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Biomedical subjects

David R Flum

Publications and source records attributed to David R Flum.

At least 37 records · Page 2Linked to original sources
PubMed2004

Impact of surgical clipping on survival in unruptured and ruptured cerebral aneurysms: a population-based study.

BACKGROUND AND PURPOSE: The management of aneurysms is controversial because little is known about the impact of clipping on long-term outcome. This study was designed to evaluate long-term survival of patients with aneurysms undergoing clipping in a statewide population. METHODS: We used a retrospective design using an administrative database to identify patients hospitalized with aneurysms (1987 to 2001). Time-to-event analysis was used to determine the risk of death from all causes and from neurological causes. RESULTS: 4619 patients (mean age 54.7+/-15.3, 66.3% female) were hospitalized with cerebral aneurysms. Survival among patients with ruptures was significantly lower compared with patients with unruptured aneurysm (P<0.001) with adjusted hazard ratio (HR) of death after clipping 40% higher (HR: 1.4; 95% CI: 1.2, 1.7) in patients with rupture compared with those that were unruptured. Survival estimates for unruptured patients who underwent clipping were significantly higher than among those unruptured patients who did not undergo clipping (P<0.001), with adjusted HR of death 30% higher in patients with unruptured aneurysm that were not clipped compared with unruptured patients who were clipped (HR: 1.3; 95% CI: 1.1, 1.6). Patients with unruptured aneurysm who underwent clipping and survived beyond the 30-day postoperative period were less likely to die from neurologically related causes (5.6 versus 2.3%, P<0.001). Patients with ruptures and aneurysms who underwent clipping have a higher rate of death compared with the general population in the long-term. CONCLUSIONS: Short-term and long-term mortality after clipping of cerebral aneurysms is higher than previously reported. Patients with unruptured aneurysms who undergo clipping have improved survival compared with those who do not undergo clipping. This study supports the use of early intervention in the management of patients with unruptured aneurysms.

Aneurysm, Ruptured↗
PubMed2004

Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review.

PURPOSE: This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis. METHODS: This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity. RESULTS: Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent. CONCLUSIONS: Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.

Anastomosis, Surgical↗
PubMed2004

The impact of low health literacy on surgical practice.

BACKGROUND: We sought to determine the prevalence of low health literacy (LHL) among patients in a preoperative clinic, the characteristics associated with LHL, and the association between LHL and adherence to preoperative instructions. METHODS: We conducted a cohort study and interviewed patients at a VA preoperative clinic. We administered a health literacy test and collected sociodemographic information. When patients returned for their scheduled surgical procedures, adherence to preoperative instructions was assessed. RESULTS: Of 332 participants, 12% (n = 40) had LHL. Low health literacy was more prevalent among older adults (more than 65 years) compared with those under age 65. Patients with LHL were more likely to be nonadherent to preoperative medication instructions (odds ratio = 1.9; 95% confidence interval: 0.8 to 4.8), but this was of borderline statistical significance. CONCLUSIONS: Low health literacy was common among older patients and appeared to be associated with lower adherence to preoperative medication instructions.

Adolescent↗
PubMed2004

Impact of gastric bypass operation on survival: a population-based analysis.

BACKGROUND: Bariatric procedures are increasingly performed but their impact on survival is unknown. STUDY DESIGN: We evaluated short- and longterm mortality rates of patients undergoing gastric bypass on a population level compared with a nonoperated cohort of patients with morbid obesity in a retrospective study, using the Washington State Comprehensive Hospital Abstract Reporting System database and the Vital Statistics database. The study included all patients (age 18 to 65 years) from 1987 to 2001 who underwent gastric bypass with ICD-9 diagnostic codes for obesity. The comparator group included patients of similar age with a diagnosis of obesity or morbid obesity who did not have a bariatric procedure. Survival analysis was used to determine the association of surgeon experience on 30-day mortality and of the procedure on survival while controlling for age, gender, and comorbidity index. RESULTS: Of the 66,109 obese patients we evaluated, 3,328 had a bariatric procedure. Incidence of the procedure increased from 0.7 to 10.6 per 100,000 from 1987 to 2001, with a 2.5-fold increase in incidence rate of the procedure in the years after 1996 (incidence rate ratio, 2.5; 95% CI, 2.4 to 2.7). Thirty-day mortality was 1.9% and was associated with surgical inexperience. Within the surgeon's first 19 procedures the odds of death within 30 days were 4.7 times higher (95% CI, 1.2 to 18.2) than at later points in a surgeon's case order. At 15 years followup, 16.3% of nonoperated patients had died as compared with 11.8% of patients who had the bariatric procedure. When survival was compared beginning 1 year after the procedure, the adjusted hazard for death was 33% lower than that of nonoperated patients (hazard ratio 0.67; 95% CI, 0.54 to 0.85). CONCLUSIONS: Thirty-day mortality after gastric bypass is higher than previously reported and closely linked to surgeon inexperience. A modest overall survival benefit was associated with the procedure but a marked survival advantage was noted for patients who survive to the first postoperative year.

