bluuebunny/crossref_metadata_2025 huggingface dataset:
Total parenteral nutrition during acute pancreatitis: Clinical experience with 156 Patients
Authors: Robin Arnold P. , Campbell Rebecca , Palani Colathur K. , Liu Katherine , Donahue Philip E. , Nyhus Lloyd M.
Published: May 2005

Over a 3‐year period, 156 of 815 patients admitted to a single institution with acute pancreatitis received total parenteral nutrition (TPN) for 2,572 patient days. Seventy had “simple” acute pancreatitis (group I) and 86 (group II) developed local complex disease (pseudocyst, abscess, or necrotic gland). In groups I and II, respectively, days without oral intake (NPO) were 13.6±1.5 (SEM) and 24.0±2.1 (p<0.005), hospital days were 19.8±1.7 and 35.8±3.2 (p<0.005), and duration of TPN was 10.9 ±1.0 and 21.0±2.3 days (p<0.005). Thirty‐three patients in group I and 53 in group II required exogenous insulin. Alteration of standard formulas was necessary in 87 patients, but cessation of therapy was necessary in only one instance. Twenty catheters were removed for suspected sepsis with only 3 confirmed cases. Fat‐based formulas were well tolerated in 15% of patients. During TPN, body weight rose from 95.0±2.4% to 97.4±4.3% of ideal in group I and remained at 90.5±1.8% in group II. Albumin rose from 3.36±0.10 to 3.50±0.08 g/dl in group I and from 3.01±0.07 to 3.35±0.07 g/dl in group II. The entire cohort differed from 10 randomly chosen patients who did not receive TPN in terms of days NPO (2.8±0.3) and hospital days (5.5±0.6). Variables associated with prolongation of hospital stay and time NPO were number of prognostic criteria, local complex disease, and underlying chronic pancreatitis only in select groups. We conclude that during acute pancreatitis, TPN can be administered safely but with careful monitoring and we recommend early aggressive therapy in the subgroups noted above and when underlying malnutrition exists. In the borderline patient, TPN may be administered by peripheral vein until the severity of disease is manifest.
Neonatal necrotizing enterocolitis: Experience with 100 consecutive surgical patients
Authors: Ricketts Richard R. , Jerles Matthew L.
Published: May 2005

One hundred newborns with neonatal necrotizing enterocolitis (NEC) were treated surgically according to a uniform protocol between July, 1980 and June, 1988. The infants (53 females, 47 males) weighed between 600 and 3,800 g, averaging 1,500 g. Twenty‐eight weighed less than or equal to 1,000 g, 38 weighed from 1,001 g to 1,500 g, and 34 weighed more than 1,500 g. Median age at the time of surgery was 14 days. Surgery was performed for pneumoperitoneum in 40, a “positive” paracentesis in 51, and for other reasons in 9 infants. A paracentesis was performed if intestinal gangrene was suspected clinically. Resection of gangrenous bowel with exteriorization was the usual procedure; in only 5 patients was primary closure performed. The hospital survival for the infants was 54% for the group weighing less than or equal to 1,000 g, 74% for the group weighing from 1,001 g to 1,500 g, and 79% for the group weighing more than 1,500 g. Overall hospital survival was 70%; it was 81% for those having a definitive procedure (excluding 14 infants with NEC “totalis”). There were 3 late deaths from causes unrelated to NEC. Significant long‐term complications included failure‐to‐thrive in 23% and stricture formation in 30% of the survivors. Long‐term follow‐up showed gastrointestinal status to be normal in 74%; only 8% have persistent major gastrointestinal dysfunction. Mental and motor development was considered grossly normal in only 53% of the patients.
Coloanal anastomosis after resection of low rectal cancer in the elderly
Authors: Huguet Claude , Harb Joseph , Bona Stefano
Published: May 2005

Twenty‐two patients had coloanal anastomoses performed after resection of low rectal tumors (16 adenocarcinomas and 6 large degenerated villous adenomas). The patients had an average age of 72 years (range: 62–85). A hand‐sewn anastomosis was performed between a “J”‐shaped colonic reservoir and the anal sphincter, except in 3 patients who underwent a straight end‐to‐end coloanal suture without pouch. A defunctionalized stoma was made in 18 cases. Mortality within 30 days of operation was 9%. Specific complications occurred in 2 patients (9%). Mean follow‐up in this series was 20.2±11.7 months (± standard deviation). Fifteen patients were alive and free of disease up to 54 months after surgery. One patient was found to have local recurrence at 19 months. The actuarial 3‐year survival rate was 73% in the whole group (operative mortality included). Functional results were good in 16 of 19 patients, with an average 1.8–2.9 stools/24 hours and the continence rate was good. Three patients had complications requiring a permanent colostomy. From these preliminary results, coloanal anastomosis appears to be satisfying in regard to oncologic results and affords good anal function, even in the elderly patient (over 62 years of age).
A new simple test for evaluation of intestinal bacteria
Authors: Takahashi Makoto , Maeda Yorinobu , Tashiro Hirotaka , Eto Takaaki , Goto Takahiko , Sanada Osamu
Published: May 2005

