Postoperative Recovery and Survivorship After Acute Hospitalization for Serious Life-Limiting Illness
This article provides a road map for discharge planning of adult patients with serious life-limiting illnesses. The need for early and guided conversations with specific prompts is offered to assist in the transition of care process. Transparent, patient-centered interactions are emphasized throughout with an acknowledgment that this type of direct, interpersonal communication may challenge a clinical team ’s typical mode of operation. Nevertheless, when done well, this approach can lead to better outcomes for everyone involved. This framework for discharge planning has led to greater patient and family satisfaction,...
Source: Surgical Clinics of North America - August 23, 2019 Category: Surgery Authors: Ann Wilborn Jackson Source Type: research
Navigating the Murky Waters of Hope, Fear, and Spiritual Suffering
How can surgeons deliver compassionate, holistic care to patients who are beyond cure? Interacting emotionally and understanding hope, fear, and spiritual suffering is key. Responsibly reframing hope to underlying meanings, and away from specific outcomes, is critical. Facilitating moves from cure to comfort to a peaceful dying process requires some retooling of the surgical toolbox. Surgeons possess a unique set of skills, including imagination and an undying sense of hope. Surgeons who have the courage to delve into their emotions and sustain realistic hope for their patients, all the way to the end, will reap deep perso...
Source: Surgical Clinics of North America - August 23, 2019 Category: Surgery Authors: Buddy Marterre, Kristel Clayville Source Type: research
Practicing Primary Palliative Care
SURGICAL CLINICS OF NORTH AMERICA (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - August 23, 2019 Category: Surgery Authors: Pringl Miller Source Type: research
The Time Is Always Right to Do What Is Right for Our Patients
As the operative repertoire and our professional status become increasingly transient, we will be compelled to ground our identities in something more fulfilling and enduring. —Geoffrey Dunn, MD, FACSSurgeons have been engaged in surgical palliation since antiquity. Trepanation was first described in 3000 bc to rid the body of spirits … and later to relieve pressure on the brain.1 Paré, a sixteenth century French surgeon, stated that to perform surgery is “to elimi nate that which is superfluous, restore that which has been dislocated, separate that which has been united, join that which has been ...
Source: Surgical Clinics of North America - August 8, 2019 Category: Surgery Authors: Pringl Miller Tags: Preface Source Type: research
Palliative Wound Care
Palliative wound care is a philosophy of wound management that prioritizes comfort over healing and attends to the emotional distress these wounds can cause. Intervention strategies focus on management of symptoms such as pain, odor, bleeding, and exudate. Historic treatments such as honey, chlorine, and vinegar have gained renewed interest, and although well suited to the palliative setting, there is an increasing amount of research exploring their efficacy in other contexts. The lived experience of patients and caregivers facing these wounds is often stressful and isolating, and any treatment plan must address these issu...
Source: Surgical Clinics of North America - August 5, 2019 Category: Surgery Authors: Emily H. Beers Source Type: research
Discussing Prognosis and Shared Decision-Making
When making high-stakes decisions with their patients, surgeons may have only one opportunity to get a life-changing conversation right. These loaded conversations cover immense ground. Bad news, emotion, prognosis, treatment choices, and patient goals all play a part in coming up with the right plan for each individual patient. Surgeons and patients may overlook important factors when the language and process of informed consent is substituted for decision-making. “Best Case/Worst Case” is a communication tool based in scenario planning that promotes shared decision-making in high-stakes surgical conversations...
Source: Surgical Clinics of North America - August 5, 2019 Category: Surgery Authors: Joshua Sommovilla, Kimberly E. Kopecky, Toby Campbell Source Type: research
Burnout is characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. All physicians, and especially surgeons, are at risk for developing burnout. The best strategies for mitigating burnout mimic a modern approach to medicine: the development of preventive practices to protect, promote, and maintain health and well-being. Job satisfaction, job engagement, and compassion satisfaction help protect from burnout. Individual commitment to self-care in conjunction with support from within health care organizations create the optimal framework in which burnout can be mitigated. (Sour...
Source: Surgical Clinics of North America - July 31, 2019 Category: Surgery Authors: Timothy R. Siegel, Andrea K. Nagengast Source Type: research
Surgical Palliative Care Education
Surgical palliative care education is in increasing demand to meet the needs of a growing geriatric population. Multiple accrediting agencies for undergraduate and graduate medical education require that students be trained in end-of-life care. These requirements, however, have resulted in didactic curricula that are implemented in various degrees with uncertain levels of success. Reviews of physician communication on palliative care topics find that skilled feedback has the best evidence for generating improvements. Once graduated, there is little to no requirement that practicing providers seek out opportunities to impro...
