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Management of penetrating neck injuries. The controversy surrounding zone II injuries 总被引:3,自引:0,他引:3
J A Asensio C P Valenziano R E Falcone J D Grosh 《The Surgical clinics of North America》1991,71(2):267-296
Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration. 相似文献
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To reevaluate the validity of our policy of mandatory surgical exploration of penetrating zone II neck injuries, the charts of 110 patients who underwent surgical exploration for such injuries were reviewed. Fifty-three percent of the patients had normal findings at exploration, whereas 33% had injuries involving vascular structures of the neck and 14% had nonvascular injuries. Injuries were not suspected on clinical grounds preoperatively in 23% of the patients in whom surgical exploration revealed injury. The injuries most likely to escape preoperative diagnosis were isolated venous injuries and isolated pharyngoesophageal injuries. Arteriography yielded false-negative results in two arterial injuries. No deaths and only a 5% incidence of minor complications occurred in the group with no injuries detected at exploration. We conclude that surgical exploration of penetrating zone II neck injuries is safe and appropriate. 相似文献
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Yamaguchi J Sakamoto I Fukuda T Fujioka H Komuta K Kanematsu T 《Archives of surgery (Chicago, Ill. : 1960)》2002,137(11):1294-1297
BACKGROUND: We recently reported that the pathologic mode of infiltrative growth (infiltrative [INF]-alpha, INF-beta, and INF-gamma) of colorectal liver metastases had characteristic morphologic findings, and furthermore showed that the INF type was a prognostic factor for disease-free survival after hepatic resection. HYPOTHESIS: Preoperative computed tomographic (CT) findings of the liver nodules may be predictive for pathologic tumor growth pattern. DESIGN: Retrospective study. SETTING: Departments of Surgery and Radiology at a university hospital in Japan. PATIENTS: A total of 25 CT examinations (1985-1998) were reviewed, and a comparison was conducted on CT findings of 2 groups with INF-alpha or INF-beta (hereafter noted as INF-alpha-beta) (n = 9 [ie, a patient with INF-alpha plus 8 with INF-beta]) and INF-gamma (n = 16) type liver metastases. MAIN OUTCOME MEASURES: chi(2) Analysis of CT morphologic features was performed between the study groups. The result of multivariate analysis was obtained using the Cox proportional hazards model. RESULTS: The morphologic features observed by CT showed a significant difference between the 2 groups (INF-alpha-beta, and INF-gamma types) in the ratio of length to breadth of nodules (<1.5 vs > or =1.5, P =.008) and in the outline of nodules (regular vs irregular, P =.01). Of these CT imaging features, the outline of the nodule was an independent prognostic factor (P =.02). CONCLUSION: Computed tomographic findings of colorectal liver lesions correlated with the pathologic tumor growth pattern and a prognosis. 相似文献
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Morris LG Miglietta MA Sikora AG Okun MN Roland JT 《Archives of surgery (Chicago, Ill. : 1960)》2007,142(12):1206-1208
Penetrating trauma to the face and upper zone III of the neck may present unique challenges when the parotid gland and associated neurovascular structures are involved. We report a case of massive hemorrhage from penetrating neck trauma that necessitated emergency parotidectomy for vascular exposure. Facial nerve repair was also necessary, underscoring the importance of this approach not only for successful vascular control but also for preservation of nearby vital structures. The management of penetrating trauma to the parotid region,and relevant anatomy, are discussed. 相似文献
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Inaba K Munera F McKenney M Rivas L de Moya M Bahouth H Cohn S 《The Journal of trauma》2006,61(1):144-149
BACKGROUND: The optimal management strategy for patients sustaining penetrating neck injury without an urgent indication for operative exploration remains controversial. The objective of this study was to prospectively assess multislice helical computed tomography angiography (MCTA) as a stand alone screening modality for the initial evaluation of hemodynamically stable patients with penetrating neck injuries. Our hypothesis was that MCTA is a sensitive diagnostic screening test that could noninvasively evaluate the vascular and aerodigestive structures of the neck. METHODS: After Institutional Review Board approval, all penetrating neck injuries assessed during a 16-month period were prospectively evaluated at a Level I trauma center. Patients without an indication for urgent neck exploration underwent MCTA screening. MCTA accuracy was tested against an aggregate gold standard of final diagnosis encompassing all imaging, surgical procedures and clinical follow-up obtained. RESULTS: In all, 106 injuries penetrated the platysma; 15 required urgent exploration and 91 underwent MCTA (34 gunshot wounds/57 stab wounds). Nineteen external wounds were in zone 1, 39 were in zone 2, 10 in zone 3, and 23 traversed multiple zones. MCTA was nondiagnostic in 2.2% secondary to artifact from retained missile fragments. Follow-up was achieved in 84.5% of patients for a mean of 33.3 days (range: 2-150). MCTA achieved 100% sensitivity and 93.5% specificity in detecting all vascular and aerodigestive injuries sustained. MCTA correctly identified two tracheal and two carotid artery injuries requiring operative or endovascular repair in asymptomatic patients. No injuries requiring intervention were missed by MCTA. CONCLUSION: In the initial evaluation of stable penetrating neck injuries, MCTA appears to be a sensitive and safe screening modality. Further investigation is warranted. 相似文献