We investigated a newly synthesized conjugate of ursodeoxycholic acid with para‐aminobenzoic acid (PABA) to determine its suitability to evaluate enteric bacteria. This compound, PABA‐UDCA, is deconjugated by cholylglycine hydrolase to release free PABA whereas it is completely resistant to deconjugation by pancreatic and intestinal mucosal enzymes. In bacteriological experiments, almost all of the microorganisms which split glycocholic acid deconjugated this compound. In animal experiments, urinary excretions of PABA were measured for 6 hours following oral administration of 10 mg PABA‐UDCA. Ten control rats excreted 338.5±43.8μg (mean ± SD) of PABA; 10 rats with intestinal bacterial overgrowth due to enteric stagnant loops excreted more (673.6±222.1μgp<0.01), whereas 10 rats in each of 8 groups with intestinal antisepsis by oral administration of various antibiotics excreted significantly less (p<0.001) (ampicillin + doxycycline + fradiomycin: 18.3±16.7, polymixin B + tinidazole: 14.0±8.0, polymixin B: 224.9±74.3, tinidazole: 42.7±27.3, kanamycin: 50.3±18.2, clindamycin: 57.4±23.3, vancomycin: 70.4±27.0, and paromomycin: 160.4±51.9μg). These observations indicate that this compound is likely to offer a simple and rapid method for evaluation of intestinal microorganisms without the use of radioisotopes or expensive, special apparatus.
Pylorus‐preserving duodenopancreatectomy: Long‐term complications and comparison with the Whipple procedure
Authors: Morel P. , Mathey P. , Corboud H. , Huber O. , Egeli R. A. , Rohner A.
Published: May 2005

We have performed 33 pylorus‐preserving duodenopancreatectomies. Twenty patients presented with severe chronic pancreatitis and 13 with periampullary adenocarcinoma. We have no postoperative mortality and a 24% rate of morbidity. Complications include anastomotic leaks (2), surgical bleeding (1), anastomotic ulceration (1), and others (4). We have complete follow‐up for all cases. In the tumor group, 8 (62%) patients are alive with a mean survival time of 20 months (range: 2–46). In the pancreatitis series, all patients are alive after a mean of 34 months (range: 4–66). We have observed 5 cases (15%) of anastomotic ulcerations responsible for stenosis (2) and acute perforation with peritonitis (2) occurring after a mean interval of 18 months. Four cases have been confirmed histologically after resection. The short‐ and long‐term beneficial effects of the pylorus‐preserving operation on patient well‐being and nutritional status were confirmed and compared with the results achieved after a Whipple procedure performed in a series of 18 consecutive patients.
Radical and nonradical hepatic resection for alveolar echinococcosis: Report of 18 cases
Authors: Partensky Christian , Landraud Richard , Valette Pierre‐Jean , Bret Patrice , Paliard Pierre
Published: May 2005

The authors report their experience with 18 patients who underwent liver resection for alveolar echinococcosis of the liver from June, 1982 to January, 1989. Preparation for surgery included transhepatic biliary external‐internal drainage in order to alleviate jaundice in 8 cases and catheterization of infected necrotic cavities in 7 cases. Resection was radical in 9 patients who underwent either right lobectomy (5 cases) or right trisegmentectomy (4 cases) with “en bloc” extension to the bifurcation of the hepatic ducts in 3 cases. Resection was nonradical in another group of 9 patients who had either atypical right hepatectomy (6 cases) or atypical left hepatectomy (3 cases). All patients were submitted to a periodic follow‐up. The 9 patients treated by radical resection are alive and symptom‐free and appear to be disease‐free at radiologic imaging, except for 1 patient who had a small area of parasitic recurrence on computed tomography scan 4 years after operation. Among the 9 patients treated by palliative resection, 3 patients died during the follow‐up period, the cause of the death having been related to the disease in 2 cases and nonrelated in 1 case. The 6 surviving patients had no noticeable growth of the parasitic mass during the period of follow‐up. When feasible, radical liver resection is the best form of therapy. When massive parasitic invasion of both lobes of the liver and the porta hepatis and vena cava precludes radical hepatectomy, palliative resection associated with percutaneous procedures has to be considered before embarking on orthotopic liver transplantation.
Diagnosis of deep vein thrombosis
Authors: Bergqvist David , Bergentz Sven‐Erik
Published: May 2005

A wide range of clinical symptoms and signs are observed with venous thrombosis. Nonetheless, clinical diagnosis has been found to be unreliable and accurate diagnostic methods must be used before potent therapy such as anticoagulation is instituted, since the complications of treatment themselves can be life‐threatening.

Phlebography is still the basic reference for evaluation of deep venous disease. While it is felt to be the most accurate, there are still limitations relative to difficulty in separating acute from chronic disease, and in obtaining adequate contrast in certain veins such as calf muscles and in the larger intraabdominal veins. Moreover, it is an uncomfortable invasive test, not without complications of its own.

The125I‐fibrinogen uptake test is an excellent test for screening for forming thrombi. The sensitivity of this test is high, particularly in the detection of small calf vein thrombi. The primary drawbacks of this technique are that it is falsely positive in cases where there has been bleeding, inflammation, gross edema, arthritis, or leg ulceration. It is not accurate above mid‐thigh because of the high blood flow at the level of the groin and pelvis.