Source: Surgical Clinics of North America - July 30, 2019 Category: Surgery Authors: Jessica H. Ballou, Karen J. Brasel Source Type: research
Concurrent Palliative Care for Surgical Patients
A common fallacy prevalent in surgical culture is for surgical intervention and palliation to be regarded as mutually exclusive or sequential strategies in the trajectory of surgical illness. Modern surgeons play a complex role as both providers and gatekeepers in meeting the palliative needs of their patients. Surgical palliative care is ideally delivered by surgical teams as a component of routine surgical care, and includes management of physical and psychosocial symptoms, basic communication about prognosis and treatment options, and identification of patient goals and values. Specialty palliative care services may be ...
Source: Surgical Clinics of North America - July 25, 2019 Category: Surgery Authors: Ana Berlin, Teresa Johelen Carleton Source Type: research
Transitioning to Comfort-Focused Care at the End of Life
Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient ’s goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integra ting primary palliative care into surgical practice can help mitigate unn...
Source: Surgical Clinics of North America - July 25, 2019 Category: Surgery Authors: Christine C. Toevs Source Type: research
There was a time when we were in the profession of patient care. Now, it may be that we are in the health care business. Perhaps those 2 constructs are similar or perhaps not. In the evolution of health care delivery, I was taught that in the beginning there were people: some of those people got sick (we call them patients); some people learn ways to help them (the various providers); and to make things more efficient, we created hospitals to have a common place and tools to take care of people. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 25, 2019 Category: Surgery Authors: Ronald F. Martin Tags: Foreword Source Type: research
Beyond the Technical
Determining valid indications for vascular access creation and hemodialysis initiation in end-stage renal disease requires utilization of verified prognostication tools and recognition of triggers to initiate serious conversations, and implementation of concurrent palliative care and/or hospice care is recommended. Establishment of a multi-disciplinary team that includes consideration of interventionalists in the pre-dialysis medical situation is important. A “catheter best” approach may be the most appropriate for some patients to meet goals of care. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 23, 2019 Category: Surgery Authors: Erika R. Ketteler Source Type: research
This article provides an overview of key palliative care considerations for management of patients with wounds and ostomies. Ostomy formation is indicated for a variety of intestinal conditions. Specifics of ostomy management, impact on quality of life, and patient perspectives can be complicated. Wound ostomy and continence nursing professionals play a central role in the successful management of this patient population. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 22, 2019 Category: Surgery Authors: Emily B. Rivet Source Type: research
Advantages and Challenges of an Interdisciplinary Palliative Care Team Approach to Surgical Care
This article discusses integrating interdisciplinary palliative care into surgical practice, and some current models of using and expanding palliative care skill sets in surgery, including training initiatives for both physicians and nurses. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 20, 2019 Category: Surgery Authors: Charles Rhee, Marlene McHugh, Sandy Tun, James Gerhart, Sean O ’Mahony Source Type: research
Perioperative Advance Directives: Do Not Resuscitate in the Operating Room
Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the proper approach. We discuss the origins of decisions not to attempt resuscitation, the special circumstances surrounding the need for resuscitation intraoperatively, and reasons to suspend, or not suspend, the DNR order during the perioperative period. DNR should be part of a comprehensive discussion of a patient and family ’s goals of care. A clear understanding of those goals will lead the care team to a better understand the role of perioperative resu...
Source: Surgical Clinics of North America - July 20, 2019 Category: Surgery Authors: Michael E. Shapiro, Eric A. Singer Source Type: research
Optimizing Pain Control During the Opioid Epidemic
The current opioid crisis has raised awareness of the risks of misuse, addiction, and overdose with opioid prescribing for pain management in the perioperative and nonoperative care of surgical patients. Despite these risks, it is essential for surgical providers to provide safe and adequate functional pain control to enhance recovery. The purpose of this review is to outline the relevance of the US opioid crisis to surgical prescribing, describe strategies for opioid reduction using a stepwise therapy approach, and provide recommendations for improving the safety of opioid prescribing. Additional recommendations for risk ...
