RESUMO
These keynote remarks were delivered by the Medical Society of New Jersey's immediate past-president at a health care system reform conference. The author reviews the state of health system reform confronting New Jersey physicians, and the need to work together for change.
Assuntos
Reforma dos Serviços de Saúde/economia , Programas de Assistência Gerenciada/economia , Planos Governamentais de Saúde/economia , Análise Custo-Benefício , Humanos , New Jersey , Estados UnidosRESUMO
The devastating consequences of reflux subsequent to transthoracic esophagogastrostomy are aspiration, regurgitation, bleeding, recurrent pneumonias, and recurrent strictures in the majority of patients. The misery of eight such patients was personally witnessed. None of them could sleep in their bed at night. Sixty-eight patients were protected from reflux by the intercostal pedicle esophagogastropexy in the last 26 years. They were followed for 1500 months with esophagram, endoscopy, motility, and pH studies. None had disabling reflux or its complications. Eight patients died. Two patients who survived 18 and 10 years have controllable dumping. The histology of the pedicle was preserved without causing any morbidity. A most gratifying group of five patients with benign disease were protected by the pedicle and survived so far from 2 to 23 years. The intercostal pedicle esophagogastropexy is the only antireflux procedure which has consistently prevented reflux through intrathoracic anastomosis over the past 26 years and 1500-month patient follow-up.
Assuntos
Esofagectomia/efeitos adversos , Refluxo Gastroesofágico/prevenção & controle , Gastrostomia/efeitos adversos , Cuidados Paliativos/métodos , Retalhos Cirúrgicos/métodos , Idoso , Idoso de 80 Anos ou mais , Neoplasias Esofágicas/cirurgia , Estenose Esofágica/cirurgia , Feminino , Seguimentos , Refluxo Gastroesofágico/epidemiologia , Refluxo Gastroesofágico/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Técnicas de Sutura , Fatores de TempoRESUMO
A primary fistula between the abdominal aorta and the duodenum is rare and usually fatal. Computed tomography in a symptomatic but stable patient enabled preoperative evaluation and even diagnosis of abnormal communications, real or incipient, between the vascular and enteric system. This case demonstrated the effectiveness, ease, and low cost of documenting a primary aortoduodenal fistula. Surgical results were ultimately improved by initiating early intervention and aggressive management. Therapeutic principles included early intervention with aneurysmectomy, duodenorrhaphy, and extra-anatomic bypass. Anatomic graft placement may be acceptable in selected cases.