Radioactive labeled plasmin which will adhere to the surface of recently formed thrombi can also be used for diagnosis. The limitations are a very short half‐life of the radioactive label so that repeated investigation of a patient cannot be performed unless new injections are given. The diagnostic accuracy is comparable to that of radioactive labeled fibrinogen and has the same advantages and disadvantages.

Plethysmographic techniques have been used with various modifications. They have the advantage of being strictly noninvasive. They are most accurate when used in association with venous emptying, but there must be at least 50% occlusion of the vein before the test is positive and large collaterals or duplication anomalies may result in a false‐negative test. Phleborrheography seems to diagnose proximal deep venous disease accurately, but is relatively insensitive to distal deep venous thrombosis. Doppler ultrasound techniques are quick and simple to apply, but interpretation requires substantial experience.

Real‐time B‐mode ultrasound has been used in recent years to detect deep venous thrombosis and permit visualization of thrombus within a vessel. With experienced hands, it is possible to differentiate between acute and chronic thrombi.

Finally, a combination of 2 or more methods has been found to increase diagnostic accuracy; combining one method which is good at detecting calf vein thrombosis with one detecting hemodynamically significant thrombi in the more proximal veins offers the best combination. Impedance plethysmography combined with radioactive labeled fibrinogen has been found to be nearly as reliable as phlebography with similar cost effectiveness.
Use of plasminogen activators in venous thrombosis
Authors: Hirsh Jack , Turpie A. G. G.
Published: May 2005

A major advance in the treatment of thrombosis has been the development of thrombolytic agents. Streptokinase and urokinase have been the standard agents available for many years, but in recent years the most exciting change in the field has been the development of a new generation of plasminogen activators, the principal one being tissue plasminogen activator.

The first generation of plasminogen activators—streptokinase and urokinase—do not have fibrin specificity and predictably induce plasma proteolysis when administered systemically in doses which introduce thrombolysis. The second generation of plasminogen activators are much more fibrin‐specific and offer a promise of fewer complications.

In a number of major randomized studies, these thrombolytic agents have proved effective clinically. The major complication of thrombolytic therapy, however, is hemorrhage. The risk of hemorrhage increases with the length of infusion and occurs most often from sites of vascular invasion such as needle punctures or cutdown sites from surgical wounds. This can be treated by applying pressure over the wound and discontinuing the thrombolytic agent whose half‐life is measured in hours. It is believed that as more experience is acquired with the second‐generation plasminogen activators, better control of these drugs will result in fewer complications and more effective and wider application of therapy.
Development of the postthrombotic syndrome: Its management at different stages
Authors: Halliday Peter
Published: May 2005

The postthrombotic syndrome consists of clinical features which follow thrombosis of deep venous return of the limb. Patterns of postthrombotic changes remain difficult to predict and once established, difficult to contain and reverse. Following a thrombotic event of the lower limb, 3 clinical stages can be observed which may be followed by intervening quiescent intervals.

Stage I, or the early phase, is characterized by the residual obstructive process following acute venous occlusion. This can be manifested by either a bursting type of pain (venous claudication) or edema of the leg. A thrombotic process can involve the calf veins, thigh veins, pelvic veins, or any combination of the three. Specific clinical syndromes develop depending on the venous pump system involved. The venous pump system consists of the plantar calf pump and the thigh pump. These serve to propel blood upward. Involvement of any one or more of the 3 in the thrombotic processes can result in a relative obstruction with a specific pattern of clinical symptoms. Optimally, the venous thrombotic process should be treated during this early phase to prevent the subsequent events which may render the process irreversible.

The second stage of the postthrombotic syndrome consists of the development of fat sclerosis. At this stage, the process becomes progressively irreversible as the extravasation of fibrin into the interstitial space results in progressive fibrosis and sclerosis. This results in damage to the skin and subcutaneous tissues which render the process irreversible. Specific treatment, while still introducible at this stage, can halt the progress of the syndrome, but rarely results in complete reversal. Stage 3 process is the advanced postthrombotic limb in which there is extensive damage to the skin usually associated with venous ulceration. By this stage, the development of the syndrome has passed beyond the point where such events can be prevented from recurring, although partial control may be obtained with proper treatment.
Surgical anatomy of the inguinal area
Authors: Skandalakis John E. , Gray Stephen W. , Skandalakis Lee J. , Colborn Gene L. , Pemberton L. Beaty
Published: May 2005

The anatomy of the inguinal region is enigmatic and confusing. Among the many structures involved in hernial repair are the iliopubic tract, the transversus abdominis aponeurosis and the transversalis fascia, the transversalis crura and sling, and the inguinal canal. There is still much disagreement among surgeons and anatomists about the existence, structure, and function of these anatomic entities.
Current concepts in inguinal hernia in infants and children
Authors: Grosfeld Jay L.
Published: May 2005