Source: Surgical Clinics of North America - July 19, 2019 Category: Surgery Authors: Calista M. Harbaugh, Pasithorn A. Suwanabol Source Type: research
Image-Guided Palliative Interventions
This article reviews a few surgical palliative care procedures that can be performed by surgeons and interventional radiologists using image-guided techniques. Treatment of recurrent pleural effusions, gastrostomy feeding tube maintenance, percutaneous cholecystostomy, and transjugular intrahepatic portosystemic shunts (TIPS) with embolotherapy of bleeding stomal varices is discussed. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 19, 2019 Category: Surgery Authors: Jay A. Requarth Source Type: research
Palliative Care and the Pregnant Surgical Patient
Obstetricians and general surgeons frequently navigate the challenges of providing surgical care that is mindful of the unique circumstances of pregnancy. Ensuring pregnant patients have high-quality surgical care is an ethical imperative. Providers should maintain a high index of suspicion for surgical disease to ensure that surgical diagnoses are not missed or inadequately treated. A variety of imaging modalities are used in pregnancy. Surgical management includes laparoscopic and open approaches. Perioperative fetal monitoring should be the subject of multidisciplinary discussion. Symptomatic control in pregnancy should...
Source: Surgical Clinics of North America - July 19, 2019 Category: Surgery Authors: Benjamin P. Brown, Roxane Holt Source Type: research
Tracheostomies and PEGs
This article discusses the most common conditions for which these procedures are requested and reviews the evidence supporting either the placement or avoidance of these tubes in each condition. It provides a framework for surgeons to use when discussing these proce dures in the context of goals of care. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 18, 2019 Category: Surgery Authors: Melissa Red Hoffman Source Type: research
Goals of Care
Advanced care planning is a critically important part of the care of seriously and critically ill patients. A responsibility of all physicians as part of primary palliative care, advanced care planning discussions are more than discussions about code status and should begin early and proceed in parallel with recovery-focused care. Strategies and best practices for advanced care planning in the elective setting and when time is short are reviewed, as are the myriad legal documents that can be used to provide a physical representation of the advanced care planning discussions. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 11, 2019 Category: Surgery Authors: Mackenzie R. Cook Source Type: research
I owe Geoffrey P. Dunn, MD, FACS a debt of gratitude for his inspiration, dedication, and pioneering work in Surgical Palliative Care and Palliative Medicine. For me personally, Dr. Dunn has been a mentor, invaluable role-model and has entrusted me with the honor of guest editor of this edition as his successor. I would also like to thank Ronald F. Martin, MD, John G. Vassallo, Meredith Madeira, and Casey Potter for their support during this project. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - July 10, 2019 Category: Surgery Authors: Pringl Miller Source Type: research
Dedication: Honoring Balfour Michael Morgan Mount, OC, OQ, MD, FRCSC, LLD - The Father of North American Palliative Care
This issue of Surgical Clinics of North America is dedicated to the father of Palliative Care in North America, Balfour Michael Morgan Mount, OC, OQ, MD, FRCSC, LLD, also described as the “compassionate vanguard of Palliative Care.” Dr Mount was named “Balfour” by his father, a neurosurgeon, in honor of his colleague and mentor, Donald Church Balfour, who is famous for his many contributions to surgery, including the abdominal Balfour retractor, which we all know of today. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - June 28, 2019 Category: Surgery Authors: Pringl Miller Source Type: research
Evaluation and Management of Primary Hyperaldosteronism
Primary hyperaldosteronism is an important and increasingly prevalent cause of hypertension that is characterized by unregulated aldosterone excess. More than 90% of primary hyperaldosteronism cases are attributable to either idiopathic adrenal hyperplasia or aldosterone-producing adenomas. The approach to the diagnosis of primary hyperaldosteronism should be step-wise, starting with screening of at-risk populations, confirmatory testing for positively screened patients, and subtype classification in order to direct surgical or medical management. Based on current guidelines, subtype classification of primary hyperaldoster...
Source: Surgical Clinics of North America - June 27, 2019 Category: Surgery Authors: Frances T. Lee, Dina Elaraj Source Type: research
The Art and Science of Endocrine Surgery
The concept of medicine as art, the physician as artist, or the artist as scientist is not as contradictory as it would seem. —Carol Z. Clark and Orlo H. Clark, MDThe Remarkables:Endocrine Abnormalities in Art (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - June 27, 2019 Category: Surgery Authors: Rebecca S. Sippel, David F. Schneider Tags: Preface Source Type: research
The current culture in which we live affords us many “instant” opportunities that simply didn’t exist even a short while ago. Major online retailers are trying to get delivery times to 1 day or less to their large subscriber base. High-speed Internet capability allows Web-based access at unparalleled speed, and we are on the verge of a 5-G netw ork that will likely bring forth new changes to communications, travel, commerce, and other parts of our lives. On of the derivative effects of this “instant-ality” is the change in the perception of some for the need for humanly stored knowledge (...
