The American surgeon
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The American surgeon · Jul 2011
ReviewIntra-abdominal hypertension and abdominal compartment syndrome in the medical patient.
Critically ill medical patients are at significant risk for developing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Although surgical IAH/ACS is commonly acute and dramatic in onset, medical IAH/ACS is more slow and insidious in its development but no less deadly. ⋯ A variety of effective medical management strategies for reducing elevated intra-abdominal pressure (IAP), coupled with early abdominal decompression when necessary, has been demonstrated to significantly improve patient survival from IAH/ACS. Serial IAP measurements, increased collaboration between surgeon and nonsurgeon, institution of medical management strategies, and early abdominal decompression for refractory IAH/ACS will lead to decreased rates of organ failure and improved survival for medical patients who develop IAH/ACS.
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Cardiopulmonary dysfunction and failure are commonly encountered in the patient with intra-abdominal hypertension (IAH) or abdominal compartment syndrome. Accurate assessment and optimization of preload, contractility, and afterload in conjunction with appropriate goal-directed resuscitation and assessment of fluid responsiveness are essential to restore end-organ perfusion. In patients with IAH, the traditional "barometric" preload indicators such as pulmonary artery occlusion pressure and central venous pressure are erroneously increased. ⋯ IAH also markedly affects the mechanical properties of the chest wall and consequently also the respiratory function. Altered mechanical properties of the chest wall may limit ventilation, influence the work of breathing, affect the interaction between the respiratory muscles, hasten the development of respiratory failure, and interfere with gas exchange. Pulmonary monitoring is important to understand the relationships between intra-abdominal pressure and chest wall mechanics and the impact of IAH on ventilator-induced lung injury, lung distention, recruitment, and lung edema.
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The American surgeon · Jul 2011
Comparative StudyPredictors and outcomes of prolonged ventilation after coronary artery bypass graft surgery.
This study investigated and compared the risk factors and outcomes of patients undergoing coronary artery bypass graft surgery with and without the occurrence of prolonged mechanical ventilation. Data in a cardiac surgery database were examined retrospectively. Data selected included any isolated coronary artery bypass graft surgery performed by the surgical group from August 2005 to June 2009. ⋯ Patients undergoing coronary artery bypass graft that experienced a prolonged ventilation time (cases) were more likely female, had a New York Hospital Association functional class of III or IV, and had a longer perfusion time. There was no significant difference between cases and controls with diabetes, chronic obstructive pulmonary disease, left ventricular ejection fraction, or body mass index while controlling for all significant risk factors. Careful patient selection and preparation during preoperative evaluation may help identify patients at risk for prolonged mechanical ventilation and thus help prevent the added morbidity and mortality associated with it.
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The American surgeon · Jul 2011
Comparative StudyA critical assessment of outcomes in emergency versus nonemergency general surgery using the American College of Surgeons National Surgical Quality Improvement Program database.
Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objective of our study was to assess and quantify postoperative morbidity and mortality for emergency versus nonemergency general surgery operations. ⋯ General surgery patients who undergo emergent operations have significantly poorer outcomes when compared with nonemergent patients; our analysis has quantified these differences. Emergent patients seem to manifest unique clinical, pathophysiologic, and inflammatory responses to their surgical disease. This data suggests that there is a need for improvement in both methods and systems of care for the emergent population.
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The American surgeon · Jul 2011
Single incision laparoscopic cholecystectomy using a "two-port" technique is safe and feasible: experience in 101 consecutive patients.
Single incision laparoscopic cholecystectomy (SILC) is a new minimally-invasive technique that has recently been developed to address several disease processes of the gallbladder. However, the safety and feasibility of this technique are still being evaluated. Utilizing a "two-port" technique with transabdominal suture retraction and a rigorous adherence to the critical view of safety, we evaluated our experience in a prospectively maintained database and compared this with standard laparoscopic cholecystectomy (SLC) over the same period. ⋯ Cholangiograms, obtained on a selective basis, were performed in 19 per cent of SILCs. No bile duct injuries occurred during SILC or SLC. Although our aggregate number is not enough to accurately assess the rate or safety of bile duct injuries, SILC seems to be safe and feasible when evaluating other metrics and does not seem to interfere with operative efficiency compared with SLC.