Trends are changing in the management of infants and children with indirect inguinal hernias. Advances in neonatal intensive care have resulted in the survival of many small premature infants who have a high incidence of inguinal hernia. The rate of incarceration, strangulation, and gonadal infarction in these babies is twice that of the general pediatric age group. Respiratory immaturity, apnea, bradycardia, and associated neonatal conditions require special management at the time of hernia repair, usually performed just before discharge from the neonatal intensive care unit. New information concerning volume loss and depletion of germ cells beginning at 6 months of age in boys with undescended testes has stimulated the performance of orchiopexy when the patient is 1 year of age. More than 90% of boys with cryptorchid testes at the age of 1 year have an associated hernia that requires concomitant repair at the time of orchiopexy. The use of the peritoneal cavity for fluid absorptive purposes in hydrocephalus treated by venticuloperitoneal shunts or of peritoneal dialysis for renal failure and metabolic diseases such as hyperammonemia and lactic acidosis causes increased intraabdominal pressure and results in the appearance of a previously unrecognized hernia. Recognition of these and other conditions associated with a high incidence of hernial occurrence should allow early diagnosis and treatment before the development of complications. Most elective repairs of hernias are safely performed in the outpatient setting; however, some infants and children with concurrent illnesses are best managed in a “morning admissions” program, in which hospital admission occurs postoperatively.
The Canadian repair: Personal observations
Authors: Wantz George E.
Published: May 2005

The Canadian hernioplasty is the modern equivalent of the original Bassini operation. Most of the criticism of the repair is unjustified, even the fact that the repair does not address the femoral canal. The incidence of the femoral type of recurrence that typically occurs in the first year was only 0.14% among the 4,366 primary Canadian hernioplasties performed by one surgeon in the years 1970 to 1987. There were a total of 58 recurrences for a raw recurrence rate of 1.3%. About half of the recurrences were considered to be failures of the hernioplasty, and the remaining ones were attributable to continued deterioration of the patient's tissues. This huge experience of one surgeon demonstrates that recurrence rates, to a great extent, depend on the skills of the surgeon. Recurrence rates decrease as a surgeon's experience with the procedure increases. It also demonstrates the importance of technique and how a minor change in the method of beginning the continuous suture reduced suture tension and eliminated the well‐known pubic tubercle type of recurrence seen after all hernioplasties. The recurrence rate for 639 recurrent and rerecurrent hernias repaired by Canadian hernioplasty was 7.2%. This rate is unsatisfactory, and a preperitoneal repair with a polyester prosthesis is preferred for these difficult problems. A local agent neutralized with sodium bicarbonate is the anesthetic of choice, and simultaneous left and right hernioplasties with the patient going home the same day as the procedure are now commonplace.
New techniques in hernia repair
Authors: Bendavid Robert
Published: May 2005

The surgical treatment of inguinal and femoral hernias has evolved through several stages to reach a modern and successful era. This success was shared by all our predecessors who contributed some knowledge with respect to anatomy, physiology, and surgery. Although most patients are treated with satisfaction by primary herniorrhaphy, difficult recurrences can also be treated successfully. The special features that characterize the modern treatment of difficult hernias are the preperitoneal approach and the availability of reliable prosthetic materials. Some of the techniques currently available are discussed. They are the femoral umbrella, transvérsalis fascial replacement, and the fletching. The results have been encouraging. As surgeons, we are behooved to look, assess, and reconsider in order to improve.
Herniography
Authors: Gullmo Åke
Published: May 2005

Herniographic examinations were performed on more than 4,000 patients. The method was found to be of great value in patients with obscure symptoms in the groin or pelvis. Herniography shows not only hernial sacs but also the general condition and tissue strength of the inguinal part of the abdominal wall. The different types of hernias have different signs that, as a rule, allow an exact diagnosis. The pelvic floor and the pouch of Douglas can always be evaluated. Young athletes with severe symptoms in the groin, in most instances, were found to have some type of hernial rupture and often osteochondritis in the pubic symphysis as well. In women, the clinical diagnosis of hernia is often difficult. Herniography was of great value in these patients.
Spigelian hernia
Authors: Spangen Leif
Published: May 2005

The diagnosis of spigelian hernia presents greater difficulties than its treatment. The clinical presentation varies, depending on the contents of the hernial sac and the degree and type of herniation. The pain, which is the most common symptom, varies and there is no typical pain of spigelian hernia. Findings to facilitate diagnosis are palpable hernia and a palpable hernial orifice. Large, easily palpable spigelian hernias are not a diagnostic problem. It is small hernias and hernial orifices that are overlooked because they are masked by the subcutaneous fat and an intact external aponeurosis. In the absence of a palpable orifice or sac, persistent point tenderness in the spigelian aponeurosis with a tensed abdominal wall most strongly suggests the diagnosis. Spigelian hernia can be ruled out in patients without palpable tenderness. Ultrasonic scanning can be recommended for verification of the diagnosis in both palpable and nonpalpable spigelian hernia. The hernial orifice and sac can also be demonstrated by computed tomography, which gives more detailed information on the contents of the sac than does ultrasonic scanning.

The treatment of spigelian hernia is surgical, and the risk of recurrence is small. A gridiron incision is excellent for operations for palpable hernias. If the hernia cannot be palpated preoperatively, preperitoneal dissection through a vertical incision is recommended. This gives good exposure, facilitates hernioplasty, and permits preperitoneal exploration and treatment of other abdominal wall hernias. The incision is also suitable for exploratory laparotomy, which should be performed on patients with abnormal ultrasonographic or computed tomographic findings in whom no palpable hernia can be detected preoperatively.
Hyperthermic perfusion with chemotherapy for melanoma of the extremities
Authors: Ghussen Farid , Krüger Ingo , Smalley Richard V. , Groth Wolfgang
Published: May 2005

A prospective randomized study was carried out to evaluate the effectiveness of additional regional cytostatic perfusion of the extremities in patients with malignant melanoma. In a control group (n=54), the tumors were widely excised, and regional lymph nodes were dissected. The patients in the perfusion group (n=53) received additional hyperthermic (42°C) perfusion with Melphalan. The disease‐free survival time was chosen as the criterion for evaluation. An intermediate analysis revealed a highly significant difference between the 2 groups (21 recurrences in the control group and 4 recurrences in the perfusion group,p< 0.001). Therefore, the study was discontinued prematurely.