Adult↗
PubMed2004

The timing of elective colectomy in diverticulitis: a decision analysis.

BACKGROUND: Determining the optimal strategy for elective colectomy in patients with diverticular disease involves a balance of the morbidity, mortality, costs, and quality of life associated with both elective and expectant management. We used decision and cost analysis to simulate the clinical and economic outcomes after recovery from an episode of nonsurgically treated diverticulitis to determine the preferable management strategy. STUDY DESIGN: A Markov model was constructed to evaluate lifetime risks of death and colostomy, care costs, and quality of life associated with elective colectomy after subsequent episodes of diverticulitis. The analysis was from the payer's perspective, using hypothetical cohorts of 35- and 50-year-old patients who recovered from a nonsurgically treated diverticulitis episode. Probabilities of clinical events and costs for the base-case analysis were derived from a large cohort using a statewide administrative database and published estimates. RESULTS: Performing colectomy after the fourth rather than the second episode in patients older than 50 years resulted in 0.5% fewer deaths, 0.7% fewer colostomies, and saved US 1,035 dollars per patient. In younger patients, performing colectomy after the fourth episode compared with the first episode resulted in 0.1% fewer deaths, 2% fewer colostomies, and saved US 5,429 dollars per patient. Expectant management through three recurrent episodes with elective colectomy after the fourth episode was the dominant strategy across the full range of the variables tested in the sensitivity analysis compared with earlier intervention. CONCLUSIONS: This study suggests that expectant management is associated with lower rates of death and colostomy and is cost-saving for both younger and older patients.

Adult↗
PubMed2003

Bile duct injury during cholecystectomy and survival in medicare beneficiaries.

CONTEXT: Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear. OBJECTIVE: To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries. DESIGN, SETTING, AND PATIENTS: Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury. MAIN OUTCOME MEASURE: Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics. RESULTS: Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.88) for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon. CONCLUSIONS: The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.

Aged↗
PubMed2003

Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy.

CONTEXT: Intraoperative cholangiography (IOC) may decrease the risk of common bile duct (CBD) injury during cholecystectomy by helping to avoid misidentification of the CBD. OBJECTIVE: To characterize the relationship of IOC use and CBD injury while controlling for patient and surgeon characteristics. DESIGN, SETTING, AND PATIENTS: Retrospective nationwide cohort analysis of Medicare patients undergoing cholecystectomy from January 1, 1992, to December 31, 1999. Patients were identified using Current Procedural Terminology codes from the Medicare Part B depository. Common bile duct injury was defined by a second surgical procedure to repair the CBD injury within 1 year of cholecystectomy. Surgeon demographic features were obtained from matching the Medicare Part B data to the American Medical Association Physician Masterfile database. MAIN OUTCOME MEASURE: Frequency of CBD injury in patients who did and did not have IOC performed during cholecystectomy, controlling for patient-level (age, sex, race, and case complexity) and surgeon-level (surgeon's age, sex, race, year of surgical procedure, case order, percentage of IOC use in prior surgical procedures, years in medical practice, board certification, and specialization) factors. RESULTS: The database search identified 1 570 361 cholecystectomies and 7911 CBD injuries (0.5%). Common bile duct injury was found in 2380 (0.39%) of 613 706 patients undergoing cholecystectomy with IOC and in 5531 (0.58%) of 956 655 patients undergoing cholecystectomy without IOC (unadjusted relative risk, 1.49; 95% confidence interval, 1.42-1.57). After controlling for patient-level factors and surgeon-level factors, the risk of injury was increased when IOC was not used (adjusted relative risk, 1.71; 95% confidence interval, 1.38-2.28). While surgeons performing IOCs routinely had a lower rate of CBD injuries than those who did not, this difference disappeared when IOC was not used. CONCLUSIONS: In this study of Medicare patients undergoing cholecystectomy in the 1990s, the risk of CBD injury was significantly higher when IOC was not used. Although IOCs may not prevent all CBD injuries, this study suggests that the routine use of IOC may decrease the rate of CBD injury.

