The Surgical clinics of North America
-
Surg. Clin. North Am. · Feb 2002
New approaches to trauma management using severity of illness and outcome prediction based on noninvasive hemodynamic monitoring.
The mathematical model satisfactorily predicted outcome in acute emergencies based on noninvasively monitored flow, pressure, pulse oximetry, tissue perfusion values, and their cumulative deficits. A decision support system provided information on the relative effectiveness of various therapeutic modalities based on the responses of patients with very similar states. The concept that hypovolemia and oxygen debt is an early primary problem that plays an important role in low flow and poor tissue perfusion states is supported by direct observation of massive hemorrhage, estimated blood loss of hemoperitoneum and hemothorax at the time of surgery, and prior studies in the literature that documented blood volume deficits in posttraumatic and postoperative patients who subsequently developed organ failures and death.
-
Many controversies and uncertainties surround resuscitation of hemorrhagic shock caused by vascular trauma. Whereas the basic pathophysiology is better understood, much remains to be learned about the many immunologic cascades that lead to problems beyond those of initial fluid resuscitation or operative hemostasis. Fluid therapy is on the verge of significant advances with substitute oxygen carriers, yet surgeons are still beset with questions of how much and what type of initial fluid to provide. Finally, the parameters chosen to guide therapy and the methods used to monitor patients present other interesting issues.
-
Surg. Clin. North Am. · Jun 2001
ReviewPostoperative care of the pancreatic surgical patient: the role of the intensivist.
Improved patient selection and intraoperative techniques have reduced the need for an intensivist in the care of the pancreaticoduodenectomy patient. Perioperative hemodynamic fine-tuning and the precise management of postoperative complications, however, are areas in which an intensivist can offer expert help. An approach to hemodynamic management and the use of mechanical ventilation is offered. Meticulous detail in each organ system is stressed.
-
Anorectal disease affects many patients with Crohn's disease. Clinical manifestations vary from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. ⋯ Medical management has had some success in improving symptoms, but as yet, it has not been able to ameliorate most perianal complaints quickly and enduringly. Many new and exciting treatment modalities are being investigated with the hope that more effective approaches to these complex and difficult problems can be realized.
-
Historically, Crohn's disease of the esophagus, stomach, and duodenum has been reported only rarely. With more frequent use of upper endoscopy, however, upper gastrointestinal involvement has been found to be more common than previously suspected. The surgeon with an interest in Crohn's disease needs to be familiar with all areas that are potentially affected in this perplexing and sometimes devastating disease. This article examines the literature on foregut Crohn's and discusses the incidence, clinical manifestations, diagnosis, medical management, surgical indications, and operative techniques.