In an analysis of the data performed after a median observation time of 5 years and 11 months, 26 recurrences were diagnosed in the control group, whereas 6 recurrences were noted in the perfusion group (p< 0.001). The retrospective breakdown into different risk groups according to tumor thickness also demonstrates a significant difference. For patients with a primary tumor of 1.5—3.0‐mm in thickness, 2 of 25 in the perfusion group and 10 of 25 in the control group have relapsed. For those with a primary tumor of greater than 3.0‐mm in thickness, 4 of 28 in the perfusion group and 16 of 29 in the control group have relapsed. Eleven patients in the control group and 3 patients in the perfusion group have died due to metastatic spread of the melanoma (p<0.01).

The results most clearly demonstrate the benefits of additional hyperthermic cytostatic perfusion.
Recurrent pulmonary embolism after inferior vena caval interruption with a greenfield filter
Authors: Richenbacher Wayne E. , Atnip Robert G. , Campbell David B. , Waldhausen John A.
Published: May 2005

Twenty‐six patients have undergone inferior vena caval interruption with a Greenfield filter. One patient (3.8%) developed a fatal, recurrent pulmonary embolism. Postmortem examination documented the presence of thrombus within the filter, proximal extension of thrombus beyond the filter apex, and fresh pulmonary emboli. In a combined series of 556 patients, 12 patients (2.2%) developed recurrent pulmonary emboli, 2 (0.36%) of which were fatal. Including case reports, 18 patients have had documented recurrent pulmonary emboli following Greenfield filter insertion. In 4 patients, the recurrent embolism was fatal. Six (60%) of 10 patients had a concomitant malignancy. A work‐up and treatment plan for patients having recurrent pulmonary emboli after the insertion of a Greenfield vena caval filter is proposed.
Restrictive versus liberal blood transfusion policy for hepatectomies in cirrhotic patients
Authors: Makuuchi Masatoshi , Takayama Tadatoshi , Gunvén Peter , Kosuge Tomoo , Yamazaki Susumu , Hasegawa Hiroshi
Published: May 2005

To evaluate the worth of intra‐ and postoperative blood transfusion in cirrhotic patients undergoing resection for hepatocellular carcinoma, we compared 13 patients receiving transfusions and 14 matched contemporary patients who did not receive blood. Preoperative hematological and biochemical parameters, the type and extent of liver resection, and the mean blood loss (862 and 870 ml) were similar in the 2 groups. The total volume of intra‐ and postoperative blood transfused ranged from 400 to 1,800 ml (mean, 1,223 ml) in the patients receiving transfusions. During various postoperative time intervals, the mean values of hematocrit, hemoglobin, serum total bilirubin, and lactic dehydrogenase activity were significantly higher in the patients who were transfused compared to those who were not. Mean serum transaminase activities were similar in the 2 groups at the same times. The mean hematocrit values decreased from 36.8% preoperatively to a postoperative minimum of 27.0% in the transfused group, and from 39.9% to 26.1% in the nontransfused group. Our experience and theoretical reasons have led us to withhold blood transfusion until the hematocrit values fall below 30% during hepatectomy and below 20% in the postoperative period (or unless circulatory instability cannot be corrected otherwise). Fresh frozen plasma is preferred for volume substitution and, if blood has to be given, only up to 60–70% of estimated losses should be replaced by fresh blood.
Operative ultrasound establishes resectability of metastases by major hepatic resection
Authors: Brower S. T. , Dumitrescu O. , Rubinoff S. , McElhinney J. A. , Aufses A. H.
Published: May 2005

In this study, the utility of intraoperative ultrasound in the surgical management of hepatic colorectal metastases requiring hepatic resection has been demonstrated. The intraoperative ultrasound technique has been described as a method to accurately monitor curative resection of large colorectal metastases requiring anatomical procedures such as right hepatic trisegmentectomy, bisegmentectomy, and hepatic lobectomy. Preoperative analysis of the patients reported utilizing either computed tomography, ultrasound, or magnetic resonance imaging demonstrated very well the extent of tumor but could not define a major anatomical resection along normal tissue planes. In the 3 patients demonstrated, intraoperative ultrasound was able to confirm a normal hepatic parenchymal dissection overlying the extensive tumors and enabled completion of the curative resections. Furthermore, we have described the intraoperative ultrasound criteria for assessment of resectability. These included a definition of the proximity of the major portal and hepatic venous structures, exclusion of simultaneous minimal metastatic disease in the remaining parenchyma, and the distinction between marginal resectability and resectability for cure along the proposed parenchymal dissection plane. We conclude that intraoperative ultrasound is important in the surgical management of metastatic colorectal cancer and can provide for a more complete clinical staging and appropriate selection of patients for curative major hepatic resection.
Metabolic basis for the management of patients undergoing major surgery
Authors: Hill Graham L. , Douglas Richard G. , Schroeder David
Published: May 2005

