Advances in surgery
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The management of penetrating injuries to the abdomen has evolved back to a selective nonoperative approach. Using clinical examination for screening, evaluable patients without hemodynamic instability or peritonitis can safely undergo a trial of nonoperative management. For stab wounds, this involves serial clinical examination with delayed laparoscopic evaluation of the diaphragm for left thoracoabdominal injuries and CT scanning for suspected solid-organ injuries. ⋯ The presence of peritoneal violation without definite organ injury requires serial clinical examination. Isolated solid-organ injury is not an absolute contraindication to nonoperative management and may benefit from advanced endovascular and percutaneous interventions to facilitate management. Selective nonoperative management of both stab wounds and gunshot injuries is safe and has been shown to decrease the rate of unnecessary laparotomy, length of hospital stay, and management costs.
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The specialty of trauma surgery is evolving. The continued decline in general surgery operative interventions in trauma patients has led to an exodus of promising young surgeons away from the field. A concurrent decline in the number of burn surgeons, as well as orthopedists and neurosurgeons interested in providing emergency care, led to a pressing need for surgeons able to perform emergency surgical care. ⋯ Training future surgeons to staff the ranks of acute care surgery is an important and exciting challenge. It may be that "Should the trauma surgeon do the emergency surgery?" is the wrong question. A better question may be "How best can we train surgeons for this new specialty"?
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Gallstones are the most common cause of acute pancreatitis in the western world. Most patients with ABP suffer a mild attack and are expected to make a full recovery. They can be managed supportively and undergo laparoscopic cholecystectomy with IOC during their initial hospitalization to prevent recurrence. ⋯ A prompt diagnosis requires a high degree of suspicion and clinical acumen. Recognizing patients with severe pancreatitis is an important priority because it affects the type and timing of intervention. The management of these patients requires close clinical observation and a multidisciplinary approach between the surgeon, radiologist, gastroenterologist, and intensivist.
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Advances in surgery · Jan 2006
ReviewThe importance of insulin administration in the critical care unit.
In the last decade investigation into the importance of glucose control and insulin administration in a wide variety of clinical settings has occurred. In virtually all studies, whether of cardiac ischemia or bypass surgery, cerebrovascular recovery from ischemia or head injury, or surgical critical illness, intensive insulin therapy with tight glucose control has resulted in improved clinical outcomes by decreasing both morbidity and mortality. The fundamental biochemical mechanisms for these findings are increasingly well understood and explain the apparent far-reaching beneficial effects of this therapy. In the future, it is likely that all hospitalized surgical patients will have tight glucose control.