Aged↗
PubMed2003

Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is a form of fatty liver disease that is increasingly recognized. There are limited data on the prevalence of NASH and the role of risk factors for NASH among the morbidly obese. HYPOTHESIS: The prevalence of asymptomatic NASH among morbidly obese patients undergoing gastric bypass surgery is high, and there are identifiable risk factors for NASH. DESIGN: Prospective case study. SETTING: University hospital. PATIENTS: Forty-eight consecutive patients undergoing gastric bypass surgery who had a concurrent open liver biopsy. Exclusion criteria included current consumption of more than 2 alcohol beverages monthly and known cirrhosis. A hepatopathologist blinded to clinical data reviewed biopsy specimens. MAIN OUTCOME MEASURES: The presence of NASH or severe fibrosis, preoperative body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters), fasting triglyceride level, and presence of type 2 diabetes mellitus (DM). RESULTS: Patients (mean +/- SD age, 42 +/- 10 years; 33 women) had an initial mean BMI of 59.9 +/- 12. Thirty-one patients (65%) had moderate to severe steatosis. Only 6 (12%) had advanced fibrosis. Sixteen (33%) had evidence of NASH. There was no difference in mean age, sex, BMI, or fasting triglyceride level between patients with and without NASH or advanced fibrosis. The odds of NASH were 128 times greater (95% confidence interval [CI], 5.2-3137.0) and the odds of severe fibrosis 75 times greater (95% CI, 4.5-1247.0) in patients with DM than in those without DM. Preoperative BMI was not independently associated with NASH (odds ratio, 1.01; 95% CI, 0.9-1.1) or severe fibrosis (odds ratio, 0.9; 95% CI, 0.86-1.02) after adjustment for DM. CONCLUSIONS: Moderate to severe hepatic steatosis and NASH are common among individuals undergoing gastric bypass procedures. Diabetes mellitus but not BMI is associated with NASH and advanced hepatic fibrosis in these patients.

Adult↗
PubMed2003

A cost-effectiveness analysis of intraoperative cholangiography in the prevention of bile duct injury during laparoscopic cholecystectomy.

BACKGROUND: Recent population-based studies have demonstrated that the use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is associated with a decrease in the rate of common bile duct (CBD) injury. The cost implications of a management strategy involving routine IOC use have not been adequately evaluated. STUDY DESIGN: Decision analytic models were developed to analyze costs and benefits of routine IOC use during LC. The models were used to calculate the cost per life saved, cost per CBD injury avoided, and incremental cost of IOC when used routinely. Transition probabilities, costs, and outcomes were derived from published sources. Sensitivity analyses were used to account for uncertainty in these estimates. RESULTS: Using base-case estimates, management of patients undergoing LC with routine IOC would cost 100 dollars more per LC. Routine IOC would prevent 2.5 deaths for every 10,000 patients at a cost of 390,000 dollars per life saved (13,900 dollars per life year saved). The cost per CBD injury avoided with IOC use is 87,143 dollars. The cost per CBD injury avoided is less for procedures done in high-risk patients (approximately 8,000 dollars) or by less experienced surgeons (approximately 61,000 dollars). CONCLUSIONS: These models describe settings where the cost of IOC and the reduction in CBD injury rates make routine IOC use cost effective. Routine IOC use among less experienced surgeons and in high-risk operations is the most cost effective, but the cost implications of routine use for the general population should also be considered cost effective.

Bile Duct Diseases↗
PubMed2003

Have outcomes of incisional hernia repair improved with time? A population-based analysis.