After reviewing our current knowledge of the metabolic response to major abdominal surgery, we present two new studies in which we have followed the changes in body composition, physiologic function, and psychological function for up to 1 year after major surgery. In the first study, 46 patients had changes in body composition, physiologic function, and psychological function measured perioperatively and again at intervals up to 1 year. There was an average loss of weight of 3000 grams (maximum at 2 weeks), and the tissue composition of this weight loss was composed of 1400 grams fat, 600 grams protein, and 1000 grams water. Normal body composition had returned to normal in most patients by 6 months. In the second study of 84 patients, deficits of skeletal muscle function and fatigue were found to be greatest at postoperative day 7. Most patients were back to preoperative levels of muscle function and fatigue 30 days after surgery, and nearly all had normal values 90 days after surgery. Based on these studies we outline our management program for the metabolic care of patients undergoing major abdominal surgery.
Overview of randomized clinical trials of total parenteral nutrition for malnourished surgical patients
Authors: Buzby Gordon P.
Published: May 2005

The past decade has seen a maturation of the art and science of perioperative nutritional support. We now have sufficient data to make informed and reasonable judgments regarding when we should and should not provide perioperative TPN. These judgments can be considered medically sound and fiscally responsible. The following guidelines are proposed: (1) Postoperative TPN should be considered when oral or enteral feeding is not anticipated within 7 to 10 days in previously well‐nourished patients or within 5 to 7 days in previously malnourished or critically ill patients. (2) Preoperative TPN should be considered in patients who cannot or should not eat or receive enteral feedings if the operation must be delayed for more than 3 to 5 days. (3) Preoperative TPN should be considered in the most severely malnourished surgical candidates if an operative delay is not contraindicated. In patients with only mild to moderate degrees of malnutrition preoperative TPN is not indicated.
Prophylaxis against sepsis in patients undergoing major surgery
Authors: Morris W. T.
Published: May 2005

Postoperative infection in general surgical patients is discussed according to operation types. A selection of the huge literature on each group is reviewed, and details from the author's own work and ideas are presented. By discussing these points attempts are made to determine the best regimens for a given set of clinical circumstances. There is a small literature indicating that postoperative chest infection can be prevented by some antibacterial drug regimens, and this question has been addressed; it seems that in the past it has been largely ignored. Some nonantibacterial methods of reducing postoperative infection are also briefly discussed.
Preparation of the intensive care patient for major surgery
Authors: Wolfe Bruce M. , Moore Peter G.
Published: May 2005

Improved methods for monitoring and treating critically ill patients have increased the number of surgical candidates with multiorgan system impairment. Whereas such patients may have been considered “too sick to undergo surgery” in the past, many such patients linger in the intensive care unit unless definitive therapy is accomplished. Specific attention to review of the patient's preoperative preparation for surgery on a system‐by‐system basis may improve outcome substantially. The need for possible mechanical ventilation prior to transport to the operating room must receive particular attention. Pneumothorax, if present, must be treated prior to institution of positive‐pressure ventilation so progression to tension pneumothorax can be avoided. Deficits in the circulating blood volume must be identified and corrected preoperatively if possible. A need for enhancement of cardiac output or alteration of vascular tone requires pulmonary arterial catheterization and indicates an increased operative risk. Metabolic abnormalities such as disturbances of acid‐base balance, sodium or potassium concentration, and endocrinopathies are identified and corrected as much as possible prior to operation. Antibiotics are instituted as appropriate. Replacement of the red blood cell mass is dictated primarily by anticipated or actual blood loss. Factors of coagulation are infused on a replacement basis as necessary. Great care must be taken during transport to the operating room, as maintenance of intravascular monitoring devices, therapeutic infusions, and mechanical ventilation must continue during transport. Precautions must be taken to avoid hypothermia during transport and institution of anesthesia. Critical illness mandates specific considerations of the anesthetic agents to be utilized.
Perioperative care of the elderly patient
Authors: Ergina Patrick Lee , Gold Susan L. , Meakins Jonathan L.
Published: May 2005

Surgical risk increases with age, primarily from loss of cardiac and pulmonary reserve. Complications are tolerated poorly by the elderly, emphasizing the importance of their prediction and prevention. Surgical risk in this population is significant, but with careful preoperative assessment and perioperative management acceptable morbidity and mortality are possible. This review proposes a general approach to the elderly surgical patient and applies it to the most significant sources of morbidity and mortality: pulmonary and cardiac complications. Risk assessment based on validated tools is utilized, and perioperative management recommendations based on the state of the art are examined. In addition, pulmonary embolism and postoperative confusion are examined separately with the same overall strategy.
Perioperative care of the oncology patient
Authors: Kelly Cathal J. , Daly John M.
Published: May 2005

Cancer patients are often at high risk for perioperative complications because of preexisting conditions, the magnitude of surgery, and the use of aggressive multimodality treatment. It is essential to identify risk factors preoperatively, correct any deficits, and monitor organ dysfunction. During the perioperative period prophylaxis and surveillance for cardiopulmonary, hematologic, and septic complications should minimize morbidity and mortality. Finally, nutritional support should be given to malnourished patients undergoing extensive operative procedures.
Postoperative pain
Authors: Kehlet Henrik , Dahl Jørgen B.
Published: May 2005