Source: Surgical Clinics of North America - June 27, 2019 Category: Surgery Authors: Ronald F. Martin Tags: Foreword Source Type: research
Surgical Management of Endocrine Disease
SURGICAL CLINICS OF NORTH AMERICA (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - June 27, 2019 Category: Surgery Authors: Rebecca S. Sippel, David F. Schneider Source Type: research
Management of Nodal Disease in Thyroid Cancer
This article delineates the management of nodal disease in thyroid cancer, focusing on the preoperative evaluation, operative management, and postoperative assessment of cervical lymph nodes. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 28, 2019 Category: Surgery Authors: Mamoona Khokhar, Mira Milas Source Type: research
Evaluation of Thyroid Nodules
This is a brief overview of the initial workup of patients with thyroid nodules. Most nodules are incidentally discovered, benign, and do not require surgery, but the clinician ’s job is to determine which nodules are concerning and what the appropriate workup should be. Ultrasound examination is the best imaging modality to evaluation thyroid nodules and, when biopsy is indicated, fine needle aspiration is the proper technique to sample thyroid nodules. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 27, 2019 Category: Surgery Authors: Keri Detweiler, Dawn M. Elfenbein, Daniel Mayers Source Type: research
When to Intervene for Subclinical Cushing's Syndrome
Without the overt clinical signs and symptoms associated with Cushing's syndrome, the diagnosis of subclinical Cushing's syndrome (SCS) is primarily based on biochemical evaluation. Despite being labeled as “subclinical,” SCS is associated with significant morbidity that can be improved with adrenalectomy. Minimally invasive adrenalectomy is associated with low morbidity in the hands of experienced adrenal surgeons and is recommended as the treatment of choice for SCS patients with SCS-associated c omorbidities. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 27, 2019 Category: Surgery Authors: Lily B. Hsieh, Erin Mackinney, Tracy S. Wang Source Type: research
Adrenocortical Cancer Treatment
Adrenocortical cancer is a rare disease. Prognosis remains poor but is improving. In this article, initial presentation, biochemical and imaging evaluation, surgical approach to resection, and postoperative care are reviewed. Prognosis, patterns of recurrence, treatment of metastatic disease using medical therapy and other surgical and nonsurgical therapies are discussed. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 27, 2019 Category: Surgery Authors: Samuel E. Long, Barbra S. Miller Source Type: research
Surgical Approaches to the Adrenal Gland
Adrenalectomy can be performed open, endoscopically or robotically, utilizing a transabdominal or retroperitoneal approach. This chapter describes the relevant anatomy, various approaches and surgical techniques, pre-operative work-up and optimization, and post-operative management of patients undergoing an adrenalectomy. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 27, 2019 Category: Surgery Authors: Amin Madani, James A. Lee Source Type: research
Evaluation and Management of Neuroendocrine Tumors of the Pancreas
Pancreatic neuroendocrine tumors are a diverse group of neoplasms with a generally favorable prognosis. Although they exhibit indolent growth, metastases are seen in roughly 60% of patients. Pancreatic neuroendocrine tumors may produce a wide variety of hormones, which are associated with dramatic symptoms, but the majority are nonfunctional. The diagnosis and treatment of these tumors is a multidisciplinary effort, and management guidelines continue to evolve. This review provides a concise summary of the presentation, diagnosis, surgical management, and systemic treatment of pancreatic neuroendocrine tumors. (Source: Sur...
Source: Surgical Clinics of North America - May 27, 2019 Category: Surgery Authors: Aaron T. Scott, James R. Howe Source Type: research
Surgical Management of Multiple Endocrine Neoplasia 1 and Multiple Endocrine Neoplasia 2
This article summarizes the surgical management of tumors associated with multiple endocrine neoplasia 1 (MEN1) and multiple endocrine neoplasia 2 (MEN2) and includes discussion of the preoperative planning, the goals, and extent of surgery, as well as the intraoperative considerations and the management of recurrent disease. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 27, 2019 Category: Surgery Authors: Colleen M. Kiernan, Elizabeth G. Grubbs Source Type: research
The Importance of Family History in the Management of Endocrine Disease
Family history is an essential component of the workup of endocrine surgery patients. The family history can change the diagnosis, management, and follow-up of endocrine patients. Here we discuss the importance of family history, review familial endocrine disorders, and develop a list of pertinent questions to ask when taking a family history of patients with endocrine disorders. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 17, 2019 Category: Surgery Authors: Raymon H. Grogan Source Type: research
Intraoperative Decision Making in Parathyroid Surgery
This article reviews intraoperative decision making related to several important aspects of parathyroid surgery. These include how to systematically identify a missing gland, when to perform a unilateral versus bilateral exploration for cure, approaches to secondary hyperparathyroidism, management of familial hyperparathyroidism, and the treatment of parathyroid cancer. The management of intraoperative complications, such as recurrent laryngeal nerve injury and devascularization of parathyroid glands, also is discussed. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 15, 2019 Category: Surgery Authors: Jason S. Dylan, Courtney J. Balentine Source Type: research
Extent of Surgery for Low-Risk Differentiated Thyroid Cancer
This article explores the controversies over the extent of surgery for patients with very low-risk and low-risk differentiated thyroid cancer. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 13, 2019 Category: Surgery Authors: Alexandria D. McDow, Susan C. Pitt Source Type: research
Who Benefits from Treatment of Primary Hyperparathyroidism?
