No abstract

The results of this study suggest that if a PEG placement is indicated for a TBI patient, a standard (7 to 14 d) timing may be associated with better patient outcomes. However, secondary to limitations associated with the use of administrative databases, further prospective studies are needed to establish clear guidelines regarding the optimal timing of placing PEG in TBI patients.

Purpose: To explore enhanced recovery after surgery (ERAS) components and their current application to major urologic surgeries, barriers to implementation and maintenance of the associated quality improvement. Data Identification: An English language literature search was done using PubMed. Study Selection: After independent review, 55 of the original 214 articles were selected to specifically address the stated purpose. Data Extraction: Clinical trials were included, randomized trials were prioritized, but robust observational studies were also included. Results of Data Synthesis: Many ERAS components have good data to support usage in radical cystectomy (RC) patients. Most ERAS programs include multidisciplinary teams carrying out multimodal pathways to hasten recovery after a major operation. ERAS components generally include preoperative counseling and medical optimization, venous thromboembolism prophylaxis, ileus prevention, avoidance of fluid overload, normothermia maintenance, early mobilization, pain control and early feeding, all leading to early discharge without increased complications or readmissions. Although there may not be specific data pertaining to other major urologic operations, the principles remain similar and ERAS is easily applicable. Conclusion: The benefits of ERAS programs are well established for RC and principles are easily applicable to other major urology operations. Barriers to implantation and maintenance of ERAS must be recognized to continue to maintain the benefits of these programs.

No abstract

Gastrointestinal and hepatic disease is seen as a complicating factor for some of the most acute and chronically ill patients in the intensive care domain. These patients are not only academically challenging but also clinically challenging and commonly fall into the practice of general surgery as well as hepatology. This chapter reviews the laboratory and clinical presentations of these patients, along with discussion pertaining to common sources of morbidity. Furthermore, scoring systems and acuity markers for these patients are reviewed, along with practical management approaches. Disturbances in the gastrointestinal system are a hallmark of the perioperative patient and should be expected on the examination and in practice.

No abstract

Pancreatic cancer is presently the fourth leading cause of cancer-related deaths in Western countries with an incidence of 8-10 new cases per 100,000 and increasing. It has a poor prognosis with an untreated 1-year survival of less than 20% and 5-year survival of 0%.1 Since current conservative oncological therapies fail to influence the long-term outcome, curative resection remains the only possibility with a potential for cure.Postoperative mortality has decreased significantly in the last decade. The contributing factors for this change include improvement in pre-operative staging, surgical technique as well as postoperative care. There is a wide variation between units in the long-term survival as well as the resection rates. The volume of patients with pancreatic cancer seen in a hospital may account for some of these differences as patients managed by higher volume hospitals have been shown to undergo a more aggressive staging and resection.2 Pancreatic resection rates have varied from 2.6% to 99%.3,4 These need to be carefully evaluated as the 99% figure was reported by a Japanese study performed in selected centres for tumours less than 2 cm in size while the 2.6% figure was observed in the West Midland region of England and included all patients having pancreatic cancer. A more recent figure from the same region showed a resection rate of 4.8%.5 Both Scottish 6 and Italian 7 studies have quoted rates of 15-18%. Five-year survival following pancreatic resection has ranged between 5% and 21%. [8][9][10] On the basis of this considerable variety in resection rates and its potential influence on survival, we have looked at the resection rates and management plans in a hospital where all patients with possible pancreatic cancer are seen by one unit -on average, 23 patients per year. The approach has been to consider all patients as potentially resectable and only then exclude those who are not appropriate for 'curative' surgery, rather than assume the opposite.

No abstract