The American surgeon
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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.
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The American surgeon · Jun 1998
Comparative StudyRecurrent inguinal hernia: preferred operative approach.
Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 10 to 20 per cent performed for recurrence. Subsequent repairs provide considerable technical challenge, as well as substantially greater risk of developing further recurrence. Mesh repair is advocated by several specialized hernia centers, demonstrating re-recurrence rates less than 2 per cent. ⋯ Follow-up ranged from 2 to 12 years. Repair of recurrent inguinal hernia using either an anterior or posterior mesh repair technique, performed at a teaching facility, provides superior recurrence rates without increasing risk for infection or length of stay. Preperitoneal mesh based repair is the preferred technique.
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The American surgeon · Jun 1998
Are chest X-rays mandatory following central venous recatheterization over a wire?
Exchange of a central venous catheter (CVC) over a guidewire is a frequent clinical procedure, especially in surgical intensive care units. At most hospitals, a chest X-ray (CXR) is obtained routinely after recatheterization to confirm accurate catheter placement and to rule out complications such as pneumothorax. We hypothesized that the incidence of complications after central venous recatheterization over a guidewire is too low to justify automatic performance and the associated expense of a routine postprocedure CXR. ⋯ With the advent of managed care, a savings of $115/CXR (one view X-ray and reading cost at our hospital) would be gained without the added risk of radiation exposure to the patient if a CXR were not mandatory after an uncomplicated guidewire replacement of a central line. It appears from these data that a CXR is not justified as a routine study after replacement of all CVCs over a wire from the standpoints of both patient risk and expense. Conscientious physical examination together with good clinical acumen and judgement in evaluating patients after replacement of a CVC over a guidewire are likely to obviate the currently mandated postprocedure CXR, reserving its use for selected patients.
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The American surgeon · May 1998
Randomized Controlled Trial Multicenter Study Comparative Study Clinical TrialImpact an anatomical site on bacteriological and clinical outcome in the management of intra-abdominal infections.
The clinical and bacteriological results of treatment for 429 patients who had intra-abdominal infection were analyzed to determine whether the anatomical origin of peritonitis influenced outcome. All patients had received effective broad spectrum antimicrobial therapy and operation in four multicenter trials. The diagnoses of infection were categorized into three sites: upper gastrointestinal tract, complicated appendicitis, and lower gastrointestinal tract. ⋯ Mortality was related to recurrent intra-abdominal infection after an unsuccessful primary operation and a serum albumin less than 25 g/l. Clinical trails of antimicrobials for intra-abdominal infection should consider stratification of patients according to these three levels of alimentary tract perforation when the site is known preoperatively. Patients who have infection secondary to previous surgery or who are malnourished represent a higher risk group even with appropriate antibiotics.
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The American surgeon · May 1998
Comparative StudyComparison of liver function tests after hepatic lobectomy and hepatic wedge resection.
Prior studies have suggested that changes in liver function tests may vary with the postoperative time interval and may be related to the extent of hepatic resection. This study describes characteristic profiles in parenchymal liver enzymes and other serum liver function tests over a 4-week course comparing anatomic to nonanatomic hepatic resections. The records of 48 patients undergoing successful major hepatic resection during a 3-year period were retrospectively reviewed. ⋯ These laboratory profiles differ with the extent of hepatic resection. The profiles reflect changes in volume status, parenchymal liver destruction, transient hepatic insufficiency, and postoperative hepatic regeneration. However, except possibly for PT and bilirubin, the routine use of these tests is not recommended, given that the results do not alter clinical management.