Mues A.C.,Columbia University |
Okhunov Z.,Columbia University |
Haramis G.,Columbia University |
D'Agostino H.,Louisiana State University Health Sciences Center |
And 2 more authors.
Journal of Endourology | Year: 2010
Purpose: We reviewed our experience with laparoscopic cryoablation (LCA) and percutaneous cryoablation (PCA) in the management of small renal tumors and compared clinical outcomes, short-term oncologic results, and patient complications. Patients and Methods: A retrospective comparison of two prospectively collected oncologic databases was performed. Ninety patients underwent PCA for 99 lesions and 81 patients underwent an LCA for 97 lesions. Patient characteristics, perioperative data, and tumor characteristics were recorded including age, estimated blood loss, complication rate, tumor size, and tumor pathology. Results: Patients in both the PCA and LCA groups had similar demographic and tumor characteristics. The PCA group had two major complications (2%), and the LCA group had three major complications (3.7%) (P? =? 0.374). In the LCA group, estimated blood loss was associated with tumor location with hilar tumor demonstrating a significantly higher mean blood loss (191? mL) compared with endophytic, mesophytic, and exophytic tumors (70? mL, 71? mL, 73.5? mL), respectively (P? =? 0.05). Malignancies rated in the PCA and LCA groups were 50.5% and 60.0%, respectively (P? 0.05). In the PCA group, nine (9.1%) patients demonstrated treatment failure with a persistent enhancement in the ablation bed. All nine were treated with a subsequent PCA. One patient had subsequent tumor bed enhancement and underwent an open radical nephrectomy. Treatment failed in three (3.1%) patients in the LCA cohort (incomplete ablation or recurrence). Conclusions: With short-term follow-up, both LCA and PCA are safe and effective treatments for small renal masses. Patients undergoing PCA had a reduced hospital stay and a lower surgical complication rate, albeit with an elevated re-treatment rate. Long-term data is needed to establish long-term oncologic efficacy. Renal function did not significantly change in patients after cryoablation, including patients with a solitary kidney. © 2010, Mary Ann Liebert, Inc.
Sessler D.I.,Cleveland Clinic |
Sigl J.C.,Covidien |
Manberg P.J.,Covidien |
Kelley S.D.,Covidien |
And 4 more authors.
Anesthesiology | Year: 2010
Background: Hospitals are increasingly required to publicly report outcomes, yet performance is best interpreted in the context of population and procedural risk. We sought to develop a risk-adjustment method using administrative claims data to assess both national-level and hospital-specific performance. Methods: A total of 35,179,507 patient stay records from 2001-2006 Medicare Provider Analysis and Review (MEDPAR) files were randomly divided into development and validation sets. Risk stratification indices (RSIs) for length of stay and mortality endpoints were derived from aggregate risk associated with individual diagnostic and procedure codes. Performance of RSIs were tested prospectively on the validation database, as well as a single institution registry of 103,324 adult surgical patients, and compared with the Charlson comorbidity index, which was designed to predict 1-yr mortality. The primary outcome was the C statistic indicating the discriminatory power of alternative risk-adjustment methods for prediction of outcome measures. Results: A single risk-stratification model predicted 30-day and 1-yr postdischarge mortality; separate risk-stratification models predicted length of stay and in-hospital mortality. The RSIs performed well on the national dataset (C statistics for median length of stay and 30-day mortality were 0.86 and 0.84). They performed significantly better than the Charlson comorbidity index on the Cleveland Clinic registry for all outcomes. The C statistics for the RSIs and Charlson comorbidity index were 0.89 versus 0.60 for median length of stay, 0.98 versus 0.65 for in-hospital mortality, 0.85 versus 0.76 for 30-day mortality, and 0.83 versus 0.77 for 1-yr mortality. Addition of demographic information only slightly improved performance of the RSI. Conclusion: RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data. © 2010, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.
Friedell M.L.,University of Missouri - Kansas City |
Vandermeer T.J.,Guthrie Clinic |
Cheatham M.L.,Orlando Regional Medical Center |
Fuhrman G.M.,Ochsner Clinic |
And 3 more authors.
Journal of the American College of Surgeons | Year: 2014
Background Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. Study Design In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). Results Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. Conclusions Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery. © 2014 by the American College of Surgeons.
Richardson W.S.,Ochsner Clinic |
Fanelli R.D.,Berkshire Medical Center
Surgical Endoscopy and Other Interventional Techniques | Year: 2010
Background: The development and implementation of evidence-based clinical practice guidelines involves many challenges. The Society of the American Gastrointestinal and Endoscopic Surgeons (SAGES) has been at the forefront of guideline development for laparoscopic surgery since 1991, providing its membership with guidelines on the clinical application of procedures and the granting of privileges. The objective of this study was to assess the use of SAGES guidelines by its members. Methods: An electronic survey of SAGES members was conducted via e-mail in August 2007. Members were asked if they used the guidelines, how often, for what purposes and when, and to rank the frequency of use and the usefulness of each of the 26 guidelines. They also were asked to suggest topics for new guideline development and to provide comments. Results: Two hundred thirty-nine SAGES members (4.1%) responded to the survey; 121 (50%) responders used the guidelines. Of these, 95% accessed the guidelines monthly or less often, 58% after hours, 52% during work hours, and 9% while on call. Reasons for guideline use included developing practice protocols (56%) and patient treatment paradigms (51%), creating education and training guidelines for staff privileges (35%), and credentialing new medical staff (25%). The most often used and most useful guidelines included clinical application guidelines on laparoscopic bariatric, antireflux, biliary, and colorectal surgery, laparoscopic appendectomy, and deep vein thrombosis prophylaxis. Some respondents indicated no knowledge of guideline existence and made requests for new guidelines. Conclusions: The results of this survey provided valuable information about current use of SAGES guidelines by its members. The pattern of use highlights the need for interventions that increase member awareness and adoption of these guidelines. Such efforts are currently underway. © 2010 Springer Science+Business Media, LLC.
Bhama J.K.,University of Pittsburgh |
Bansal A.,Ochsner Clinic |
Shigemura N.,University of Pittsburgh |
Toyoda Y.,Temple University
European Journal of Cardio-thoracic Surgery | Year: 2014
A simple technique for reconstructing a short recipient left atrial cuff during lung transplantation is described. After opening the confluence of the pulmonary veins, the cut ends of the pulmonary veins are sutured together, posteriorly and anteriorly. This effectively lengthens the cuff allowing safe left atrial anastomosis. This technique has been applied in 3 patients with no technique-related complications. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.