The American surgeon
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The American surgeon · Jan 1996
Comparative StudyLaparoscopic L5-S1 diskectomy: a cost-effective, minimally invasive general surgery--neurosurgery team alternative to laminectomy.
Laparoscopic L5-S1 diskectomy (LLD) is a promising new technique for managing disabling pain from herniated lumbar disks. It is unknown, however, whether the clinical results of LLD are superior to those of traditional laminectomy (LAM). This study was undertaken, therefore, in order to compare LLD and LAM in the management of L5-S1 disk herniation unresponsive to conservative treatment measures. ⋯ LLD is a safe, cost-effective, minimally invasive operation for managing disabling L5-S1 disk herniation. Compared with LAM, LLD reduces blood loss, length of stay, rehabilitation time, and patient charges, and improves long-term functional and pain-free status. LLD should be considered as an alternative to LAM for patients with herniated L5-S1 intervertebral disks unresponsive to conservative management.
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The American surgeon · Jan 1996
Comparative StudyPostoperative pulmonary complications and morbidity after abdominal aneurysmectomy: a comparison of postoperative epidural versus parenteral opioid analgesia.
Patients undergoing aortic aneurysm repair have a high prevalence of coexisting cardiac and pulmonary disease, and the postoperative recovery is especially delayed by pulmonary complications. A review of all elective abdominal aneurysm repairs over a 29-month period was undertaken to evaluate the effectiveness of postoperative epidural analgesia in decreasing morbidity and mortality, and specifically pulmonary complications. Patients were placed into two groups; Group 1 (34 patients) used an epidural catheter for postoperative pain control, and Group II (31 patients) used standard parenteral opioid analgesia. ⋯ Although no significant difference (P = > 0.05) was seen in decreasing time to ambulation (P = 0.054), average time required on the ventilator (P = 0.053), or hospital days (P = 0.181), all of these did show a trend in favor of epidural catheter utilization. There were no complications or infections related to the use of the epidural catheter during this study period. In conclusion, the use of an epidural catheter for postoperative pain control has been shown to decrease time of intubation, time in the ICU, number of cardiac and pulmonary complications, which should lead to an overall decrease in hospital charges after elective repair of abdominal aortic aneurysms.
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Jejunal diverticular (JD) perforation is an uncommon cause of acute abdominal pain in the elderly. From 1971 to 1994 we treated 13 such patients, 9 men and 4 women, with a mean age of 68 years. All patients experienced sudden onset of abdominal pain, nausea and vomiting, and leukocytosis (range of white blood cell counts, 14,000-21,000). ⋯ In conclusion, JD perforation is an uncommon and frequently overlooked cause of acute abdominal pain in elderly patients. Timely operative intervention and resection of the involved jejunum are the keys to a successful outcome. Because the presentation and physical findings of perforated JD can be highly variable, a history of preexisting JD should arouse suspicion for JD perforation as the etiology of acute abdominal pain in the elderly.
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Mechanical ventilatory support requiring tracheal intubation may be necessary for variable lengths of time in injured patients. Criteria useful in predicting the need for prolonged tracheal intubation has not been clearly established in the trauma population. Early identification of patients requiring prolonged tracheal intubation and mechanical ventilatory support could lead to earlier tracheostomy and subsequent reductions in complications associated with prolonged endotracheal intubation. ⋯ At ages of 40 to 60, GCS < or = 7 and (A-a)O2 > or = 150 indicated the need for long term mechanical ventilatory support. In older patients (age > or = 80), GCS < or = 7 and (A-a)O2 gradient > or = 100 were predictive of long-term mechanical ventilatory support. Appropriate use of these clinical indicators may assist in early identification of patients requiring prolonged mechanical ventilatory support, and subsequent conversion from endotracheal intubation to tracheostomy with anticipated reduction in complications.
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A retrospective study was performed to evaluate the use of abdominopelvic computed tomography of the abdomen (CTA) in the initial evaluation of hemodynamically stable blunt trauma patients. Two hundred fifty-six of 2,047 injury admissions over a 2-year period underwent CTA. Sixty-two (24.2%) scans were positive for visceral injury. ⋯ When indications included early need for nonabdominal operation, only three of 41 scans were positive. Yield for patients scanned with obtundation as an isolated indication was diminished. Cost of CTA exceeds that of DPL, but lower procedure-related risk and lower estimated rate of nontherapeutic laparotomy leads to clinical favor of CTA in this group of patients.