Annals of surgery
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Injuries to the porta hepatis pose difficult problems in management, and transection of the bile ducts, portal vein and hepatic artery is among the most challenging. Twenty-one patients with severe injuries to the porta hepatis were treated over a ten-year period. Ages ranged from 13 to 56 years, and follow-up was up to nine years. ⋯ Associated injuries to liver, pancreas, kidney and duodenum were common. In four patients there was injury to the main or left or right hepatic artery which was managed successfully by repair or ligation, with or without hepatic lobectomy. By adhering to the principles of management to be outlined, many patients with injury to the porta hepatis will survive, and the long term outcome can be gratifying.
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Assessment of living related donor (LRD) survival statistics offers the opportunity to gauge the effects of recipient characteristics without the perturbations of viability, function, and antigen sharing that are inherent in cadaveric organ grafting. From January 1, 1969 to January 1, 1979, 167 LRD grafts were performed. Crude patient survival at one year is 92% and 84% at five years. ⋯ Cadaveric graft statistics vary with recipient race when adjusted to exclude older patients and diabetics, white recipient one-year graft survival 74%, black 38%. No meaningful difference exists among LRD recipients as to graft function, but there is a trend toward improved black patient survival. This suggests that there is not an inherent difference in immune response to genetically similar grafts, but that the disparate results with racially mixed donor-recipient combinations rests with other factors.
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This study of 73 patients with the clinical diagnosis of thromboembolism has shown that the pulse rate, respiratory rate, and arterial partial pressure of carbon dioxide have discriminatory value in identifying the group of acutely ill patients who are most likely to have pulmonary embolism. In contrast, the clinical diagnosis of deep venous thrombosis, PaO2 chest radiography and electrocardiography which are all essential to patient management have no such value. In this series, only 29% of the patients had a pulmonary arteriogram positive for thromboembolism, but the mortality rate in this group was 33%. Pulmonary perfusion scanning has been shown to be a useful and accurate screening investigation and should be routinely employed prior to pulmonary angiography if the patient is stable hemodynamically.
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Case Reports
Total or near total pancreatectomy and islet autotransplantation for treatment of chronic pancreatitis.
Total or near total pancreatectomy is the surest way to relieve the pain of chronic pancreatitis but is rarely applied because the metabolic consequences are so severe. For most patients drainage procedures are applicable, but pancreatectomy may be the only alternative for small duct disease or where procedures to improve duct drainage have failed. Preservation of endocrine function is a major problem in patients who require pancreatectomy. ⋯ Islet tissue preparation from a diseased pancreas is difficult. The surgeon and the patient must still be willing to accept diabetes for relief of pain when performing this operation. In some patients, however, islet autotransplantation can prevent or partially ameliorate diabetes after pancreatectomy, and preservation of endocrine function is worthwhile.
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The charts of 937 patients have been reviewed for survival and length of stay. Probit analysis and binary logistic regression has been performed to develop probability of dying contours incorporating age and per cent burn. It appears that improvement in survival has occurred over the last 16 years. ⋯ A significant decrease in hospitalization time has occurred in the past year with the advent of a selective wound excisional protocol, without adversely affecting survival. A burn bed requirement chart is presented which incorporates age, burn size, survival probability and predicted length of stay. The chart allows for estimation of burn bed needs for a known or predicted population of regional burn victims.