Treatment of postoperative pain has not received sufficient attention by the surgical profession. Recent developments concerned with acute pain physiology and improved techniques for postoperative pain relief should result in more satisfactory treatment of postoperative pain. Such pain relief may also modify various aspects of the surgical stress response, and nociceptive blockade by regional anesthetic techniques has been demonstrated to improve various parameters of postoperative outcome. It is therefore stressed that effective control of postoperative pain, combined with a high degree of surgical expertise and use of other perioperative therapeutic interventions including nutrition and mobilization, should be combined to improve overall perioperative care and surgical outcome.
Postoperative fatigue
Authors: Christensen Tom , Kehlet Henrik
Published: May 2005

Uncomplicated major surgery is followed by a pronounced increased feeling of fatigue extending throughout the first month in about one‐third of patients. Postoperative fatigue correlates with the degree of surgical trauma but is not related to duration of general anesthesia and surgery or to preoperative nutritional status, age, or sex. Fatigue also correlates with postoperative deterioration in nutritional parameters and impaired adaptability of heart rate during exercise. Furthermore, a postoperative decrease in muscle force and endurance is related to postoperative fatigue, whereas psychological factors are of minor importance. These findings suggest postoperative fatigue to be mediated by the endocrine‐metabolic response to surgery, impaired nutritional intake, or immobilization, but the relative role of these factors remains to be established. Until then, therapeutic measures against the development of postoperative fatigue should aim at reducing the surgical stress response, effective treatment of pain to facilitate mobilization, and exercise to increase postoperative nutritional intake.
Predicting postoperative fatigue: Importance of preoperative factors
Authors: Schroeder David , Hill Graham L.
Published: May 2005

Postoperative fatigue as defined by a 10‐point scale (1=fit, 10=fatigued) was determined prospectively in 84 patients undergoing major surgery. Results from this scale correlated well with standard psychological assessment of fatigue (Profile of Mood States Questionnaire) (bir=0.767;bip<0.0001). Fatigue values were 3.46±0.19 arbitrary units (mean±SEM) preoperatively; and postoperatively they were 5.61±0.24 at day 7, 5.02±0.24 at day 14, 3.74±0.19 at day 28, and 2.77±0.18 at day 90. Fatigue during the postoperative period was integrated to give a total fatigue score (332±14 arbitrary units, range 90–664), and this score was correlated with preoperative and early postoperative factors. The best predictor of postoperative fatigue was preoperative fatigue (bir=0.545;bip=0.001), with lesser correlations with diagnosis (especially cancer); preoperative weight, particularly total body protein (bir=0.317;bip=0.01); and weight loss (bir=0.29;bip=0.03), grip strength (bir=0.352;bip=0.01), and age (bir=0.267;bip=0.01). Postoperative fatigue was not correlated with preoperative anxiety, depression, or hostility, involuntary muscle function, gender, preoperative stress, or changes in total body protein or fat over the two postoperative weeks. It is concluded that patients who present for surgery already fatigued are the ones who are most likely to suffer from prolonged postoperative fatigue, particularly so if they are elderly, suffer from cancer, or have few extra reserves of body protein.
Occupational risk to surgeons of unrecognized HIV infection in a low‐prevalence area
Authors: Evrard Serge , Meyer Pierre , van Haaften Korinne , Christmann Daniel , Marescaux Jacques
Published: May 2005

Data are available on the occupational risk to surgeons of the human immunodeficiency virus (HIV) for areas of high HIV prevalence but not for low‐risk areas and particularly for unrecognized HIV infection. The 40‐year cumulative occupational risk to surgeons caring for patients with unknown HIV serologies in a low‐prevalence area was estimated. From May 1989 to May 1991, 4119 consecutive patients with unknown HIV status, hospitalized in our department, were proposed for testing; 100% complied. Acquired immunodeficiency syndrome (AIDS) patients and known seropositive patients operated on during this period were excluded from the study. The prevalence of unknown HIV infection was 0.07%. Taking into account the rate of parenteral injuries, the rate of contamination after an infected parenteral injury, and the total number of operations performed during a 40‐year career, we estimated the cumulative risk of unknown HIV infection in our area to be 1%. This risk must be added to those of caring for known infected patients. In high‐risk areas (cumulative risk 10%), a high standard of infection control is required for every surgical procedure, even if it is expensive or of doubtful efficacy. It is unrealistic to apply this standard in a low‐risk area. HIV testing with informed consent of the patient is an imperfect guard against infection but has the advantage of alerting the surgeon to the risk of contamination on a case‐by‐case basis; it also offers the seropositive patient the best possibility for a longer life expectancy.
Appendicitis diagnosis today: Clinical and ultrasonic deductions
Authors: John Hubert , Neff Urs , Kelemen Milos
Published: May 2005

