Surgery
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To determine factors leading to pleural effusion after hepatectomy, the frequency of pleural effusion was investigated in 68 patients who underwent hepatic resection, with or without dissection of the right coronary ligament. In 36 of 44 patients (81.8%) who underwent hepatic resection with complete dissection of the right coronary ligament, and in two of 24 (8.3%) who underwent the procedure without dissection of this ligament, pleural effusion developed in the right hemithorax (p less than 0.001). Difference in pressure between the abdominal and thoracic cavities was considered to lead to ascites in the chest via the diaphragmatic triangular area (where there is no parietal peritoneum). While investigating the preventive effect of mechanical ventilation following hepatic resection on the occurrence of pleural effusion in 12 patients, we concluded that effusion could be prevented with use of mechanical ventilation--an approach that retained the intrathoracic pressure in a positive state.
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Comparative Study
Extravascular lung water changes following smoke inhalation and massive burn injury.
During a 3-year period (1984 through 1987), 40 patients with smoke inhalation, cutaneous burns, or a combination of both injuries were studied. Injuries were assigned to the three categories on the basis of bronchoscopic findings and clinical history. Eleven patients had simultaneously sustained a common smoke-inhalation injury without burns while trapped in a burning ship; twelve patients had massive cutaneous burns over 50% of the total body surface area (TBSA); and seventeen patients had cutaneous burns over more than 30% of the TBSA and inhalation injury. ⋯ The group with both smoke-inhalation and burn injuries showed an early increase in EVLW, which returned to normal by 28 hours after injury and which remained normal until 5 days after injury. The EVLW level then increased again until the end of the study period. In this study, lung edema formation is attributed to the toxic effect of smoke inhalation.
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The circular stapler has lowered the leakage rate of an esophageal anastomosis to a level hitherto achieved by only a few surgeons performing hand anastomosis on selected patients with carcinoma of the esophagus. However, the esophageal anastomosis performed with a stapler is also associated with a high stricture rate. Our prospective study was conducted to determine the leakage rate and the incidence of stricture after esophagogastric anastomosis was performed with a stapler, the relationship of stricture to the size of the stapler, and the risk of stricture in relation to time. ⋯ Treatment by bougienage was satisfactory. In conclusion, esophagogastric anastomosis performed with a stapler is a very safe procedure with respect to leakage but is associated with a high risk of stricture, except when the largest ILS staplers are used. However, dilatation readily overcomes the stricture occurrence and adequately compensates for the reduced leakage rate and its attendant serious consequences.
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A method for determining the optimal level of positive end-expiratory pressure (PEEP) by means of noninvasive conjunctival oxygen (PcjO2) monitoring and arterial blood gas analysis was developed from the pattern of changes in PcjO2 tension, invasive hemodynamic parameters, and oxygen transport variables during PEEP titration in a series of patients with adult respiratory distress syndrome. All patients had radial and pulmonary artery (PA) catheters inserted and blood volume was measured with 125I serum albumin before each study. During progressive increases in the level of PEEP, PcjO2 tensions reflected changes in both PaO2 and cardiac index (CI), depending on whether PEEP produced a significant decrease in CI. ⋯ In patients whose CjI significantly decreases because of PEEP, PA catheterization and measurement of cardiac output are indicated because of the likelihood of a significant (greater than 15%) decrease in CI. In the absence of a significant decrease in the CjI, optimum PEEP occurs at the level producing maximum PcjO2. It is hoped that by following the described algorithm, many patients will be spared the cost and morbidity of unnecessary PA catheterization.
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We investigated the cuff-occluded rate of rise of peripheral venous pressure (CORRP)--a new, nearly noninvasive peripheral hemodynamic monitoring parameter--in dogs subjected to hemorrhage and resuscitation. Twelve adult mongrel dogs under general anesthesia were subjected to hemorrhage of 30% of their estimated total blood volume (TBV) for 30 minutes; after this time the extracted blood was reinfused. Arterial pressure (AP), central venous pressure (CVP), pulmonary arterial pressure (PAP), cardiac output (CO), pulmonary venous pressure (PWP), heart rate, and CORRP were continuously monitored. ⋯ These average blood losses are all significantly different from the average blood loss required to effect a CSC in CORRP. The blood loss required to effect a CSC in CO averaged 9.7% +/- 6%. We conclude that in these anesthetized dogs, CORRP detected blood loss earlier than other commonly used hemodynamic parameters, including several invasive parameters such as CVP, PAP, and PWP; CORRP and CO were equivalent in their ability to detect early stages of blood loss.