The American surgeon
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The American surgeon · Dec 2008
ReviewCurrent evidence based guidelines for factor VIIa use in trauma: the good, the bad, and the ugly.
Recombinant factor VII (rFVIIa) has arisen as an option for the control of life-threatening traumatic bleeding unresponsive to other means. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and risk/benefits ratio are presently poorly defined. A Medline search from 1995 through March 2008 was conducted. ⋯ There is Level I supporting the use of rFVIIa for blunt trauma patients only. There is no Class I evidence supporting decreased mortality or differences in thromboembolic events. Minimal effective dosing regimens and cost/benefit analyses have not yet been examined.
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Pancreatic injuries are rare, with penetrating mechanisms being causative in majority of cases. They can create major diagnostic and therapeutic challenges and require multiple diagnostic modalities, including multislice high-definition computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, ultrasonography, and at times, surgery and direct visualization of the pancreas. Pancreatic trauma is frequently associated with duodenal and other severe vascular and visceral injuries. ⋯ Wide surgical drainage is a key to any surgical trauma technique and access for enteral nutrition, or occasionally parenteral nutrition, are important adjuncts. Morbidity associated with pancreatic trauma is high and can be quite severe. Treatment of pancreatic trauma-related complications often requires a combination of interventional, endoscopic, and surgical approaches.
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The American surgeon · Dec 2008
Case ReportsEarly thrombosis of the superior vena cava in a patient with a central venous catheter and carcinoma of the ampulla of Vater.
Superior vena cava syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology. Thrombosis of the vessel most often occurs in the setting of indwelling catheters or pacemakers. ⋯ In this report, we present a patient who developed superior vena cava thrombosis after undergoing a short period of central venous catheterization and a Whipple procedure for adenocarcinoma of the ampulla of Vater. The endothelial damage caused by the catheter, the low-flow state induced by the large fluid shifts during the operation, and the hypercoagulable state induced by malignancy fulfill Virchow's triad for venous thrombosis. To our knowledge, this is the first reported case of superior vena cava syndrome after the Whipple procedure with symptoms appearing after a shorter period of catheterization than previously reported in the adult literature.
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The American surgeon · Dec 2008
23-hour stay outcomes for laparoscopic Roux-en-Y gastric bypass in a small, teaching community hospital.
The goal of every surgery is a successful outcome with the shortest hospital stay. Morbidly obese patients with their myriad of comorbidities have confounded surgeons over the years, usually leading to an increased length of hospital stays after complicated surgeries. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has proven to be an effective treatment for the morbidly obese with a usual length of stay of 3 days. ⋯ In conclusion, we have demonstrated that a comprehensive bariatric program in a small teaching community hospital can successfully perform LRYGB and discharge a high percentage of patients within 23 hours with a very low complication rate. We also believe the Obesity Surgery Mortality Risk Score will help bariatric programs to risk-stratify their patients preoperatively. This will contribute to decision-making and further inform patients of their risk as part of their education preoperatively.
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In intubated patients the presence of a cuff leak (CL) is used as a predictor of successful extubation. CL is proposed to indicate laryngeal edema and predict which patients may develop complications such as postextubation stridor and eventual reintubation. Our objective was to evaluate the reliability of CL in our population of critically ill trauma patients. ⋯ Four patients (10%) in the +CL cohort failed extubation, whereas none of the -CL cohort failed (0%) (P = 0.40). The CL test does not reliably identify those patients who will require reintubation in our trauma population. In addition, the ratio of ETT and tracheal diameter is not predictive of successful extubation.