A total of 111 patients referred with a diagnosis of suspected “appendicitis” were entered into a prospective study. The surgeon and radiologist in charge of ultrasonography made separate diagnoses, and their findings were then combined and discussed as indications for surgery. Clinically, a history of pain migration proved to be reliable (p < 0.0001) as a diagnostic indicator, in contrast to nausea and initial irregularity of bowels. The duration of symptoms was significantly shorter in patients with proved appendicitis than among patients with negative findings (median 24 hours compared with 41 hours,p<0.04). Among patients with perforated appendicitis, the symptomatic history was prolonged (not significantly) by 3 hours. Peritoneal signs such as pain on percussion, rebound tenderness, guarding, and a leukocytosis of more than 13,000/mm3 were indicative of appendicitis (p=0.0001 for each sign). Lively bowel sounds excluded the possibility of appendicitis (p=0.001). Scanty bowel sounds, rectal tenderness, axillorectal temperature difference, and a left shift in leukocytes were of no diagnostic significance. The doctor's “clinical experience” is significant at the level ofp<0.03. On ultrasonography, the following signs were indicative of appendicitis: periappendicular infiltration (p=0.0003), a visible “cockade,” and an appendix larger than 12 mm in diameter (p=0.04). For 75% of the patients the surgeon was sure of his own clinical diagnosis and did not allow himself to be influenced by the sonographic findings. In 12% of doubtful cases ultrasonographic results decisively favored operation, and in 4.5% (n = 5) it prevented an unnecessary laparotomy in the presence of positive clinical symptoms. Among the patients without appendicitis (n = 56) the diagnosis could be definitely excluded by ultrasonography in 45% (n = 25); for the other patients without appendicitis ultrasonography did not provide a conclusive diagnosis. We deduce from our results that clinical examination is still the most important basis for decision making regarding the diagnosis of appendicitis but that it may be successfully supplemented by ultrasonography in doubtful cases.
Neoadjuvant chemotherapy for high‐grade advanced gastric cancer
Authors: Yonemura Yutaka , Sawa Tosiharu , Kinoshita Kazuo , Matsuki Nobuo , Fushida Sachio , Tanaka Sigehiro , Ohoyama Shigekazu , Takashima Tooru , Kimura Hironobu , Kamata Tooru , Fujimura Takashi , Sugiyama Kazuo , Shima Kouzou , Miyazaki Itsuo
Published: May 2005

Fifty‐five patients with high‐grade advanced gastric cancer in whom the presence of stage IV was confirmed by preoperative diagnostic imaging were treated with PMUE therapy by a combined use of cisplatin (CDDP) 75 mg/m2, mitomycin C (MMC) 10 mg/body, etoposide 150 mg/body, and UFT (a combination of 1‐(2‐tetrahydrofuryl)‐5‐fluorouracil and uracil in a molar ratio of 1∶4) 400 mg/day. CDDP and MMC was administered intravenously on the first day, followed by etoposide 50 mg/day on the 3rd, 4th, and 5th days. All the patients had measurable lesions that were evaluated by computed tomography scanning before and after the treatments. These patients were allocated randomly to two groups. Of these cases, 29 belonged to the neoadjuvant chemotherapy (NAC) group to whom PMUE therapy was given preoperatively; the remaining 26 patients underwent operation first and received PMUE thereafter (control group). Background factors did not differ significantly between the two groups. The response rate was higher in the NAC group than in the control group (62% in the former versus 35% in the latter). The resectability rates were 79% and 88% in the NAC and control groups, respectively. However, the rate of potentially curable cases was higher in the NAC group than in the control group (38% in the former versus 15% in the latter). Among the nonresection cases, the prognosis was highly unfavorable in both groups. In the resection cases, however, the survival rate was significantly better in the NAC group than in the control group. These results may indicate that in patients with high‐grade, advanced gastric cancer initial chemotherapy (neoadjuvant chemotherapy) and then surgery should be considered.
Adenomas and hyperplastic polyps in screening studies
Authors: Bech Karsten , Kronborg Ole , Fenger Claus
Published: May 2005

A survey is given of colorectal polyps detected in a prospective randomized screening study with the fecal occult blood test. It is demonstrated that colonoscopy in persons with positive Hemoccult‐II tests results in detection of and removal of a higher number of adenomas than among controls. The strategy may, therefore, possibly be followed by a reduction of the incidence of colorectal cancer. Screen‐detected adenomas were most often in males and were larger than among controls; they were most often in the sigmoid colon, whereas the rectum was the most frequent location for adenomas in controls. Eight percent of persons with screen‐detected adenomas had some symptoms, which could be referred to adenomas, in contrast to 50% among controls.

Hyperplastic polyps served as markers for adenomas in persons with positive Hemoccult‐II as well as in controls with adenomas detected by colonoscopy; however, most persons with adenomas had no hyperplastic polyps.

Endoscopic polypectomy did not result in any severe complications, but surgical removal in 2 of 22 patients proved fatal.

The results presented are compared with those of other prospective randomized trials. The optimistic view—that the incidence of cancer may be reduced by polypectomy in persons with positive Hemoccult‐II tests—stresses the importance of securing optimal colonoscopy service.
Endoscopic treatment of adenomas
Authors: Waye Jerome D.
Published: May 2005

The endoscopic removal of colon polyps can be safely and efficiently accomplished when established principles of colonoscopy and electrosurgery are followed. This technique requires the proper equipment, a skilled endoscopy assistant, and a well‐trained, experienced endoscopist. Complete mastery of basic colonoscopy is essential along with an understanding of the concepts of electrocautery and knowledge concerning the structural configurations of polyps.