American journal of surgery
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Comparative Study
Epidural anesthesia as an adjunct to retroperitoneal aortic surgery.
Recent developments in vascular surgery suggest that the retroperitoneal approach to the aorta and the use of epidural anesthesia for lower limb revascularization are associated with decreased morbidity and shorter hospital stays. By combining these principles, we sought to determine if retroperitoneal aortic surgery could be performed under epidural anesthesia and if this might be advantageous. Over a 16-month period, 57 patients underwent aortic surgery via the retroperitoneal (n = 33) or transperitoneal (n = 24) approach. ⋯ With the exception of one death due to aspiration, there were no significant differences between the transperitoneal and retroperitoneal groups with respect to overall morbidity, pulmonary complications, and length of stay in the intensive care unit and hospital. Despite these findings, we favor the combination of epidural and general anesthesia for retroperitoneal aortic surgery. Morbidity was significantly decreased (p less than 0.05) in low-risk retroperitoneal patients when combined epidural anesthesia and general anesthesia were employed.
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Patients with extrahepatic portal vein thrombosis may present from infancy through adulthood with variceal bleeding. Physiologically, such patients differ from patients with cirrhosis and variceal bleeding in that they have a normal liver and maintain good portal perfusion through hepatopedal collaterals. Complete evaluation of these patients requires identification of the bleeding site by endoscopy, definition of the anatomy by angiography, and confirmation of a normal liver by biopsy examination. ⋯ Distal splenorenal shunt offers the best option if technically feasible, but if no shuntable veins are patent, ablative procedures and sclerotherapy may be required. A noninterventive, noninvestigational approach is inappropriate in patients who can be offered definitive therapy. Splenectomy for hypersplenism should not be done in these patients.
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In the past 7 years, we have encountered six patients with finger ischemia as a result of digital artery occlusion associated with seven distal ulnar artery aneurysms. Our experience with the management of these patients forms the basis of this report. All patients were men, with a mean age of 29 years, and all experienced repetitive trauma to the involved upper extremity. ⋯ All patients have improved symptoms, and the grafts remained patent over a mean follow-up of 24 months (range: 13 to 57 months). Based on these results, we recommend that excision and grafting be considered for patients with symptomatic patent ulnar artery aneurysms. Selected patients with thrombosed aneurysms with ongoing digital ischemia may also benefit from surgical intervention.
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A prospective time-management analysis of trauma resuscitation (TR) of 431 patients arriving at a university trauma center documents timing and organization. Severity of injury, patient age, and potential airway injury were significant factors increasing the duration of TR up to a certain time (36 minutes). Moderately injured patients required less time (under 25 minutes). ⋯ With surgery faculty supervision and senior resident attendance, the month of resident experience had no effect on TR times. A timely and organized TR is critical to trauma care. TR times should be documented for quality assurance and ongoing review.
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This study reviews 186 deaths resulting from trauma in a 2-year period in the Charity Hospital of Louisiana at New Orleans Accident Room in order to evaluate problems in prehospital and hospital resuscitative care. All subjects underwent autopsy, and only six were found to have injuries compatible with survival. Three of these were late arrivals (by transfer or self-imposed delay) and died of protracted hemorrhage. ⋯ The important factors in maximizing survival of trauma patients remain rapid transport; immediate, appropriate, rapid evaluation; and quick diagnosis, resuscitation, and definitive therapy. These require a well-trained emergency medical ambulance service delivering patients quickly to a hospital designed to handle trauma patients. One person, preferably a general surgeon with trauma experience, should supervise and monitor the patient continually until the resuscitation phase and all diagnostic tests are completed and definitive therapy is initiated.