There are multiple accepted technical variations for the ileostomy reversal procedure. In order of sequence, these may include the skin incision (circular vs. tapered), creation of the anastomosis (hand-sewn vs. stapled), closure of the abdominal wall fascia (primary vs. mesh), and wound management (purse-string vs. skin closure).11,12 Both hand-sewn and stapled anastomotic techniques have similar morbidity and mortality in retrospective analyses.13 Although primary closure of the abdominal wall fascia has been the standard of care, recent evidence suggests that retromuscular placement of synthetic mesh at the time of ostomy closure significantly reduces subsequent hernia formation without increased wound complications.14 Further studies are needed to better clarify the role of mesh for ileostomy reversal. Finally, a recent meta-analysis evaluated purse-string vs. linear wound closure after ileostomy reversal, and it was observed that a purse-string closure was associated with significantly reduced infection rates.11
https://jomi.com/article/356/altemeier-perineal-proctosigmoidectomy-for-rectal-prolapse
Colonic polyps are projections from the surface of the colonic mucosa. Most are asymptomatic and benign. Over time, some colonic polyps develop into cancers. Colorectal polyps are classified as non-neoplastic and neoplastic. Non-neoplastic polyps include hyperplastic, inflammatory, and hamartomatous polyps. They are typically harmless and do not become cancerous. Neoplastic polyps include adenomas and serrated polyps. They are premalignant lesions that may progress to colon cancer over time. In general, the larger the polyp, the greater the risk of cancer, especially with neoplastic polyps. Polyps are diagnosed using colonoscopy and are removed via polypectomy if they are small and pedunculated. If the polyps are too large or cannot be removed safely, they may be removed by colonic resection.
Many randomized clinical trials including the COLOR, CLASSIC, and COST trials have shown that laparoscopic-assisted colectomy surgery has the same outcome (69%) as open surgery (68%) in terms of 5-year survival. In addition, retrospectively it has been found that open surgery resections have a higher positive margin rate at 5.3% with a hazard ratio of 3.39, 95% CI 2.41 โ 4.77.7 The usual length of hospitalization following laparoscopic right colectomy is 2-3 days. The use of enhanced recovery after surgery (ERAS) protocols has been an essential component of post-operative care, shortening hospital stay, and reducing complication rates. Most patients with node-negative colon cancer ( i.e. Stages I-II) are cured by surgery alone. Some patients with Stage II adenocarcinoma that has aggressive histologic features (such as lymphovascular invasion) may benefit from adjuvant chemotherapy. The risk/benefit ratio is such that decision making should be individualized. However, adjuvant chemotherapy is clearly indicated for those with Stage III tumors. Treatment of patients with isolated liver metastases needs to be individualized and should be discussed by a multidisciplinary tumor board to optimize treatment planning
https://jomi.com/article/125/Laparoscopic-Right-Colectomy-with-Ileocolic-Anastomosis
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Ileus is uniform dilated loops instead of discrete transition point/obstruction in SBO
50 y.o. female with right breast IDCA with focal lobular features T1 in size, at 3 o'clock, ?grade, >90%ER+/>90%PR+/HER2 pending
We have discussed the diagnosis and reviewed her pathology report and imaging in detail.
I discussed that I would review her case at tumor board and would also need to have the OSH send the path slides.
We discussed the options for treatment, including mastectomy, lumpectomy, and oncoplastics. I believe that given her stage 1 breast cancer, mastectomy would be considered an extreme option, and I would recommend either lumpectomy or oncoplastics. We have reviewed that there is no difference in the overall survival between the three options. I explained that in the case of lumpectomy, the surgery would involve removal of the area of concern and we would monitor her closely to screen for further cancer. In the case of oncoplastic, I explained that reconstruction preserves the patient's breast using the patient's own breast tissue for reconstruction using volume displacement and replacement techniques, and a symmetrizing procedure on the contralateral side. This would entail either an extended superomedial pedicle or inferior pedicle with wise skin incision design on the cancer side with a symmetry operation on the contralateral side. We went into detailed discussion on complications for each operative intervention.
The patient experiences significant symptoms associated with her breast hypertrophy and is thus interested in the oncoplastic option with a right inferior pedicle wise pattern and left symmetrization. Risks discussed include bleeding, infection, seroma, hematoma, wound separation, breast asymmetry, nipple necrosis, scarring and the possibility for a positive margin requiring additional surgery.
We reviewed the need for sentinel lymph node biopsy. We have reviewed the method of sentinel lymph node biopsy including the possible need for axillary lymph node dissection. We discussed that during sentinel lymph node biopsy, generally 1-3 axillary lymph nodes are identified with the use of blue dye and a radiotracer. With breast conservation therapy no further nodal dissection would be required unless more than 2 lymph nodes are positive (per ACOSOG Z0011 study)
Plan discussed with the patient and they are in agreement.
Surgical plan is oncoplastic breast surgery with right volume displacement using inferior pedicle wise pattern incision design and left breast symmetry surgery, and right sentinel lymph node biopsy
Will need to hold off on the estrogen pill at least 1 week before surgery
Will order genetic testing
Will order pre-op labs, EKG, CXR
Will need OSH path slides
Yilun Zhang
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Is our current practice at TMC of using the common 24h capping trials for patients with tracheostomy a good assessment of decannulation readiness?
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source: https://www.passy-muir.com/wp-content/uploads/2018/10/costs_related_to_tracheostomy.pdf
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Patients who require tracheostomy for respiratory failure, diagnosis-related group (DRG) 483,
have a high consumption of resources. By DRG categories, they have the highest patient costs
and the highest hospital reimbursement.4
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29 days Average length of stay for a tracheostomized patient5
$265,499 Average amount of hospital charges associated with tracheostomy5
$60 Billion Expected national bill in the year 2020 associated with prolonged mechanical ventilation6
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Four hundred twenty-nine patients were studied. Hospital mortality was 19%. Only 57% of
survivors were liberated from mechanical ventilation. At 100 days, 6 months, 1 year, and 2
years after discharge, 24%, 30%, 36%, and 42% of hospital survivors had died, respectively.
Patients liberated from mechanical ventilation and having their tracheostomy tubes
decannulated had the lowest mortality (8% at 1 year); the mortality of ventilator-dependent
patients was highest (57%). Sixty-six patients completed the SF-36 for functional status. While
emotional health was generally good, physical function was quite limited. **Median hospital direct
variable cost was $29,340. **
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https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-017-0234-z
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