The American surgeon
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The American surgeon · Aug 1998
Case ReportsPreoperative diagnosis of isolated penetrating gallbladder injury in an asymptomatic patient: the role of hepato-iminodiacetic acid scan as the definitive diagnostic test.
The decision for nonoperative treatment of abdominal stab wounds is usually based on clinical examination findings. It is important, however, to identify patients who may suffer occult injuries and, therefore, be benefited from further diagnostic evaluation. ⋯ A high index of suspicion and appropriate selection of imaging studies may lead to early identification. Hepato-iminodiacetic acid scan can be used as the definitive diagnostic imaging test in such occasions.
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The American surgeon · Aug 1998
Computed tomographic grading is useful in the selection of patients for nonoperative management of blunt injury to the spleen.
Although nonoperative management of blunt splenic injury (NMBSI) has an established role in the overall management of adult patients with blunt splenic injury, the criteria by which patients are selected continue to be debated. The purpose of this study is to establish the effectiveness of a defined set of criteria that includes CT grading for the selection of patients for NMBSI by examining the outcomes of patients managed in this manner 1 year before with those 1 year after the implementation of this specific set of selection criteria. All patients hospitalized at St. ⋯ In Group II, after the implementation of selection criteria that included CT grade, no patient required delayed operation. Eleven underwent immediate operation, whereas 18 were successfully managed nonoperatively. We conclude that, in the hemodynamically stable patient without clinical indication for laparotomy, CT grading of the splenic injury is a reliable criterion by which patients may be selected for nonoperative management.
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The American surgeon · Jul 1998
Randomized Controlled Trial Clinical TrialRole of prophylactic antibiotics for tube thoracostomy in chest trauma.
The objective of this study was to evaluate the efficacy of antibiotic prophylaxis in association with tube thoracostomy for chest trauma patients with Injury Severity Scores of 9 or 10. A double-blind randomized clinical trial of patients requiring tube thoracostomy was performed at an urban Level 1 trauma center. All patients included in this series were patients with Injury Severity Scores of 9 or 10 (hemothorax/pneumothorax) who suffered isolated chest trauma secondary to blunt or penetrating trauma. ⋯ In the 71 patients receiving antibiotic, 7 complications (1 pleural effusion, 2 chest tube reinsertions, 4 additional chest tubes) occurred, none of which were infectious. In the 68 patients receiving placebo, 7 complications (2 empyemas, 2 pneumonias with effusions, 1 pleural effusion, 2 chest tube reinsertions) occurred, 4 of which were infectious and required antibiotic intervention (P = 0.05, Fisher's exact test). This study showed that patients receiving antibiotics have a significantly reduced incidence of infectious complications and suggests that patients who undergo tube thoracostomy for chest trauma would benefit from administration of prophylactic antibiotics.
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The American surgeon · Jul 1998
Comparative Study Clinical TrialPreoperative versus postoperative chemoradiation for patients with resected pancreatic adenocarcinoma.
Two groups of patients with adenocarcinoma of the pancreas treated with either preoperative chemoradiation (preop CTRT) or postoperative chemoradiation (postop CTRT) were retrospectively analyzed for various treatment-related parameters. Between November 1986 and October 1996, a total of 70 patients with pancreatic adenocarcinoma were enrolled into preop CTRT protocols at our institution. Twenty-five patients with adenocarcinoma of the head of the pancreas underwent pancreaticoduodenectomy with curative intent. ⋯ Local failure either alone or as a component of distant failure occurred in 16 per cent (4 of 25 patients) with preop CTRT and 16.6 per cent (3 of 18) with postop CTRT. Analysis of differences between those treated with preoperative and postoperative CTRT demonstrates similarity in toxicity and effects. However, 22 per cent of patients intended for postoperative therapy did not receive treatment.
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Previous reports in selected patient populations have noted an increase in the number of cholecystectomies since the introduction of laparoscopic cholecystectomy. To assess the impact of laparoscopic cholecystectomy in a more general population, 6473 consecutive cholecystectomies from 7/1/86 to 6/30/95 were reviewed to assess changes in rate of cholecystectomy, diagnosis leading to cholecystectomy, and general patient demographics. During the 9-year period, the number of cholecystectomies increased from 618 to 800 per year (29%; P < 0.002). ⋯ The introduction of laparoscopic cholecystectomy was followed by a dramatic increase in cholecystectomies performed for acalculous disease and less so for cholelithiasis. Accompanying the increase were significant alterations in patient demographics. The study provides indirect evidence for lowering thresholds and changing indications with reasons for the increases yet to be determined.