Journal of the American College of Surgeons
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Multicenter Study Comparative Study
Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program.
The postmastectomy patient faces a plethora of choices when opting for autologous breast reconstruction; however, multi-institutional data comparing the available techniques are lacking. The National Surgical Quality Improvement Program (NSQIP) database provides a robust patient cohort for comparing outcomes and determining independent predictors of complications for each autologous method. ⋯ This large-scale, multicenter evaluation of outcomes in autologous breast reconstruction found that free flaps have the highest captured 30-day complication and reoperation rates of any autologous reconstructive method; complications in latissimus flaps were surprisingly few. Pedicled TRAM and latissimus flaps remain the most commonly used autologous reconstructive methods. In addition to providing statistically robust outcomes data, this study contributes significantly to patient education and preoperative planning discussions.
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To evaluate the technical feasibility and safety of laparoscopic total gastrectomy (LTG) for gastric carcinoma, this study compared short-term surgical outcomes between LTG and open total gastrectomy (OTG) using the propensity score matching method. ⋯ Laparoscopic total gastrectomy is a safe and feasible technique for treatment of upper gastric carcinoma. However, LTG with D2 LND for upper gastric cancer may increase the operative risk and requires considerable experience in laparoscopic surgery.
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Warnings of deteriorating condition provided to patients at hospital discharge are highly subjective, based on conventional wisdom, and lack systematic implementation. We conducted a standardized Delphi process to achieve national consensus on warning indicators and recommended action plans for patients after colorectal surgery. ⋯ Expert consensus on discharge warning signs and appropriate action plans are identified for patients after colorectal surgery. The result of this study will help develop a more sophisticated patient-centered discharge tool for surgical patients.
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For critically injured patients requiring a massive transfusion, the optimal plasma fibrinogen level is unknown. The purpose of this study was to examine the impact of the fibrinogen level on mortality. We hypothesized that decreasing fibrinogen levels are associated with worse outcomes. ⋯ For patients undergoing a massive transfusion after injury, as the fibrinogen level increased, a stepwise improvement in survival was noted. A fibrinogen level ≤100 mg/dL was a strong independent risk factor for death. The impact of an aggressive fibrinogen replacement strategy using readily available products warrants further prospective evaluation.
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Acute care surgery (ACS) includes trauma, surgical critical care, and emergent general surgery. There is a national shortage of institutions that can provide for patients needing access to emergency surgical care. Inability to fund ACS surgeons can be a barrier. We hypothesize that an ACS service, in an appropriately staffed hospital, generates a positive contribution margin (CM). ⋯ Acute care surgery generates a positive CM. Emergent general surgery generates a greater CM than elective general surgery because of increased case mix index. These data suggest that hospital subsidization of acute care surgeons is financially feasible and might address the surgical workforce shortage and the critical problem of access to emergency surgical services.