Annals of surgery
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Comparative Study
Venovenous perfusion in ECMO for newborn respiratory insufficiency. A clinical comparison with venoarterial perfusion.
Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has been successful in the treatment of newborns less than 1 week of age and greater than 2000 gm birthweight with respiratory failure resistant to current medical and surgical management. While VA ECMO supports the heart as well as the lungs, it has the disadvantage of requiring carotid artery ligation and the possibility of perfusing air bubbles or particles into the arterial tree. We have treated 11 newborns with respiratory failure with venovenous (VV) ECMO returning the oxygenated blood to a cannula in the distal iliac vein. ⋯ The better survival in these patients treated with VV ECMO is attributed to their more favorable initial condition compared to patients treated with VA ECMO. The disadvantages of VV ECMO include a longer operative time to place the cannulas, groin wound problems, and persistent leg swelling along with the necessity to convert some patients to VA ECMO. Although this experience demonstrates that newborns with severe respiratory failure can be supported with VV ECMO, the complications and lack of practical advantages over VA lead us to recommend VA ECMO for routine clinical use at present.
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Although a thickness of less than or equal to 0.76 mm has been used to define biologically favorable (thin) melanoma, there is evidence that 1 mm may be a reasonable cutoff to categorize favorable extremity melanomas. This is tempered, however, by the claim that histologic regression in thin melanomas is associated with an increased metastatic rate. We have therefore addressed the following questions: Is 1 mm an appropriate cutoff point to define thin melanoma on the extremities? Does regression in a thin lesion truly signify a poor prognosis? Is the width of excision (narrow vs. wide) related to recurrence rates in these lesions? To address these issues we reviewed 48 patients with extremity melanomas, less than or equal to 1 mm in maximum thickness, treated at this institution during a 20-year period. ⋯ We conclude that melanomas less than or equal to 1 mm in thickness on the extremities can be defined as biologically highly favorable, "thin" lesions. Foci of regression do not alter their behavior. Their favorable prognosis justifies conservative excision in most cases.
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There were 425 consecutive patients treated for Hodgkin's disease at this Medical Center from 1943 to 1983. Of these, 255 patients underwent a staging laparotomy and had complete preoperative clinical records. Overall, 35% had a change in stage (24% were upstaged, 11% downstaged). ⋯ A mathematical model was derived for identifying dominant prognostic factors for predicting the risk of abdominal disease in an individual patient setting. The lowest risk patients were asymptomatic females with NS histology (6%) or LP histology (8%), while the highest risk patients were men with multiple symptoms and either MC histology (85%) or LD histology (93%). This information can be useful in making clinical decisions in Hodgkin's lymphoma patients, especially those at an increased risk for surgery.
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Gangrene of the hand associated with acute upper extremity venous insufficiency has been seen in four limbs in three patients treated at Vanderbilt University Medical Center. All three patients had life-threatening illnesses associated with diminished tissue perfusion, hypercoagulability, and venous injury. One patient progressed to above-elbow amputation, but venous thrombectomy in one limb and thrombolytic therapy in two others were successful in preventing major tissue loss. ⋯ An underlying life-threatening illness was present in the majority of these patients (7/13, 54%) and, like the Vanderbilt series, amputations were frequent (7/13, 54%) and mortality (5/13, 38%) was high. This unusual form of ischemia appears to be produced by permutations of global circulatory stasis, subclavian or axillary vein occlusion, and peripheral venous thrombosis. Early, aggressive restoration of adequate cardiac output and thrombectomy and/or thrombolytic therapy may provide the best chance for tissue salvage and survival in this group of patients.
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During a period of 11 1/2 months, 41 of 217 adult burn patients admitted to the U. S. Army Institute of Surgical Research Burn Center required endotracheal intubation or tracheostomy for management of the airway and/or ventilatory assistance. ⋯ For initial respiratory support, we favor the use of translaryngeal (nasotracheal) tubes for periods up to 3 weeks. Fiberoptic bronchoscopic examination is the most reliable follow-up method for detecting anatomic damage in such patients. Spirometry can be used as a noninvasive screening test and xeroradiograms are helpful in assessing the degree of tracheal stenosis.