The American surgeon
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The American surgeon · Apr 2002
Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit.
To simplify long-term airway management in critically ill patients the feasibility of performing percutaneous tracheostomy (PT) in the intensive care unit (ICU) was investigated from August of 1997 to March of 2000. Bedside PT was considered for patients with positive end-expiratory pressure <10 cm H20, no previous tracheostomy, no anatomic distortion of the tracheal region, and no other indication to go to the operating room. Indication for tracheostomy, duration of endotracheal intubation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, morbidity, and mortality were determined. ⋯ Sixteen patients died of causes unrelated to PT. Forty-five patients were decannulated after an average of 57 days (range 9-170 days); two noted a minor voice change. PT can be performed in the ICU with minimal morbidity eliminating the need for an operating room, the risks of patient transport, and the costs associated with each.
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The American surgeon · Apr 2002
Continuing experience with liver resection and vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest.
When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. ⋯ First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.
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The American surgeon · Mar 2002
Comparative StudyOutcome analysis of pancreaticoduodenectomy at a community hospital.
There is an ongoing debate about the proposed regionalization of pancreaticoduodenectomies. The purpose of our study is to demonstrate that good outcomes can be achieved in a well-managed low-volume community hospital. We retrospectively analyzed pathologic findings, morbidity, mortality, and one-year survival in 32 patients who underwent pancreaticoduodenectomy at Providence Hospital over a 10-year period and compared these results with data collected at Johns Hopkins, and the Mayo Clinic. ⋯ The higher rate of malignant disease treated in the population at Providence Hospital may contribute to a higher complication rate and lower one-year survival rate than the reported rates at Johns Hopkins because of the poorer health of cancer patients. However, statistical analysis of mortality rates for pancreaticoduodenectomy at Providence Hospital show no difference from mortality rates at Johns Hopkins and Mayo Clinic. Therefore in low-volume community hospitals pancreaticoduodenectomy can be performed safely as evidenced by a comparable low mortality rate and a high one-year survival rate.
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The purpose of this study was to determine the incidence, mechanisms, and outcomes of management in patients with multisystem trauma and associated burn injury. A retrospective review was performed of patients admitted with combined burns and trauma from 1990 through 1999. Mechanism of injury, extent of burns, associated injuries, Injury Severity Score (ISS), and patient outcomes were identified. ⋯ The combination of burns with multiple system trauma is uncommon. Fractures are the most frequent associated injury, and the majority of patients will require skin grafting in their burn treatment. Outcomes with appropriate management are favorable and are primarily dependent on the degree of associated trauma.
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The American surgeon · Mar 2002
Comparative StudyNonoperative management of blunt splenic injuries: factors influencing success in age >55 years.
Historically poor success rates of nonoperative management of splenic injuries in elderly patients have led to recommendations for operative intervention in patients more than 55 years of age. Recent studies are in opposition to earlier recommendations revealing equal success rates of nonoperative management of splenic injuries in all age groups. A retrospective chart review was performed to assess factors related to the successful management of splenic injuries in patients over 55 years of age at a Level I trauma center. ⋯ Patients with higher-grade injuries and pelvic free fluid are at greater risk for failure. Patients with these two findings must be monitored closely. The physicians caring for elderly patients with high-grade splenic injuries and free fluid in the pelvis must use clinical judgment regarding the need and timing of operative management.