Surgery
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Conventional resuscitation (CR) from hemorrhagic shock (HS) often restores and maintains hemodynamics but fails to restore intestinal perfusion. Post-CR intestinal ischemia has been implicated in the initiation of a gut-derived exaggerated systemic inflammatory response and in the progressive organ failure following HS. We propose that intestinal ischemia can be prevented with hypertonic saline resuscitation (HTSR). ⋯ Small-volume HTSR can be used as a resuscitation regimen at the trauma scene and for selective clinical conditions where hypotensive resuscitation is indicated. HTSR improves intestinal perfusion by selective vasodilation of the precapillary arterioles even at MAP close to shock levels.
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Postinjury organ dysfunction is a result of unbridled systemic hyperinflammation. According to the two-event construct, patients are resuscitated into an early vulnerable window of systemic hyperinflammation (primed) in which a second otherwise innocuous event precipitates uncontrolled hyperinflammation, leading to secondary organ damage and dysfunction (activated). Recent efforts to decrease postinjury morbidity have focused on limiting the potential of second events and systemic inflammation. We hypothesized that the collective effects of recently implemented therapeutic strategies have resulted in decreased activation of the systemic inflammatory response relative to priming in recent years. ⋯ Priming of the postinjury inflammatory response is an early event and is primarily influenced by the injury itself. Recent advances in postinjury care such as judicious blood transfusion, lung protective ventilation, treatment of adrenal insufficiency, and tight glucose control are known to attenuate systemic inflammation. Step-wise adoption of these therapies is coincident with a decrease in the destructive processes resulting in ARDS and MOF. The global effect is a decrease in activation of the systemic inflammatory response over recent years.
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Super-super obesity (body mass index [BMI] >/= 60 kg/m(2)) is thought to be a risk factor for complications and mortality in laparoscopic Roux-en-Y gastric bypass. Excess weight loss has been demonstrated to be diminished compared with less obese patients following surgery. However, we hypothesize that super-super obese patients who undergo laparoscopic gastric bypass can realize major improvements in their health and a good quality of life without a significantly increased risk of complications when compared with less obese patients. ⋯ Laparoscopic Roux-en-Y gastric bypass can be accomplished safely even in extremely obese patients. Although excess weight loss in the super-super obese is diminished postoperatively when compared with less obese patients, health is improved and quality of life is good regardless of a patient's preoperative BMI. Therefore, laparoscopic gastric bypass is a good option even in the extremely obese.
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Operating rooms (ORs) are important resources for patient care and revenue, yet a significant portion of OR time is taken up by nonoperative activities. We hypothesized that redesigning the process that occurs between operations would lead to a decrease in nonoperative time (NOT = room turnover time plus anesthesia induction and emergence time). ⋯ These results demonstrate that a coordinated multidisciplinary process redesign can significantly reduce NOT. This process is applicable to most ORs and has optimal benefit for cases of 2 hours or less in duration. The high percentage of residual process-related delays suggests that further improvements can be anticipated.
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The outcome of laparoscopic colectomy with completely intracorporeal anastomosis (LCIA) in obese and nonobese patients is assessed. ⋯ LCIA can offer smaller incisions, improved cosmesis, and low conversion rates while oncologic principles are preserved. LCIA is a feasible and safe technique with equally successful outcomes in thin and obese patients.