American journal of surgery
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Because the abdominal insufflation and desufflation associated with laparoscopic procedures may adversely effect a compromised myocardium, patients with significant cardiopulmonary disease should be closely monitored during these procedures. The utility of intraoperative pulmonary artery catheter (PAC) and transesophageal echocardiography (TEE) monitoring was studied in 10 patients with moderate to severe cardiopulmonary disease to identify patients at greatest risk for cardiovascular complications during laparoscopic cholecystectomy. ⋯ PCA monitoring in patients with compromised cardiac function is useful in identifying patients who may not tolerate hemodynamic changes after pneumoperitoneum release. Normalization of hemodynamic changes secondary to abdominal insufflation and desufflation in patients with compromised hearts may not occur in patients with compromised hearts may not occur for hours postoperatively. Abnormal hemodynamic changes occur within the first hour after desufflation in patients who later develop cardiovascular complications, which are heralded by significant drops in left ventricular stroke work, cardiac index, and stroke volume. TEE did not prove to be useful for intraoperative monitoring.
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Anorectal function was studied in 55 patients undergoing low anterior resection for rectal adenocarcinoma. Patients were examined preoperatively and 3 months postoperatively by anorectal manometry and standardized interview. Postoperatively, the patients showed, in general, an impairment of anorectal functions. ⋯ However, the two groups with the level of the anastomosis less than or equal to 6 cm (n = 27, range 3 to 6) and more than 6 cm (n = 28, range 7 to 10) above the anal verge showed no differences in manometric values, stool frequency, or fecal continence assessed by the interview. No correlation was found between the level of the anastomosis and manometric values and between the level of the anastomosis and stool frequency (regression analysis = not significant). We concluded that anorectal function after anterior resection and low colorectal anastomosis are not influenced by the remaining length of the rectum but by the surgical trauma to the sphincter and its innervation.
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Metastatic neuroendocrine malignancies frequently cause incapacitating endocrinopathies, and metastases predominant in the liver. Hepatic resection of metastases from such tumors is attractive because the natural history of neuroendocrine tumors is protracted, clinical severity of the endocrinopathy correlates with tumor volume, and local and intrahepatic growth characteristics often allow complete resection. ⋯ Hepatic resection for metastatic neuroendocrine malignancies is safe, provides effective palliation, and probably prolongs survival.
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Associated injuries and central nervous system (CNS) trauma are historically associated with poor outcome in patients with pulmonary contusions, but the value of specific factors reflecting shock, fluid resuscitation requirement and pulmonary parenchymal injury in predicting mortality in this population is not well established. ⋯ Outcome in patients with pulmonary contusion is dependent upon a number of variables including the severity of pulmonary parenchymal injury as reflected in PaO2/FiO2 ratio.