Journal of the American College of Surgeons
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A new device for mechanical sphincter augmentation (MSA) of the lower esophageal sphincter was approved by the FDA on March 22, 2012. We report early experience with MSA, specifically addressing postoperative management. ⋯ Single-center early results are promising and parallel those from a multicenter trial. There is significant interest in MSA, with referrals and direct patient appointments specifically for MSA. Outcomes improve over time after implantation. The surgeon learning curve is different than with the Nissen, both in operative technique and postoperative management. This is a promising new offering for patients with GERD, and surgeons will need to learn how to integrate this into their practices.
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Well-differentiated neuroendocrine tumors (NETs) of the gastrointestinal tract are rare, slow-growing neoplasms. Clinical outcomes in a group of stage IV, well-differentiated patients with NETs with small bowel primaries undergoing cytoreductive surgery and multidisciplinary management at a single center were evaluated. ⋯ Cytoreductive surgery in patients with well-differentiated midgut NETs has low mortality and complication rates and is associated with prolonged survival. We believe that cytoreductive surgery is a key component in the care of patients with NETs.
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Unexpected clinical deterioration (failure events) in surgical patients on standard nursing units (WARDs) could have a significant impact on eventual survival. We sought to investigate failure events requiring intensive care (surgical ICU [SICU]) transfer of surgical patients on WARDs in a single-center academic setting. ⋯ Patients most at risk for WARD failures were those with acute surgical emergencies or recently discharged from the SICU or PACU. Respiratory complications were the most common cause of WARD failure events. Many early failures may have been due to premature transfer from the SICU or PACU. Failure events on WARDs can have lethal consequences. Awareness, monitoring, and communication are important components of preventative measures.
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The Affordable Care Act provides health care coverage to an increasing segment of the population at Medicaid reimbursement rates. Health care systems currently offset lower Medicaid reimbursement through higher payers. The ability to "cost shift" will be diminished as the Medicaid population increases. ⋯ Our analysis demonstrates that laparoscopic cholecystectomy can be performed with a positive margin at Medicaid reimbursement rates with sufficient volume. The minimal margin, however, could substantially limit the ability of lower-volume hospitals to provide these services and negatively impact access to care in this patient population.