OBJECTIVE: To determine if certain outcomes of incisional hernia repair have improved in recent eras. SUMMARY BACKGROUND DATA: Technological developments have been reported to improve outcomes in the repair of abdominal wall incisional hernias. METHODS: This retrospective, population-based cohort study was conducted using a 1987 to 1999 Washington hospital discharge database. Subjects were all Washington state residents assigned ICD9 procedure codes for incisional hernia repair with or without synthetic material (mesh). Main outcome measure was the rate of reoperative incisional hernia repair, length of hospitalization, and hospital charges based on the use of synthetic material and the era of operative repair (before and after 1995). RESULTS: A total of 10,822 Washington state patients underwent incisional hernia repair (mean age 58.7 +/- 15.6, 64% female). Of patients undergoing incisional hernia repair, 12.3% underwent at least one subsequent reoperative incisional hernia repair within the first 5 years after initial repair (23.1% at 13 years follow-up). The 5-year reoperative rate was 23.8% after the first reoperation, 35.3% after the second, and 38.7% after the third. The use of synthetic mesh in incisional hernia repairs increased from 34.2% in 1987 to 65.5% in 1999. When controlling for age, sex, comorbidity index of the patient, year of the initial procedure, and hospital descriptors (rural location, nonprofit and teaching status), the hazard for recurrence was 24.1% higher if no mesh was used compared to the hazard if mesh was used. After similar adjustment, no differences were found in the hazard of reoperation based on the era of the operative repair. Mean length of stay for procedures performed after 1995 was 4.9 days compared to 4.8 days in preceding eras. CONCLUSIONS: Incisional hernia repair is associated with high cumulative rates of reoperative repairs. The expectation that important measures of adverse outcome have improved in recent eras is not supported by the results of this large population-based study.

Adult↗
PubMed2002

The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis.

BACKGROUND: Negative appendectomy (NA)--the nonincidental removal of a normal appendix--occurs commonly but the associated clinical- and system-level costs are not well studied. HYPOTHESIS: The frequency of adverse clinical outcomes and associated financial burden of hospitalizations during which NA is performed is greater than previously recognized and varies widely among demographic groups. DESIGN: Population-based, retrospective cohort study. SETTING: The 1997 Nationwide Inpatient Sample of the Health Care Utilization Project. PATIENTS: All surveyed patients assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy but without an associated diagnosis of acute appendicitis. MAIN OUTCOME MEASURES: The age- and sex-stratified rates of NA, the incidence of associated infectious complications and case fatality, and the average length of stay and hospitalization charges during those admissions. RESULTS: Nationwide, an estimated 261 134 patients underwent nonincidental appendectomies in 1997, and 39 901 (15.3%) were negative for appendicitis. Women had a higher rate of NA as did patients younger than 5 years and older than 60 years. When compared with patients with appendicitis, NA was associated with a significantly longer length of stay (5.8 vs 3.6 days, P<.001), total charge-admission ($18 780 vs $10 584, P<.001), case fatality rate (1.5% vs 0.2%, P<.001), and rate of infectious complications (2.6% vs 1.8%, P<.001). An estimated $741.5 million in total hospital charges resulted from admissions in which a NA was performed. CONCLUSIONS: There are significant clinical and financial costs incurred by patients undergoing NA during the treatment of presumed appendicitis. These should be considered when evaluating system-level interventions to improve the management of appendicitis.

Adolescent↗
PubMed2002

The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992-1997.

BACKGROUND: The population level frequency of adverse events after antireflux procedures and its relationship to surgical experience has not been well studied. STUDY DESIGN: Two parallel retrospective, population-based cohort studies were conducted using the Washington State discharge database and the United States Health Care Utilization Project (HCUP) database. All adult patients assigned ICD-9 procedure codes for antireflux surgery from 1992 to 1997 were included. The frequency of case fatality, splenectomy, and esophageal injury was measured. In Washington State, the relationship of adverse outcomes to the cumulative number of procedures performed by a given surgeon (case-order) was determined. RESULTS: Nationwide, an estimated 86,411 patients underwent antireflux surgery between 1992 and 1997. Splenectomy was performed in 2.3%, suture of esophageal laceration in 1.1%, and in-hospital death occurred in 0.8%. Adverse events were significantly more likely when procedures at case-order less than or equal to 15 (median) were compared with those at case-order greater than 15. As case-order increased by 1, the risk of death decreased by 1.7% (p = 0.001), and the risk of splenectomy and injury repair decreased by 1.6% (p = 0.001). If performed at case-order less than 15, the odds ofsplenectomy were 2.7 times, esophageal laceration repair 2.3 times, and death 5.6 times greater than the odds of adverse outcomes for procedures performed at later case-orders. CONCLUSIONS: On a national level, morbidity and mortality associated with antireflux surgery performed in the 1 990s was quite low, but was somewhat higher than suggested by case series. Surgical experience with the procedure was linked to better outcomes.

