Surgery
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Historical Article
The Ethicon-Society of University Surgeons Surgical Research Fellowship.
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Randomized Controlled Trial Comparative Study Clinical Trial
Intercostal blockade and pulmonary function after cholecystectomy.
Sixty-six patients undergoing cholecystectomy were randomly allocated to receive either intercostal blockade with bupivacaine supplemented with papaveretum or papaveretum alone for postoperative analgesia. Both groups were similar regarding distribution of sex, age, and weight. These two groups were compared. ⋯ There was no significant difference, however, in the total consumption of papaveretum. Both groups experienced similar degrees of pain, and there were no differences in postoperative pulmonary function. We conclude that although single intercostal blockade is an effective analgesic, it does not improve pain relief and does not improve pulmonary function after cholecystectomy when compared with a regimen of on-demand, intramuscularly administered papaveretum.
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Controversy persists over the best choice of fluid to use for resuscitation. A number of published articles promote the use of either colloid or crystalloid fluids. Most of the arguments for use of one fluid or the other are based on cardiopulmonary data collected during and after fluid resuscitation. ⋯ In patients with trauma who are septic and in whom the capillary leak syndrome leads to adult respiratory distress syndrome, it may be assumed that colloid resuscitation would be no better than crystalloid resuscitation. In this study the meta-analysis of published data showed that this form of treatment is deleterious. In patients who are nonseptic or having elective surgery, however, the basement membrane is intact, and meta-analysis of data in this setting showed that treatment with colloids would be efficacious.
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Tracheomalacia may result from prolonged compression by expanding goiter, particularly within the confines of the thoracic inlet. Constriction of the upper airway by the growing goiter may be indication for operation, but the residual problem of tracheomalacia after thyroidectomy is a life-threatening postoperative complication. Examples of postoperative tracheomalacia in patients with neglected goiters endemic in the third world or recurrent goiter with airway compromise in a western medical center referral practice are described for development of management methods. ⋯ The patient with the most dramatic airway impairment from the most extensive tracheomalacia experienced very satisfactory airway security. A second patient was also supported by the prosthetic rings but extruded one of them, possibly because of tracheostomy contamination. Until tracheal replacement or better tolerated prosthetic or biologic supports are devised, tracheomalacia will remain a vexing problem complicating thyroidectomy for long-standing or recurrent airway-compressing goiter.
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In 6307 cervicotomies for thyroid and parathyroid excision, 33 cases of nonrecurrent inferior laryngeal nerve were identified (0.52%). The anomaly was observed in 31 cases from 4921 dissections on the right side (0.63%) and in two cases from 4673 dissections on the left side (0.04%). Of the 31 patients who were initially seen with this anomaly on the right side, no innominate (brachiocephalic) artery was found; the right common carotid artery was arising directly from the aortic arch. ⋯ The retroesophageal subclavian artery may be detected on chest x-ray films (20%) or by the compression and distortion of the esophagus shown during barium swallow tests (97%). Although rare on the right side and exceptional on the left, an aberrant nonrecurrent pathway for the inferior laryngeal nerve represents a major surgical risk. This is an additional argument in favor of systematic dissection of the inferior laryngeal nerve during thyroid or parathyroid excision.