Annals of surgery
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Case Reports Clinical Trial
Re-engineering ventilatory support to decrease days and improve resource utilization.
The objective of this study was to describe the development of a cost-effective ventilatory strategy using a portable microprocessor-controlled respiratory monitor (Bicore CP-100; Allied Healthcare Products, Riverside, CA.) ⋯ Objective measurement to guide the adequacy of ventilatory support and interpret apparent clinical weaning failures decreased total ventilatory time by 50%, permitting extubation in nearly 20% of patients previously considered failures.
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Clinical Trial
Carotid endarterectomy. Lessons from intraoperative monitoring--a decade of experience.
The authors analyzed a single institution's 10-year experience with intraoperative monitoring during 709 primary carotid endarterectomies and investigated the impact of contralateral internal carotid artery stenosis on carotid artery stump pressure (SP). ⋯ The mean SP for the group (n = 709) was 46.7 +/- 15.3 mmHg (mean +/- standard deviation [SD]) with a mean SI of 54.9 +/- 22.6. The distribution for the SI is a more gaussian curve than that for SP. There were 19 ipsilateral CVAs (2.7%). The mean SP in the nonstroke group was 47.1 +/- 15.2 mmHg (mean SI = 54.7 +/- 16.5) compared with 31.9 +/- 13.2 mmHg (mean SI = 38.8 +/- 18.2) in the stroke group (P < 0.0001). Stroke rate for SP < or = 35 mmHg was 7% (13/185) versus 1.1% (6/524) for SP > 35 (p < 0.0001). Stump index and SP are related to contralateral carotid artery stenosis. The pattern of SI or SP versus contralateral stenosis is biphasic, with an increase at 75%. If SI is < or = 40, the mean contralateral stenosis is 55.1%; if SI is > 40, the mean contralateral stenosis is 35.1% (p < 0.05). Continuous EEG monitoring was completed for the 549 most recent operations. Patients who had a perioperative stroke had EEG changes observed during the procedure in only 6 of 12 cases (50% sensitivity), with 76% specificity. Using SP < or = 35 mmHg, sensitivity was 68% and specificity was 75%.
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The authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis. ⋯ Sepsis represents the host's systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.
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Comparative Study
Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy.
The authors review the results and outcomes of esophagectomy (prophylactic esophagectomy) for patients with Barrett's esophagus and high-grade epithelial dysplasia (HGD). ⋯ High-grade epithelial dysplasia is an indication for esophagectomy because of the prevalence of occult adenocarcinoma (43%). Esophagectomy can be performed safely, and survival in patients with completely resected Barrett's esophagus and early-stage adenocarcinoma is excellent.