Current opinion in general surgery
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Perianal complications of Crohn's disease are fairly common in the adult and pediatric populations. Transrectal ultrasonography is effective for the diagnosis and follow-up of patients with anorectal abscesses and fistulas in Crohn's disease. Metronidazole and 6-mercaptopurine therapy have been used effectively to treat perianal complications of Crohn's disease in the pediatric population. ⋯ The management of rectovaginal fistulas in the presence of Crohn's disease is controversial. Conventional fistulotomy and transvaginal mucosal advancement flap with diverting ileostomy have been advocated as primary treatment modalities. Rectovaginal fistulas secondary to ulcerative colitis may be treated by ileoanal pouch anastomosis and primary repair.
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Pharyngoesophageal dysphagia is chiefly a disorder of the elderly. This review examines recent advances in the understanding of the normal physiology of oropharyngeal bolus transport. ⋯ Therapy for the condition is aimed at the underlying cause, and patients with neurologic deficits (largest subgroup of patients) should have a good response to myotomy provided they fulfill basic criteria. Surgery for Zenker's diverticulum is always necessary, and a short discussion of technique has been included.
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This review of early care covers issues pertaining to the analysis of system function, prehospital intravascular volume replacement, diagnosis of proximity vascular injury, the role of emergency thoracotomy, and the value of transesophageal echocardiography. The first six articles deal with various aspects of system function, from triage to analysis of outcome. The next series of articles reviews work in progress evaluating optimal fluid for resuscitation. ⋯ An article and two editorials summarize state of the art for diagnosis and treatment of proximity vascular injury. Two articles describe the potential use of the new technique of transesophageal echocardiography. This new modality has not formed a solid indication at present and can be considered investigational in trauma care.
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Several new developments promise to improve the lot of the morbidly obese. Perhaps the most important of these is the gradual recognition that morbid obesity is a serious illness that is not the result of immorality or gluttony but is, in most cases, a disabling genetically determined handicap. ⋯ The third development has been the improvement of bariatric surgery, ie, the surgery for morbid obesity, with better operations, better quality controls, and rigorous follow-up. This article reviews the newer concepts of morbid obesity as a disease, delineates the indications for surgery, describes the currently recommended operations, and presents the risks and benefits of these procedures.
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Multiple organ failure remains a leading cause of death in surgical intensive care units. This review of multiple organ failure focuses on recent (1990 to 1992) laboratory and clinical advances related to diagnosis, prognosis, and therapy of multiple organ failure and is divided into three parts. ⋯ The three hypotheses focus on the gut, molecular mediators, and the microvasculature. Third, it synthesizes those three mechanisms into a single paradigm; this unifying paradigm can serve as a framework in which to interpret subsequent laboratory and clinical advances.