Journal of the American College of Surgeons
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Conservative management with intrapleural drainage and total parenteral nutrition (TPN) has been the first choice of treatment for postoperative chylothorax. With this approach, however, it usually takes several weeks for the chylothorax to resolve and it is sometimes unsuccessful. In this study, we reviewed seven patients who had chylothorax develop after pulmonary resection for primary carcinoma of the lung. ⋯ One patient did not consent to the "one-week trial" and underwent operative treatment on the third postoperative day. Two patients had chylous leaks less than 100 mL/day or less than 15 percent of the maximum daily chylous leak after one week observation. Conservative management with TPN was continued in these patients for two more weeks and operation was performed in one on the 20th day and in the other on the 22nd postoperative day. The remaining four patients underwent operative treatment on the seventh or eighth postoperative day. All of the operations for chylothorax were successful, and chest tubes were removed promptly. These results show that operative management of chylothorax was reliable and safe. The "one-week trial," however, offered few advantages in determining the therapeutic strategy for postoperative chylothorax.
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Review Comparative Study
Carbon dioxide absorption during laparoscopic pelvic operation.
Several factors may influence the degree of carbon dioxide (CO2) absorption during laparoscopy. Hypercapnia as a result of excessive CO2 absorption may have adverse clinical effects. ⋯ The risk factors for hypercapnia can be identified. Careful consideration of the patient's ability to tolerate hypercapnia should be made when planning extraperitoneal laparoscopy, especially if the procedure is likely to be prolonged. The clinical development of subcutaneous emphysema should alert the surgeon to the possibility of subsequent hypercapnia.
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Multicenter Study Comparative Study
The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care.
The use of surgical outcome in the comparative assessment of the quality of surgical care is predicted on the development of proper models that adjust for the severity of the preoperative risk factors of the patient. The National Veterans Administration Surgical Risk Study was designed to collect reliable, valid data about patient risk and outcome for major surgery in the Veterans Health Administration (VHA) and to report comparative risk-adjusted surgical morbidity and mortality rates for surgical services in VHA. This study describes the rationale and methods used in the Risk Study and reports on the frequency distribution of the data elements that will be used in the development of risk-adjusted reporting of surgical outcome. ⋯ The Veterans Health Administration has successfully implemented an outcome reporting system for major surgery that prospectively collects patient risk and outcome information reliably and validly. Risk adjustment models and comparative hospital-specific rates of risk-adjusted outcomes are currently being developed.
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Subungual melanoma is an unpredictable and aggressive tumor with a propensity to metastasize widely. Because it is an uncommon condition, statistical analysis of its behavior patterns is difficult, factors that determine its prognosis are unclear, and optimal management is ill defined. ⋯ The treatment of subungual melanoma of the toenail apparatus is primarily surgical, by amputation at or proximal to the metatarsophalangeal joint. Even if there is no clinical evidence of metastatic disease in regional lymph nodes, radical node dissection is desirable. The condition is most appropriately managed at a specialist center.
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Developments in the specialty of general surgery have never been more important, nor have the opportunities for general surgeons been more exciting, than at the present. Technologic advances and the expansion of basic knowledge of surgical diseases have contributed to this renaissance of the field. ⋯ Education of the student preparing for a nonsurgical career in the fundamental concepts underlying surgical therapy must be kept at the forefront of an undergraduate surgical curriculum. Integration and coordination of graduate surgical education in all of the general surgery-based specialties is an important obligation for the future, as knowledge expands in each specialty and the need for more specialty-specific education becomes apparent.