER) symptoms. The aim of this study was to assess reflux symptoms and quality of life (QOL) effects in patients undergoing esophageal stenting across the GE junction. ⋯ Esophageal stenting across the GE junction remains the optimal therapy for dysphagia relief in esophageal malignancies and does not adversely affect a patient's GER-QOL. Esophageal stenting across the GE junction is not contraindicated and should be the initial therapy in patient management.
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Clinical Trial
Does PET with CT Have Clinical Utility in the Management of Patients with Intraductal Papillary Mucinous Neoplasm?
Intraductal papillary mucinous neoplasms (IPMNs) are well-established pancreatic precancerous lesions. Indications for resection are outlined in the 2012 International Consensus Guidelines (ICG). Because of the low specificity of the ICG, many patients will undergo potentially unnecessary surgery for nonmalignant IPMNs. Several retrospective studies have reported that positron emission tomography (PET) with CT (PET/CT) is highly sensitive and specific in detecting malignant IPMNs. We hypothesized that PET/CT complements the ICG in identification of malignant IPMNs. ⋯ The addition of PET/CT to preoperative workup improves the performance of the ICG for predicting malignant risk in patients with IPMN.