Annals of surgery
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Randomized Controlled Trial Comparative Study Clinical Trial
A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters.
Vertical banded gastroplasty (VBGP) was compared with Roux-en-Y gastric bypass (RYGBP) in a randomized prospective trial that included preoperative dietary separation of "sweets eaters" versus "non-sweets eaters." Randomization was stopped at 9 months after 20 patients had undergone each procedure because a greater weight loss (p less than 0.05) was noted after RYGBP than VBGP. This difference became more significant (p less than 0.001) at each 3-month interval through 3 years, when patients who had VBGPs had lost 37 +/- 20% of excess weight compared with 64 +/- 19% for patients who had RYGBPs. The members of the groups were comparable with regard to age, sex, eating habits, morbidity rates before surgery, ideal body weight, and weight before surgery. ⋯ RYGBP was clearly superior to VBGP for "sweets eaters," probably because of the development of dumping syndrome symptoms. However, RYGBP was associated with a larger number of correctable problems. Thus, it is important to evaluate a patient's eating habits before surgery for morbid obesity; "non-sweets eaters" probably should be treated with VBGP and "sweets eaters" with RYGBP.
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It has previously been shown that in 62% of patients the medial pectoral nerve courses through the pectoralis minor muscle to innervate the lower half or two thirds of the pectoralis major muscle. In the other 38% of patients, the medial pectoral nerve exits around the lateral aspect of the pectoralis minor muscle. The lateral pectoral nerve courses on the undersurface of the pectoralis major muscle, innervating the proximal one third or more of the muscle. ⋯ In cosmetic augmentations, when the breast implant is placed behind the pectoralis major muscle, that muscle is partially deinnervated. In this clinical situation, this is believed to be advantageous because it allows the breast to project better. This paper details the anatomy of the pectoral nerves and discusses the clinical implications of surgery in this region as it relates to the size and function of the pectoral muscles.
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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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Comparative Study
Fatty acid and glycerol kinetics in septic patients and in patients with gastrointestinal cancer. The response to glucose infusion and parenteral feeding.
The rates of glycerol and free fatty acid (FFA) kinetics in normal volunteers (VOL), non-weight-losing (NWL) gastrointestinal cancer patients, weight-losing (WL) gastrointestinal cancer patients, and in severely septic patients, using constant infusions of d-glycerol and 1-13C palmitic acid; were determined. Rates of FFA oxidation have also been quantitated. Measurements were made in the basal state, during glucose infusion (4 mg/kg/min), and during total parenteral nutrition (TPN). ⋯ Despite the fact that the WL cancer patients had an increased FFA availability, they were significantly less able to oxidize either endogenous FFA or infused lipid when compared with NWL cancer patients (the basal % of FFA uptake oxidized in WL cancer patients was 10 +/- 2% vs. 18 +/- 3% in NWL cancer patients). In contrast, the septic patients had an enhanced capacity to oxidize either endogenous FFA or infused lipid (the basal % of FFA uptake oxidized was 40 +/- 8%, and during TPN this increased in 65 +/- 10%). From these studies the following was concluded: in terms of lipid kinetics, NWL cancer patients are not significantly different from volunteers; WL cancer patients and septic patients have elevated rates of lipolysis, and in contrast to what was seen in NWL cancer patients and in volunteers, glucose infusion in WL cancer patients and in septic patients does not result in a significant inhibition of lipolysis; and WL cancer patients have an impaired capacity to oxidize either endogenous FFA or infused lipid.(ABSTRACT TRUNCATED AT 400 WORDS)
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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.