Parathyroidectomy (PTx) is the only definitive treatment for primary hyperparathyroidism (PHPT), but is commonly underutilized. Most patients are medically observed, whereas approximately 30% of patients are treated operatively. PTx is a low-risk surgical procedure and the most cost-effective treatment option. An international consensus statement was published in 1990 to guide clinicians in the management of patients with PHPT, particularly those with asymptomatic disease. Most patients with PHPT and low perioperative risk benefit from surgical treatment, regardless of whether they meet consensus criteria, due to fracture ...
Source: Surgical Clinics of North America - May 11, 2019 Category: Surgery Authors: Catherine Y. Zhu, Dalena T. Nguyen, Michael W. Yeh Source Type: research
Diagnosis and Evaluation of Primary Hyperparathyroidism
This article outlines the epidemiology, clinical presentation, and diagnostic algorithm for PHPT. Key laboratory assessments are discussed, as are imaging studies for preoperative localization. Indications for surgical intervention are detailed, as are potential indications for surveillance. Sporadic and genetic syndromes associated with PHPT are also described. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 10, 2019 Category: Surgery Authors: Nikita N. Machado, Scott M. Wilhelm Source Type: research
Decision Making in Indeterminate Thyroid Nodules and the Role of Molecular Testing
Cytologically indeterminate thyroid nodules are associated with a broad range (5% –75%) of malignant risk and accurately informing definitive management poses a challenge. Advancements in molecular testing of fine-needle aspiration biopsies have improved preoperative diagnostic accuracy and prognostication. For indeterminate nodules, such testing ideally will reduce the need fo r surgery for benign nodules and potentially guide appropriate extent of initial surgery for malignancy. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 9, 2019 Category: Surgery Authors: Janeil Mitchell, Linwah Yip Source Type: research
The Role of Surgery in Autoimmune Conditions of the Thyroid
The two most common autoimmune conditions of the thyroid include chronic lymphocytic (Hashimoto's) thyroiditis and Graves ’ disease. Both conditions can be treated medically, but surgery plays an important role. Hashimoto's thyroiditis and Graves’ disease are mediated by autoantibodies that interact directly with the thyroid, creating inflammation and impacting thyroid function. Patients may develop large goiters w ith compressive symptoms or malignancy requiring surgical intervention. In addition, there are several surgical indications specific to Hashimoto's and Graves’ Disease. (Source: Surgical Clinics of North America)
Source: Surgical Clinics of North America - May 9, 2019 Category: Surgery Authors: Tong Gan, Reese W. Randle Source Type: research
Evaluation of an Adrenal Incidentaloma
Given the frequent use of cross-sectional imaging in medicine, adrenal masses are discovered at an increasing rate. Once detected, it is critical to ensure the patient undergoes the appropriate biochemical/hormonal workup to rule out any aberrant activity and ensure imaging features do not raise suspicion for a malignant neoplasm. Patients with hormonal overactivity, concerning size, and/or imaging characteristics must be referred for surgical consideration. For those not requiring adrenalectomy, it is important to determine which patients mandate follow-up to ensure no further growth or development of hormonal production....
Source: Surgical Clinics of North America - May 9, 2019 Category: Surgery Authors: Dylan S. Jason, Sarah C. Oltmann Source Type: research
The Molecular Biologic Basis of Esophageal and Gastric Cancers
Esophageal cancer and gastric cancer are leading causes of cancer-related mortality worldwide. In this article, the authors discuss the molecular biology of esophageal and gastric cancer with a focus on esophageal adenocarcinoma. They review data from The Cancer Genome Atlas project and advances in the molecular stratification and classification of esophageal carcinoma and gastric cancer. They also summarize advances in microRNA, molecular staging, gene expression profiling, tumor microenvironment, and detection of circulating tumor DNA. Finally, the authors summarize some of the implications of understanding the molecular...
Source: Surgical Clinics of North America - April 30, 2019 Category: Surgery Authors: Arjun Pennathur, Tony E. Godfrey, James D. Luketich Source Type: research