Annals of surgery
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The efficacy of routine screening coagulation tests was studied to identify occult coagulopathies in patients prior to elective general and vascular surgery procedures. The efficacy of screening tests was compared to that of indicated tests performed for predefined clinical indications, which were elicited by history and physical examination and a detailed coagulation history questionnaire. Tests were prothrombin time (PT), partial thromboplastin time (PTT), platelet count (PC), and bleeding time (BT). ⋯ Of the 605 indicated tests, 7.4% were abnormal, and all significant coagulopathies were found in this group. The study shows that preoperative screening tests for coagulopathies not suspected on the basis of detailed clinical information are unnecessary and should not be done. In the authors' institution 46% of screening coagulation tests could be eliminated.
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A retrospective analysis of all patients with traumatic thoracic aortic rupture (TAR) admitted to the hospital over a consecutive 10-year period was performed in order to define the incidence, morbidity, and mortality of associated cardiac contusion (CC) in patients with TAR. Of the 13 patients with TAR, eight (62%) had associated CC. All patients with CC had two or more of the following positive findings: abnormal ECG, elevated myocardial-band creatinine kinase levels, abnormal radionuclide angiography/left ventricular segmental wall motion studies, or cardiac damage seen at surgery and postmortem examination. ⋯ All patients with isolated TAR survived, whereas three of eight patients suffering combined TAR and CC died perioperatively, secondary to cardiac arrest. In patients with TAR, the presence of associated CC occurs with increased frequency, is associated with increased morbidity (cardiac arrest, ARDS), and results in increased operative mortality secondary to cardiac instability. A branch-chain decision tree (clinical algorithm) was developed as a means of improving management of patients with combined TAR and CC, including indications for preoperative pulmonary artery catheterization.
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Comparative Study
A clinical survey of aortobifemoral bypass using two inherently different graft types.
The performance of knitted Dacron and polytetrafluoroethylene (PTFE) bifurcated grafts are compared in this study of 312 patients at a single institution. Patients of the two graft groups were statistically well-matched in risk factors and degree of distal obstructive disease. Operating time needed to implant either graft was approximately equal. ⋯ Complications affected 13% of the patients of the Dacron group and 4% of the PTFE group. All six graft infections and all seven graft double-limb thromboses occurred in Dacron grafts. Anastomotic aneurysms, amputations, and late graft revisions occurred with greater frequency in patients with Dacron grafts.
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Acute aortic dissection occurred in 18 patients who had previously diagnosed atherosclerotic aneurysms of the thoracic and/or abdominal aorta. These patients were reviewed to assess the clinical course when these two forms of aortic pathology coexist. Patients were grouped according to status of their atherosclerotic aneurysm (previously repaired vs. untreated) and the segments of the aorta effected by the acute spontaneous dissection. ⋯ In Group 3 patients, rupture occurred both at the atherosclerotic aneurysm (four patients) and at the site of the aortic intimal tear of the dissection (two patients) after AAA repair. The use of Magnetic Resonance Imaging (MRI) has proven to be highly accurate in delineating the nature and extent of pathology in recently encountered patients with complicated aortic disease. Coexistence of atherosclerotic aneurysm and acute dissection appears to increase the risk of aortic rupture, in both proximal and distal aortic segments.
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With refinements in surgical techniques and increased clinical experience, there has been a resurgence of interest in vascularized pancreas transplantation. From December 1986 to April 1988, 30 whole-organ vascularized pancreas transplants with pancreatico duodenocystostomy were performed simultaneously with renal transplantation. The recipient population consisted of 20 men and ten women, with a mean age of 34.7 years (range of 25-53 years). ⋯ In conclusion, renal transplantation in concert with pancreas transplantation has a dramatic positive impact on pancreas allograft survival. Combined engraftment does not appear to jeopardize renal allograft functional survival. In view of these results, simultaneous pancreas-kidney transplantation appears to be the treatment of choice for Type I diabetic patients.