Journal of the American College of Surgeons
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Comparative Study
Laparoscopic vs open appendectomy in obese patients: outcomes using the American College of Surgeons National Surgical Quality Improvement Program database.
Although open and laparoscopic appendectomies are comparable operations in terms of outcomes, it is unknown whether this is true in the obese patient. Our objective was to compare short-term outcomes in obese patients after laparoscopic vs open appendectomy. ⋯ In obese patients, laparoscopic appendectomy had superior clinical outcomes compared with open appendectomy after accounting for preoperative risk factors.
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Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy. ⋯ In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.
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It has been suggested that implementation of quality-improvement benchmarking programs can lead to risk-avoidance behaviors in some physicians and hospitals in an attempt to improve their rankings, potentially denying patients needed treatment. We hypothesize that avoidance of high-risk patients will not change risk-adjusted rankings. ⋯ Risk-adjusted rankings of hospitals likely cannot be changed by simply avoiding high-risk patients. In the minority of scenarios in which risk-adjusted rankings changed, they were as likely to improve as worsen after risk avoidance.
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Comparative Study
Comparison of outcomes of breast conserving therapy in multifocal and unifocal invasive breast cancer.
There is controversy about whether breast conserving therapy (BCT) should be contraindicated in multifocal (MF) breast cancer. Few studies have reported on the oncologic safety of BCT in MF breast cancer. ⋯ Our data suggest that BCT in MF breast cancer is oncologically safe but may result in a slightly inferior outcome compared with BCT in unifocal breast cancer.
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The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce. ⋯ Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.