The Surgical clinics of North America
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Surg. Clin. North Am. · Dec 2000
ReviewSentinel lymphadenectomy in breast cancer: university research tool or community practice?
There is considerable controversy regarding the introduction and granting of credentials for sentinel lymphadenectomy in breast cancer. Given the workload of the average general surgeon and current procedural guidelines, two to three years would be required to demonstrate competence before a surgeon might perform sentinel lymphadenectomy without an immediate completion axillary node dissection. This article reviews issues related to the introduction of sentinel lymphadenectomy in the general surgeon's armamentarium.
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VATS has a diagnostic and therapeutic role in the treatment of patients with chest trauma, but the basic rule of safety over technology must be applied. It is an effective means for managing diaphragmatic injuries, hemothorax, empyemas, and persistent air leaks in selected hemodynamically stable patients. ⋯ In appropriately selected cases, thoracoscopy can prove to be useful, with conversion to thoracotomy in only 10% of patients. Additional studies must be performed to determine any cost benefit compared with conventional therapy.
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An analysis of these results indicates that laparoscopic hernia repair can be performed safely by experienced laparoscopic surgeons, and with lower perioperative complication rates than for open hernia repair. Although the follow-up period for the laparoscopic repair is only 2 or 3 years, the recurrence rate is likely lower than with open repair. Most patients with ventral hernias are candidates for this laparoscopic repair if safe access and trocar placement can be obtained. ⋯ These conditions do not apply for most cases of elective hernia repair. Laparoscopic ventral hernia repair offers advantages over the conventional open mesh repair and may decrease the hernia recurrence rate to 10% to 15%. When properly performed, the laparoscopic approach does not and should not compromise the principles for successful mesh repair of ventral hernias.
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Modern hemodynamic therapy is not only the recognition and treatment of hypotension but also the avoidance and treatment of shock in its broadest sense. The major issues include the recognition of hypoperfusion of the body as a whole or its individual tissues and organ systems and the determination of the best endpoints for the treatment of shock. Even if all of the commonly used clinical indicators of shock are "normal," shock on a cellular, tissue, or organ basis may still be present. ⋯ The determination of adequate intravascular volume (preload) continues to present major difficulties in the care of critically ill or injured patients. Although PCWP is frequently helpful, it is not a gold standard. A bedside ultrasonic technique, such as esophageal Doppler sonography, may replace the Swan-Ganz catheter technique in many patients.
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Surg. Clin. North Am. · Jun 2000
ReviewThe early assessment and intensive care unit management of patients with severe traumatic brain and spinal cord injuries.
The assessment and management of neurotrauma have progressed significantly over the past several years. Improved understanding of the physiology of injured neural tissue and advances in technology have refined the approach to the care of patients suffering neurologic injury. ⋯ The ongoing evolution of critical care also has had a significant impact on the care of patients suffering from neurotrauma. This article reviews some current issues related to the diagnosis and management of traumatic brain injury and spinal cord injury as we head into the next millennium.