Annals of surgery
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This study represents the personal experience of a general surgeon in 70 cases of penetrating injuries of the heart. Eighteen patients with no signs of life on admission were subjected to a thoracotomy on the stretcher with a mortality of 94%. ⋯ In the author's opinion, percardiocentesis has no place in the diagnosis or treatment of cardiac injuries. Particular attention has been paid to the management of coronary artery injuries and the high incidence of air embolism in certain patients.
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Nearly 30% of patients with Crohn's disease requiring operative treatment have severe peripheral lymphopenia. The surgical significance of this finding had not been previously determined. One hundred fifty-eight patients with Crohn's disease admitted for resection of the diseased bowel were studied. ⋯ Also, lymphopenic patients were more likely to require separate resections of the diseased bowel and more than one anastomosis. Postoperative follow-up revealed that patients with preoperative lymphopenia had a markedly higher incidence of symptomatic recurrences within 3 years of operation (67 vs. 36%, p less than 0.01). It appears that the preoperative peripheral lymphocyte count may be used as an indicator of disease severity and prognosis in patients with Crohn's disease.
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Case Reports
Perforation of the colon in renal homograft recipients. A report of 11 cases and a review of the literature.
Colon perforation in renal transplant recipients is a potentially lethal condition that is amenable to appropriate medical and surgical treatment. The 11 cases seen at the Cleveland Clinic (incidence 1.1% of all renal transplant patients) and previous reports in the literature have been reviewed. The pathogenesis is related to a high incidence of diverticular disease in patients with polycystic kidneys and/or chronic renal failure, the effects of long-term immunosuppression, and the transplant procedure itself. ⋯ Mortality has fallen from 88% (1970-1974) to 53% (1975-1979), and there are indications that it is continuing to fall. All four cases operated on here since 1980 have survived, giving a total operative mortality of 2/6, and all have maintained excellent allograft function. A high clinical index of suspicion, prompt exteriorization of the perforated colon, reduction of immunosuppression to minimal levels, and effective antibiotic coverage have all contributed to the declining mortality.
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Randomized Controlled Trial Clinical Trial
Prophylactic platelet administration during massive transfusion. A prospective, randomized, double-blind clinical study.
Prior studies at Harborview Medical Center have suggested that dilutional thrombocytopenia is a major etiology of microvascular, nonmechanical bleeding (MVB). We undertook a prospective randomized double-blind clinical study to compare the prophylactic effects of 6 units of platelet concentrates (PLT) versus 2 units of fresh frozen plasma (FFP) administered with every 12 units of modified whole blood in patients undergoing massive transfusion (12 or more units in 12 hours). ⋯ Only one patient had evidence of dilutional thrombocytopenia as a cause for MVB. Prophylactic platelet administration is not warranted as a routine measure to prevent MVB.
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Comparative Study
Manometric diagnosis of sphincter of Oddi spasm as a cause of postcholecystectomy pain and the treatment by endoscopic sphincterotomy.
Seventeen patients with postcholecystectomy pain and nine controls were studied by nonoperative biliary manometry with stimulation of sphincter of Oddi spasm by morphine. The controls remained asymptomatic despite an elevation of bile duct pressure after morphine. In 13 patients with postcholecystectomy pain, morphine induced pain paralleling a pressure rise. ⋯ Endoscopic sphincterotomy provided complete (8), moderate (3), or slight (1) relief of pain to 12 patients with the parallel pain-pressure relationship. Postsphincterotomy manometry showed disappearance of both the pressure elevation and pain induction, and the morphine-Prostigmin test turned negative. It is concluded that morphine-induced bile duct pressure elevation coinciding with pain is diagnostic of sphincter spasm as a cause of postcholecystectomy pain, the morphine-Prostigmin test, although helpful, is less specific and less sensitive in diagnosing sphincter spasm than the manometry, and endoscopic sphincterotomy relieves the pain due to this condition in most cases.