Annals of surgery
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Randomized Controlled Trial Clinical Trial
Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. A prospective, randomized clinical trial.
The hypothesis that optimizing hemodynamics using pulmonary artery (PA) catheter (preoperative 'tune-up') would improve outcome in patients undergoing limb-salvage arterial surgery was tested. Eighty-nine patients were randomized to preoperative tune-up either in the surgical intensive care unit (SICU) (group 1) or the preinduction room (group 2) or to control (group 3). The tune-up consisted of fluid loading, afterload reduction, and/or inotropic support to achieve predetermined endpoints. ⋯ The overall study mortality rate was 3.4%, with a mortality rate of 9.5% in the control group and 1.5% in the PA catheter groups. There were no differences in ICU length of stay (LOS), hospital LOS, or total hospital costs, although the percentage of cost from complications was higher in group 3 (p greater than 0.05). In this group of patients, preoperative cardiac assessment and optimization is associated with improved outcome.
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During a 16-year interval ending in October 1990, 168 patients underwent 172 aortic root replacements. Thirty patients (18%) had Marfan syndrome. Annuloaortic ectasia (81 patients) and aortic dissection (63 patients) were the principal indications for operation. ⋯ Anticoagulant therapy was not used in these patients and no thromboembolic episodes occurred in the follow-up period (mean, 7 months). The satisfactory results observed with extended follow-up support the continued use of the composite graft technique as the preferred method of treatment for patients with annuloaortic ectasia, persistent aneurysms of the sinuses of Valsalva following previous operations, and for patients with ascending aortic dissection who require aortic valve replacement. The availability of aortic root allografts and the perfection of techniques for safe implantation of the autologous pulmonary root into the aortic position have broadened the indications for aortic root replacement.
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Little information has been reported on the metabolic characteristics of the totally pancreatectomized patient or the efficacy of medical management after radical pancreatic surgery. The prospective evaluation of 49 such patients, with 31% followed for 48 or more months, forms the basis of this report. The major immediate postoperative challenge is control of diarrhea and weight stabilization. ⋯ No patient has developed clinically overt diabetic micro- or macrovascular disease. Performance status in long-term survivors has been reasonable. However adverse chronic sequelae of the operation occur and include an unusual frequency of liver disease, characterized by accelerated fatty infiltration, and osteopenia, with an 18% reduction in radial bone mineral content noted in pancreatectomized patients studied more than 5 years after surgery.
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Inflammation of the appendix is a common cause of acute abdominal pain. The etiology and pathophysiology of appendicitis have been well described. ⋯ Although absolute documentation of trauma as an etiologic factor in these cases is difficult, theoretical mechanisms for the occurrence are discussed. In the setting of right lower quadrant pain following mild to moderate blunt abdominal trauma, acute appendicitis should be considered as a possibility.
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Comparative Study
Verification of a new clinicopathologic staging system for colorectal adenocarcinoma.
Rectal adenocarcinoma is said to have a poorer outcome than colon adenocarcinoma when compared on the basis of Dukes' staging. However a new staging system, determined by a multivariate analysis of 147 patients with rectal adenocarcinoma, has revealed three other variables significantly related to outcome. Therefore this study analyzed the authors' experience with colonic carcinoma during the same time period as they had studied for rectal carcinoma to determine whether the new staging system is valid for colon carcinoma as well, and, if so, to compare the outcome of patients with colon and rectal carcinoma on the basis of this new staging. ⋯ In addition, by using the results of their previous staging system for rectal adenocarcinoma patients, they 'predicted' the 5-year survival rates of the colon adenocarcinoma patients, divided in 16 staging subgroups. In subgroups of at least 15 patients, the rectal staging system predicted the outcome to within 1 to 6 percentage points of the observed outcome of the colonic adenocarcinoma patients. Thus this study validates this staging system, incorporating stage, race, tumor morphology, and microinvasion to predict 5-year survival rate more accurately than Dukes' staging alone for both colon and rectal adenocarcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)