Surg J R Coll Surg E
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The concept of bacterial translocation and gut-origin sepsis as a cause of systemic infectious complications and the multiple organ dysfunction syndrome (MODS) in surgical and ICU patients has emerged over the last several decades, although the exact clinical relevance of these phenomena continues to be debated. Thus, the goal of this review is to trace the evolution of gut-origin sepsis and gut-induced MODS and put these disorders and observations into clinical perspective. Additionally, the mechanisms leading to gut-derived complications are explored as well as therapeutic options to limit or prevent these complications. ⋯ However, the phenomenon of bacterial translocation is not sufficient to explain the development of MODS in ICU patients. Instead, the development of MODS in these high-risk patients is likely due to gut injury and the systemic spread of non-microbial, tissue-injurious factors that reach the systemic circulation via the intestinal lymphatics. These observations have resulted in the gut-lymph hypothesis of MODS.
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Effective post-operative pain management can positively influence patient outcome. Multimodal analgesic regimes are often limited by side-effects. Epidural analgesia may be resource-consuming, restrict mobility and have negative cardiovascular and gastrointestinal consequences. Consequently, there is a need for regional anaesthetic techniques to minimise opioid use, and provide alternatives to epidurals, especially within the context of minimally invasive abdominal surgery and enhanced recovery programmes. This review aims to evaluate the evidence base underlying Transversus abdominis plane (TAP) blockade. ⋯ The limited evidence to date suggests that TAP blockade is an effective adjunct to multimodal post-operative analgesia following a range of abdominal surgical procedures. Whether TAP blocks are a viable alternative to epidural analgesia remains to be determined. However, it is likely that as this technique grows in popularity its role, particularly that in enhanced recovery programmes, will be better delineated and refined.
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Surg J R Coll Surg E · Dec 2012
Comparative StudyIs there a requirement for axillary lymph node dissection following identification of micro-metastasis or isolated tumour cells at sentinel node biopsy for breast cancer?
Recent decades have seen a significant shift towards conservative management of the axilla. Increasingly, immunohistochemical analysis of sentinel nodes leads to the detection of small tumour deposits, the significance of which remains uncertain. The aims of this study are to examine patients whose sentinel lymph nodes are positive for macro-metastasis, micro-metastasis or isolated tumour cells (ITCs) and to determine the rate of further nodal disease after axillary lymph node dissection (ALND). ⋯ ALND should be considered in patients with micro-metastasis at SLNB. It should rarely be employed in the setting of SLNB positive for ITCs.
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Surg J R Coll Surg E · Dec 2012
Comparative StudyA review of major trauma admissions to a tertiary adult referral hospital over a ten year period: fewer patients, similar survival.
Trauma is an important cause for presentation to the emergency department, representing a significant number of emergency surgical admissions. Societal changes result in alterations in the epidemiology of trauma. ⋯ Admissions resulting from RTAs and of patients aged under 30 reduced significantly, however, young males remain the most affected sub-group. Firearm injuries increased significantly, a worrying trend in view of the severity of injury sustained by these victims.