The Surgical clinics of North America
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Surg. Clin. North Am. · Apr 1992
ReviewDo perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?
If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. ⋯ Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)
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Surg. Clin. North Am. · Apr 1992
ReviewEndoscopic interventional management of bleeding duodenal and gastric ulcers.
Bleeding duodenal and gastric ulcers continue to be a common and serious problem. Definition of the precise appearance and location of the ulcer by endoscopy gives important information about the source of bleeding and additional information about the risk of rebleeding and the indications for surgery. Several endoscopic hemostatic methods are available. ⋯ Injection therapy with vasoconstrictors or sclerosing agents can also be recommended as a safe, efficacious, and economical means of treatment. Several hemostatic modalities should be available for use depending on the anatomic location and type of bleeding ulcers. The collaboration of skilled interventional endoscopists with their traditional surgical colleagues offers the patient with bleeding peptic ulcer disease the optimum probability of a successful outcome, with minimum treatment-associated morbidity.
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Surg. Clin. North Am. · Dec 1991
ReviewVenous access. Preoperative, operative, and postoperative dilemmas.
The past two decades have seen a tremendous increase in the use of central venous catheters and its associated complications. The increased sophistication that physicians now have with regard to nutritional and metabolic needs has escalated the use of central venous catheters. As the acquired immunodeficiency syndrome epidemic grows, so too will the number of patients with infections and metabolic complications, many of whom will have conditions severe enough to benefit from the use of central venous catheters to deliver antimicrobial drugs and other supportive intravenous therapy. ⋯ Better prophylaxis against the development of catheter-related sepsis and catheter-related thrombosis is also needed. Further prospective investigations should be performed, however, to define precisely cost-effective methods of detection and duration of therapy for patients with both catheter-related sepsis and catheter-related thrombosis. Further advances in the technology and management of catheters need to continue to meet these ongoing challenges.
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The pace of change in hepatobiliary surgery requires a sound foundation in basic surgical principles. Further reductions in morbidity and mortality rates and appropriate use of alternative therapies require careful attention to preoperative risk assessment and patient selection. To operate safely and successfully on the liver and bile ducts, the surgeon must be well versed in normal and variant hepatobiliary anatomy, understand the underlying disease and therapeutic alternatives, and known techniques of reoperative biliary surgery. ⋯ Complex biliary operations require a great level of technical expertise and judgment to obtain successful results and should only be undertaken by experienced hepatobiliary surgeons. As proficiency with the more routine procedures improves, increasingly complex and extensive procedures become possible. We must constantly police ourselves to be certain that these more extensive procedures truly benefit our patients.
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Surg. Clin. North Am. · Dec 1991
ReviewAirway injury after tracheotomy and endotracheal intubation.
Iatrogenic airway injury after tracheotomy and endotracheal intubation continues to be a serious clinical problem. Endotracheal tubes cause pressure injury to the glottis and may result in severe commissural scarring that is difficult to treat. ⋯ The technique of laryngotracheal resection and reconstruction has been well developed and may be applied successfully to most patients with subglottic and tracheal stenosis. The surgical treatment of glottic stenosis remains a challenge.