American journal of surgery
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Comparative Study
Selective management of abdominal and thoracic stab wounds with established peritoneal penetration: the eviscerated omentum.
In a prospective study involving 276 patients, stab wounds to the abdomen and lower chest with certain penetration into the peritoneal cavity were managed selectively. On the basis of physical findings, patients underwent either immediate laparotomy or close observation with frequent reexaminations and operation only if signs changed. The reliability of physical examination and the safety of nonoperative treatment in the absence of peritoneal signs were assessed. ⋯ Physical examination correctly predicted the findings in 90 to 96 percent of patients at initial assessment, with a sensitivity of 88.4 percent and a specificity of 93.9 percent. As delayed laparotomy after a change in signs during observation did not increase morbidity or hospital stay, and the unnecessary laparotomy rate in this study was 5.9 percent, we recommend a policy of selective management of abdominal and thoracic stab wounds with omental evisceration or other evidence of peritoneal penetration. Local wound care with amputation of the protruded omentum followed by close observation and monitoring of vital signs is safe surgical practice when no peritoneal signs or other indication for urgent exploration are present on admission.
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Comparative Study
Infectious complications with the use of cyclosporine versus azathioprine after cadaveric kidney transplantation.
Infectious complications within 1 year of cadaveric kidney transplantation were compared in 45 patients treated with azathioprine, prednisone, and antilymphocyte globulin and 38 patients treated with cyclosporine and prednisone. Although there was no difference in the 1 year patient or graft survival rate, cyclosporine-treated patients had significantly fewer wound infections, infection-related transplant nephrectomies, and infection-related graft failures than azathioprine-treated patients. The cyclosporine-treated diabetic recipients had more nonviral pneumonias and opportunistic infections but fewer cases of infection-related transplant nephrectomy than did the azathioprine-treated diabetic patients. Our data suggest cyclosporine is associated with reduced infectious morbidity after cadaveric kidney transplantation in nondiabetic patients.
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Thirty-four patients with colovesical fistulas seen over a recent 10 year period were reviewed. Diverticulitis was the most common cause of colovesical fistula, accounting for 71 percent of patients in our series. The majority of patients present electively, and most have urinary tract complaints. ⋯ Operations in three stages for colovesical fistula are not indicated. The primary objectives in the management of colovesical fistulas due to unresectable malignancy are relief of intestinal and urinary obstruction and fecal diversion. Resection of the malignancy should be performed whenever possible.
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Emergency center thoracotomy is a heroic technique of resuscitation and treatment which was revived in the 1960s to improve the survival of patients presenting with cardiac wounds. With excellent survival rates attained in such patients, the technique was extended to victims of trauma with other mechanisms and locations of injury. ⋯ Patients with isolated stab wounds to the thorax, especially those with cardiac injuries, had the best survival rate of any subgroup in the series. If emergency center thoracotomy was utilized for patients with some vital signs on admission and with neck or truncal gunshot wounds, blunt trauma, or abdominal trauma, the survival rate decreased to 2 to 4 percent; however, the small but constant survival rate in all of these groups justifies its continued use.