Annals of surgery
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Radical ablative surgery for upper extremity sarcoma often results in significant loss of function. With the recent emphasis on limb preservation, function-sparing excision has been combined with adjuvant radiation and chemotherapy in an increasing number of patients. To assess the effect of changing management on local recurrence rates and identify factors governing local failure, the records of 108 patients with operable, nonmetastatic soft tissue sarcoma of the upper extremity, treated at the Memorial Sloan-Kettering Cancer Center between 1968 and 1978, were reviewed. ⋯ Local failure varied significantly with histologic type and was highest in patients with embryonal rhabdomyosarcoma and angiosarcoma. When the data were subjected to multivariate analysis, the following variables emerged as independent predictors of local failure: presentation with local recurrence, surgery by LSS, inadequate margins, angiosarcoma, and invasion of vital structures. These risk factors should be carefully weighed when selecting local treatment for patients with upper extremity soft tissue sarcomas.
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Retroperitoneal space abscesses are unusual clinical problems encountered by general surgeons, internists, and surgical subspecialists. An insidious, occult illness marked by diagnostic delay, inadequate drainage, and considerable morbidity and mortality is common. Anatomic reviews detailing the complex extraperitoneal spaces have been published, but less attention has been focused on diagnostic and drainage techniques useful to the practicing surgeon. ⋯ A strikingly high mortality was associated with positive blood cultures and persistent fever within 48 hours of drainage (75% and 71%, respectively). Computed tomography has greatly enhanced the diagnosis of extraperitoneal abscesses, and radiologic drainage in selected cases appears to be a useful initial approach. A simplified anatomic classification and treatment plan is proposed to facilitate comparison between clinical series.
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Of 51 patients with major blunt hepatic trauma treated at a Level I trauma center, 29 patients (56.8%) survived. Nine of the 51 patients required insertion of the atrial caval shunt, as indicated by uncontrollable hemorrhage due to disruption of the perihepatic veins. ⋯ Of the eight patients with hepatic vascular injury, four (50.0%) were long-term survivors. In hepatic trauma patients with suspected hepatic vascular injury, aggressive use of the shunt can control hemorrhage before the onset of coagulopathy or hypothermia.
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Baboons that were subjected to systemic hypothermia at 32 C had an arm skin temperature of 27.3 C and bleeding time of 5.8 minutes. With local warming of the arm skin to 34 C, the bleeding time was 2.4 minutes. In normothermic baboons with arm skin temperature of 34.6 C, the bleeding time was 3.1 minutes. ⋯ There was a significant positive correlation between the thromboxane B2 level in the shed blood and the arm skin temperature. Both in-vivo and in-vitro studies have shown that the production of thromboxane B2 by platelets is temperature-dependent, and that a cooling of skin temperature produces a reversible platelet dysfunction. Data also suggest that when a hypothermic patient bleeds without surgical cause, skin and wound temperature should be restored to normal before the administration of blood products that are not only expensive but may also transmit disease.
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In order to assess the specific effects of inhalation injury and pneumonia on mortality in burn patients, the records of 1058 patients treated at a single institution over a five-year period, 1980-1984, were reviewed. Of these patients, 373 (35%) had inhalation injury diagnosed by bronchoscopy and/or ventilation perfusion lung scan. Of the 373 patients, 141 (38%) had subsequent pneumonia. ⋯ Inhalation injury alone increased mortality by a maximum of 20% and pneumonia by a maximum of 40%, with a maximum increase of approximately 60% when both were present. The influence on mortality was maximal in the midrange of expected mortality without these complications for any age group. These data indicate that inhalation injury and pneumonia have significant, independent, additive effects on burn mortality and that these effects vary with age and burn size in a predictable manner.