Adult↗
PubMedDate not supplied

Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

BACKGROUND: A gap exists between patients' desire to be told about medical errors and present practice. Little is known about how physicians approach disclosure. The objective of the present study was to describe how physicians disclose errors to patients. METHODS: Mailed survey of 2637 medical and surgical physicians in the United States (Missouri and Washington) and Canada (national sample). Participants received 1 of 4 scenarios depicting serious errors that varied by specialty (medical and surgical scenarios) and by how obvious the error would be to the patient if not disclosed (more apparent vs less apparent). Five questions measured what respondents would disclose using scripted statements. RESULTS: Wide variation existed regarding what information respondents would disclose. Of the respondents, 56% chose statements that mentioned the adverse event but not the error, while 42% would explicitly state that an error occurred. Some physicians disclosed little information: 19% would not volunteer any information about the error's cause, and 63% would not provide specific information about preventing future errors. Disclosure was affected by the nature of the error and physician specialty. Of the respondents, 51% who received the more apparent errors explicitly mentioned the error, compared with 32% who received the less apparent errors (P<.001); 58% of medical specialists explicitly mentioned the error, compared with 19% of surgical specialists (P<.001). Respondents disclosed more information if they had positive disclosure attitudes, felt responsible for the error, had prior positive disclosure experiences, and were Canadian. CONCLUSIONS: Physicians vary widely in how they would disclose errors to patients. Disclosure standards and training are necessary to meet public expectations and promote professional responsibility following errors.

Attitude of Health Personnel↗
PubMedDate not supplied

Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review.

This review was designed to describe the diagnostic performance of computed tomography (CT) in assessing bowel ischemia and complete obstruction in small bowel obstruction (SBO). A MEDLINE search (1966-2004) identified 15 studies dealing with the CT diagnosis of ischemia and complete obstruction in SBO. Ischemia was defined by operative findings, and complete obstruction was defined by enteroclysis or operative findings. Aggregated sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Eleven of 15 studies reported on the CT diagnosis of ischemia in SBO based on 743 patients. The aggregated performance characteristics of CT for ischemia in SBO were sensitivity of 83% (range, 63-100%), specificity of 92% (range, 61-100%), PPV of 79% (range, 69-100%), and NPV of 93% (range, 33.3-100%). Seven of 15 studies evaluated the CT classification of complete obstruction based on 408 patients. The aggregated performance characteristics of CT for complete obstruction were sensitivity of 92% (range, 81-100%), specificity of 93% (range, 68-100%), PPV of 91% (range, 84-100%), and NPV of 93% (range, 76-100%). This review demonstrates the high sensitivity of CT for ischemia in the setting of SBO and suggests that a CT scan finding of partial SBO is likely to reflect a clinical condition that will resolve without surgical intervention.

Female↗
PubMedDate not supplied

Prophylactic cholecystectomy in transplant patients: a decision analysis.

Prophylactic laparoscopic cholecystectomy should be performed in solid organ transplant patients with asymptomatic cholelithiasis. Modeled, decision analytic techniques were used to evaluate the different management strategies for asymptomatic cholelithiasis in cardiac and pancreas/renal transplant recipients. The clinical outcomes of expectant management, pretransplantation prophylactic cholecystectomy, and posttransplantation prophylactic cholecystectomy were analyzed for each population. The probabilities and outcomes were derived form a pooled analysis of published studies. One- and two-way sensitivity and cost analyses were performed. Prophylactic posttransplantation cholecystectomy is favored for cardiac transplant recipients with asymptomatic cholelithiasis, resulting in 5:1000 deaths versus 80:1000 for pretransplantation cholecystectomy and 44:1000 for expectant management. In distinction, expectant management for asymptomatic cholelithiasis is favored in pancreas/renal transplant patients, resulting in 2:1000 deaths compared with 5:1000 for prophylactic cholecystectomy. After heart transplantation, a strategy of routine, prophylactic cholecystectomy is anticipated to result in a cost savings of $17,779 per quality-adjusted life-year. Prophylactic posttransplantation cholecystectomy is the preferred management strategy for cardiac transplant patients with incidental gallstones, resulting in decreased mortality and significant cost savings per quality-adjusted life-year. Expectant management is the preferred strategy for pancreas and/or kidney transplant recipients with asymptomatic cholelithiasis.

Cause of Death↗