American journal of surgery
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This study was undertaken to evaluate the clinical significance of periportal tracking on computed tomography (CT) in patients with blunt liver trauma. The clinical records and CT findings of 88 patients were reviewed. Angiographic study revealed potential injury to portal triads in patients with periportal tracking on CT. ⋯ Hepatic complications such as bile leak, biloma, hemobilia, and infected hematoma were evaluated separately in 43 patients treated conservatively and 45 patients treated surgically. The incidence of complications in patients with periportal tracking was significantly higher in both groups (nonoperative; P < 0.01, chi-square = 8.46 and operative; P < 0.01, chi-square = 8.48). We conclude that periportal tracking on CT implies injury to the subhepatic region and intrahepatic portal triads and that it requires careful examination for extrahepatic injuries in the initial management and late hepatic complications in the follow-up management.
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The retroperitoneal approach for elective infrarenal aortic procedures is an attractive alternative to the standard transperitoneal approach. In an effort to limit the number of extraneous influences on patient outcome, this approach was performed using epidural anesthesia without the use of endotracheal intubation or general anesthesia. ⋯ No large series using the retroperitoneal approach exclusively under epidural anesthesia has been reported. Recent literature on the retroperitoneal approach makes use of general anesthesia with/without epidural anesthesia. This review supports our contention that the procedure of choice for elective infrarenal aortic surgery is the retroperitoneal approach utilizing epidural anesthesia in the absence of endotracheal intubation and general anesthesia. There is a decrease in the physiologic disturbances associated with general anesthesia, notably pulmonary and gastrointestinal, when only epidural anesthesia is used. This translated into a low complication rate, improved patient comfort, early hospital discharge, and subsequent lower costs.
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Few guidelines exist for determining transfusion needs and strategies, namely, the appropriate use of autologous versus homologous blood for elective vascular surgery. To address this deficiency, we have developed and used an algorithm based on an analysis of the procedure, maximum surgical blood ordering schedule, patient status, and patient suitability for autologous alternatives. Data were derived from consecutive major vascular procedures done at our hospital from 1991 to 1992. ⋯ Using this algorithm during the past year with 120 patients, we simplified transfusion decisions, reduced homologous blood use (to only 4.2%), and reduced wasting of autologous blood to less than 5% of the units predonated. We believe that the use of this algorithm will aid the vascular surgeon in choosing appropriate alternatives to allogeneic blood transfusion, thereby reducing the patient's exposure to risk. The algorithm should also reduce wasting of autologous blood.
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Randomized Controlled Trial Comparative Study Clinical Trial
Shouldice is superior to Bassini inguinal herniorrhaphy.
The original Bassini and Shouldice methods for inguinal herniorrhaphy were tested against each other and against their respective variants that avoid permanent suturing of the internal oblique muscle. Seven hundred fifty inguinal hernia repairs were prospectively allocated to 1 of 4 groups: group A: Bassini with absorbable sutures (polyglycolic acid); group B: Bassini with nonabsorbable sutures (polyester); group C: Shouldice with four rows of polypropylene sutures; and group D: Shouldice with two rows of polypropylene sutures. Outcome was correlated to prospectively defined types and risk factors such as direct hernia, repair for recurrent hernia, hernial sac diameter greater than 8 cm, age greater than 70 years, overweight, and chronic bronchitis. ⋯ Repair of recurrent hernia was the only patient-related risk factor of equal significance as the method of repair. The Shouldice technique is superior to and more than merely a reinvention of Bassini's original method. The omission of muscle sutures is physiologically sound and recommended for the Shouldice operation.