Surgery
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Hemorrhage-induced activation of endothelial cell Na+/H+ -exchanger results in cellular swelling, which physically impedes capillary filling and compromises gut perfusion. We hypothesized that correction of the vascular volume deficit by conventional resuscitation does not improve capillary filling unless cellular swelling is prevented. Also, we hypothesized that adjunctive direct peritoneal resuscitation (DPR) with topical peritoneal dialysis solution (Delflex; Fresenius USA, Inc., Ogden, Ut) enhances capillary filling and gut perfusion by mechanisms that are independent of the Na+/H+ function. ⋯ Paradoxical endothelial cell swelling occurs early during hemorrhagic shock because of activation of the Na+/H+ exchanger. This cellular edema, which is not resolved by correction of the vascular volume deficit, explains the persistent postresuscitation endothelial cell dysfunction and gut hypoperfusion. Simulated adjunctive DPR in this study reversed endothelial cell swelling and enhanced gut perfusion by mechanisms that are independent of the Na+/H+ exchanger activity.
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The field of postgraduate minimally invasive surgery/gastrointestinal surgery (MIS/GIS) training has undergone substantial growth and change. To determine whether fellowships are meeting a strategic need in training, we conducted a survey to assess the current status and trends of change in MIS/GIS fellowships. ⋯ It seems that the MIS/GIS Fellowship is meeting a real need among graduating surgical residents; fellows felt unprepared for clinical practice at the completion of residency. It is encouraging to note the improvements in fellowship structure, standards, and overall experience, brought by the efforts of the FC. It is hoped that this report of the state of MIS fellowship with a comprehensive review of current data will aid in further evaluation and improvement.
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Intussusception remains a common cause of bowel obstruction in young children and results in significant morbidity and mortality if not promptly treated. The goal of this study was to determine the current success rate of radiologic reduction, the requirements for operative intervention, and the effect of delay in presentation on outcome. ⋯ Success of intussusception reduction is improved with air-contrasted techniques and is not affected by previously failed, outside attempts. Delay in presentation decreases success in radiologic reduction and increases risk of operative intervention and bowel resection.
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Although previously examined, the potential relationship between preoperative biliary drainage (PBD), intraoperative bile culture (IBC), and postoperative morbidity and mortality rate for pancreatic surgery remains unclear. ⋯ PBD predisposes to a positive IBC. Patients with a positive IBC have a clinically important increased risk of developing both infectious complications and wound infection after pancreatic surgery.
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"Fast-track" surgery, involving multimodal care, improves efficiency and short-term outcomes in patients undergoing bowel resection. The sustainability of the benefits and the "drag" effect on non-participating surgeons through changed nursing and resident practice is undetermined. ⋯ Implementation of a new practice pattern in a shared environment leads to improved outcomes for patients of other surgeons within the same environment. Dissemination and cross-pollination of new methods through resident, nurse, and case manager practice pattern modification creates a favorable force for change and this impact is sustained over a 3-year period.