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1.
Curr Probl Surg ; 57(3): 100762, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32151328
2.
Curr Probl Surg ; 57(2): 100747, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32138834
3.
Surgery ; 167(4): 765-771, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32063341

RESUMO

BACKGROUND: Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence. METHODS: Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data. RESULTS: Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence. CONCLUSION: 1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence.

4.
Curr Probl Surg ; 57(1): 100731, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32033708
6.
Curr Probl Surg ; 56(12): 100712, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31837717
7.
J Gastrointest Surg ; 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31768824

RESUMO

The Society for Surgery of the Alimentary Tract is a robust clinical society with over 2500 members. As a society that is focused on the entire alimentary tract, we overlap with other more organ-centric societies. This has led to a constant struggle of knowing how the Society for Surgery of the Alimentary Tract can best serve the surgical community. The board of directors held its second strategic retreat in 10 years to develop aspirational goals in hopes to define the direction of the society for the next 5 years. The output of this meeting is presented in this document.

8.
Curr Probl Surg ; 56(11): 100680, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31779777
9.
Curr Probl Surg ; 56(10): 100666, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31581981
10.
Curr Probl Surg ; 56(9): 100651, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31585555
11.
Curr Probl Surg ; 56(8): 336, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31511144
12.
Curr Probl Surg ; 56(7): 252, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31229135
13.
Curr Probl Surg ; 56(6): 203, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31155031
14.
Ann Gastroenterol Surg ; 3(3): 247-253, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31131353

RESUMO

The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4-6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity-matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best-practice surgical techniques, adjunct intra-operative imaging, and bail-out options when performing LC.

15.
J Gastrointest Surg ; 23(1): 1-10, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30132297

RESUMO

In preparation for an upcoming SSAT strategic planning process, the rich history, current demographics, and financial outlook of the Society are reviewed. Building on a strong tradition of innovative leadership, the SSAT remains a vibrant and financially sound organization that continues to attract new members from across the spectrum of GI surgery. However, several trends-subspecialization, an increasing focus on clinical research, the size of DDW, among others-challenge the society to better to define its identity as we plan for and prioritize for the future.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Sociedades Médicas/história , Previsões , História do Século XX , História do Século XXI , Humanos , Sociedades Médicas/organização & administração , Sociedades Médicas/estatística & dados numéricos , Sociedades Médicas/tendências
16.
Jt Comm J Qual Patient Saf ; 45(1): 3-13, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30166254

RESUMO

BACKGROUND: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge. METHODS: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated. RESULTS: The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29). CONCLUSION: This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.


Assuntos
Analgésicos Opioides/administração & dosagem , Uso de Medicamentos/normas , Administração Hospitalar , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Comitês Consultivos/organização & administração , Humanos , Sistemas de Informação/organização & administração , Capacitação em Serviço , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/organização & administração , Estados Unidos
17.
J Gastrointest Surg ; 23(6): 1172-1179, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30334179

RESUMO

BACKGROUND: The economic implications of relevant clinicopathologic factors on the surgical approach to distal pancreatectomy (DP) should be clearly defined and understood to potentially allow the implementation of cost reduction strategies. METHODS: Administrative and clinical datasets of patients undergoing a DP between 2012 and 2016 were merged and queried. Univariate and multivariate analyses were used to identify clinicopathologic predictors of cost differentials for minimally invasive DP (MIDP) relative to open DP (ODP). Time trends in cost were also assessed to identify opportunities for cost containment. RESULTS: Among two hundred and twenty five patients, 128 underwent an ODP (57%) and 97 a MIDP (43%). The DP groups were comparable with regard to relevant perioperative and disease characteristics. Total hospitalization and total OR costs for MIDP were significantly lower (- 12%, P = 0.0048) and higher (+ 16%, P < 0.0001) respectively, compared to ODP. On univariate analysis, age > 60 (- 12%, P = 0.0262), BMI > 25 (- 10%, P = 0.0222), ASA class ≥ 3 (- 11%, P = 0.0045), OpTime > 230 min (- 16%, P = 0.0004), and T stage ≥ 3 (- 8%, P = 0.0452) were associated with decreased total costs after MIDP compared to ODP. Linear regression analysis revealed that BMI > 25 (Estimate - 0.31, SE 0.15, P = 0.0482), ASA class ≥ 3 (Estimate - 0.36, SE 0.17, P = 0.0344), and T stage ≥ 3 (Estimate - 0.57, SE 0.26, P = 0.0320) were associated with decreased hospitalization costs after MIDP compared to ODP. Overtime, total hospitalization cost for MIDP increased from - 21 to 1% (P = 0.0197), while OR costs for MIDP decreased from + 41% to - 2% (P = 0.0049), nearly equalizing the cost differences between ODP and MIDP. CONCLUSIONS: Relevant clinicopathologic factors predicted decreased hospitalization costs after MIDP relative to ODP. In equivalent stages of disease, optimizing the surgical approach to DP based on specific clinicopathologic characteristics may afford significant cost-saving opportunities.

18.
J Gastrointest Surg ; 22(11): 1920-1927, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30039447

RESUMO

BACKGROUND: The Medicare Severity-Diagnosis Related Group coding system (MS-DRG) is routinely used by hospitals for reimbursement purposes following pancreatic surgery. We aimed to determine whether specific pancreatectomy MS-DRG codes, when combined with distinct clinicopathologic and perioperative characteristics, increased the accuracy of predicting 30-day readmission after pancreaticoduodenectomy (PD). METHODS: Demographic, clinicopathologic, and perioperative factors were compared between readmitted and non-readmitted patients at Brigham and Women's Hospital following PD. Different pancreatectomy DRG codes, currently used for reimbursement purposes [407: without complication/co-morbidity (CC), 406: with CC, and 405: with major CC] were combined with clinical factors to assess their predictability of readmission. Univariate and multivariable analyses were performed to evaluate outcomes. RESULTS: Among 354 patients who underwent PD between 2010 and 2017, 69 (19%) were readmitted. The incidence of readmission was 13, 32, and 55% for patients with assigned DRG codes 407, 406, and 405, respectively (P = 0.0395). Readmitted patients were more likely to have had T4 disease (P = 0.0007), a vascular resection (P = 0.0078), and longer operative times (P = 0.012). On multivariable analysis, combining DRG 407 with relevant clinicopathologic factors was unable to predict readmission. In contrast, DRG 406 code among patients with N positive disease (P = 0.0263) and LOS > 10 days (P = 0.0505) was associated with readmission. DRG 405, preoperative obstructive jaundice (OR: 7.5, CI: 1.5-36, P = 0.0130), vascular resection (OR: 7.7, CI: 1.1-51, P = 0.0336), N positive stage of disease (OR: 0.2, CI: 0-0.9, P = 0.0447), and operative time > 410 min (OR: 5.9, CI: 1-32, P = 0.0399) were each strongly associated with 30-day readmission after PD [likelihood ratio (LR) < 0.0001]. CONCLUSIONS: Distinct pancreatectomy MS-DRG classification codes (405), combined with relevant clinicopathologic and perioperative characteristics, strongly predicted 30-day readmission after PD. DRG classification algorithms can be implemented to more accurately identify patients at a higher risk of readmission.


Assuntos
Grupos Diagnósticos Relacionados , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Icterícia Obstrutiva/complicações , Metástase Linfática , Masculino , Medicare , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Duração da Cirurgia , Pancreatectomia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Estados Unidos , Procedimentos Cirúrgicos Vasculares , Adulto Jovem
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