Anterior fundoplication at the time of congenital diaphragmatic hernia repair

The loss of normal anatomic barriers in neonates with congenital diaphragmatic hernia (CDH) can predispose children to gastroesophageal reflux (GER). In an attempt to improve post-operative feeding, we have added a modified anterior fundoplication to restore natural gastric and esophageal positioning. The institutional review board of both participating centers approved this study. Between 1997 and 2008, 13 neonates with high-risk anatomy underwent repair of CDH combined with an anterior fundoplication (Boix-Ochoa). The anatomic indications for concomitant fundoplication were absence of an intra-abdominal esophagus, an obtuse angle of His, and a small, vertically oriented stomach. Ten patients survived to discharge and eight were on full oral nourishment. One required partial gastrostomy feedings for an improving oral aversion and quickly progressed to full oral feedings. One patient with chromosomal anomalies and swallowing dysfunction remained on long-term bolus gastrostomy feedings. Two with progressive symptoms of GER and failure to thrive required conversion to a 360° wrap after 18 months of medical management. This was performed in conjunction with a planned, staged muscle flap reconstruction in one patient. There were no complications related to the fundoplication. Anatomic predictors of severe GER can be efficiently countered at the time of CDH repair. A modified fundoplication should be considered in the operative management of high-risk infants

Plant Networks for Processing Recyclable Materials

10.1287/msom.2013.0437Manufacturing and Service Operations Management154670-688MSOM

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro–con debate format

High Stakes for the Health of Sexual and Gender Minority Patients of Color

As clinicians, educators, and researchers, our ability to provide the best possible care to our patients who are sexual and gender minority (SGM) people of color is increasingly challenged. Relative to the general population, SGM patients often have worse health outcomes, and among SGM patients, racial and ethnic minorities are particularly vulnerable. Healthcare policies proposed by the current administration, along with an increasingly hostile and dangerous social climate, have the potential to seriously harm SGM patients of color. In this paper, we discuss these key policy issues impacting the health of SGM patients of color. We then suggest questions for clinicians to consider to help them decide which advocacy activities are right for them, recommending self-examination, skills development, and political action. We end by outlining concrete, actionable steps to advocate for SGM patients of color in patient care, healthcare organizations, medical education, research, and public policy