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The purpose of this study was to assess the role of arteriography (AG) in the diagnosis and treatment of vascular trauma in patients with zone 3 penetrating neck injuries. The records of all cases of penetrating neck trauma for the past 14 years at a level 1 trauma center were reviewed retrospectively. Eight hundred forty-four penetrating neck injuries were documented, of which 72 (8.5%) traversed zone 3 of the neck (gunshot, 35; stab, 32; shotgun, 5). Twenty patients (27%) had hard signs of vascular injury (hemorrhage, expanding hematoma, bruit, thrill, neurologic deficit). Twelve of these (60%) underwent immediate exploration, 1 had no significant injury, and 11 had successful surgical repair or ligation of the vascular injury. AG in the other eight patients with hard signs revealed injuries requiring embolization (three patients), urokinase infusion (one patient), and observation (three patients) and one normal examination. Fifty-two patients had no hard signs of vascular injury. Twenty-four of these underwent AG, of which 18 were negative. Positive findings included internal carotid artery narrowings (two patients), external compression of the internal carotid artery (one patient), vertebral artery intimal flap (one patient), and nonbleeding injuries to small, noncritical arteries (two patients), none of which required treatment. Twenty-four of the remaining 28 patients were observed clinically, and 4 patients had negative explorations. Nine patients had ultrasonography performed, but these examinations did not yield any useful information. The absence of hard signs reliably excludes surgically significant vascular injuries in penetrating zone 3 neck trauma, suggesting that AG is not necessary. Hard signs in stable patients should mandate AG because these vascular injuries may be amenable to endovascular therapy. 相似文献
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Veljko Strajina Zahraa Al-Hilli James C. Andrews Irina Bancos Geoffrey B. Thompson David R. Farley Melanie L. Lyden Benzon M. Dy William F. Young Travis J. McKenzie 《Surgery》2018,163(4):801-806
Background
It has been suggested that accurate clinical decisions may be made in patients with primary aldosteronism (PA) in the setting of failed cannulation of an adrenal vein, thereby utilizing only data from either right or left adrenal venous sampling (AVS) alone.Methods
Retrospective analysis was performed for all patients with PA who underwent successful bilateral AVS. Adrenal vein/inferior vena cava index (AV/IVC index) was calculated by dividing aldosterone/cortisol ratio of the adrenal vein by aldosterone/cortisol ratio in the inferior vena cava, as described in a previously published study. We examined the rates of inappropriate adrenalectomy and failure to recognize unilateral disease when previously published cutoffs are used.Results
Inclusion criteria were met in 150 patients; 61 with bilateral and 89 with unilateral disease. AV/IVC index cutoff of ≤0.5 to predict contralateral disease would have not led to any inappropriate adrenalectomies and would have missed 19% of patients with unilateral disease; AV/IVC index cutoff of ≥5.5 to predict ipsilateral unilateral disease would have resulted in inappropriate adrenalectomy in 18% of patients (95% CI 8–34%, P?<?.01) and would have not recognized 55% of patients with unilateral disease (P?<?.01).Conclusion
The cortisol-corrected adrenal vein/inferior vena cava aldosterone index with a cutoff value of ≤0.5 performed well in identifying patients with contralateral unilateral disease. AV/IVC index of ≥5.5 cannot be used to reliably diagnose ipsilateral unilateral disease because 18% of patients undergoing adrenalectomy based on this cutoff would have bilateral disease. 相似文献14.
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《Current surgery》1999,56(3):165-168
PurposeTo determine how computer-based training (CBT) can be integrated into a general surgical residency education program for training and assessing decision-making skills in surgery.MethodsBecause of the emphasis on the American Board of Surgery In-training Exam (ABSITE) and Qualifying Exam preparation, traditional paper-and-pencil multiple choice quiz format testing predominates within most surgical programs. However, decision skills also require training and assessment for residents. Established methods of oral examinations for practice testing require a significant commitment of faculty time. Various CBT programs, with the necessary interactivity, are currently available for supplementing a residency’s education curriculum in the arena of decision making. Moreover, multimedia capability allows integration of new image technologies into training in decision making. One residency program is exploring new CBT systems to aid curriculum development and education in its subspecialty section curricula.ResultsThe divisions of cardiothoracic and vascular surgery have 2 concurrent and parallel CBT modules in place for service residents at the start of the 1998–1999 academic year. Both modules have flexibility that allows function as either testing or teaching modules. Either module can run when faculty are not available, requiring only a Windows-compatible computer. More important, both modules contain the requisite interactivity and branch-based decision trees that potentially model a certifying examination. The same decision branching also supports weighted scoring, allowing for emphasis and recording of certain responses. Each module also can integrate sophisticated multimedia, allowing exposure to medical imaging information. The enhanced and engaging feedback capabilities have generated high levels of resident acceptance.ConclusionsComputer-based training modules offer a promising new direction in decision-making-skill curriculum development for surgical education. It also allows integration of multimedia in creating tools for assessment and training of new image-intensive modalities in residency programs. 相似文献
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Identifying the sick: can biochemical measurements be used to aid decision making on presentation to the accident and emergency department 总被引:2,自引:0,他引:2
Hucker TR Mitchell GP Blake LD Cheek E Bewick V Grocutt M Forni LG Venn RM 《British journal of anaesthesia》2005,94(6):735-741
Background. Early and accurate identification of patients whomay benefit from aggressive optimal medical intervention isessential if improved outcomes in terms of survival are to beachieved. We studied the usefulness of routine clinical measurementsand/or markers of metabolic abnormality in the early identificationof those patients at greatest risk of deterioration on presentationto the accident and emergency department. Methods. We conducted a prospective observational study in theaccident and emergency department of a 602-bed district generalhospital. Routine clinical measurements (heart rate, systolicblood pressure, temperature, oxygen saturation in room air,level of consciousness and ventilatory frequency) and venousblood analysis for metabolic markers (pH, bicarbonate, standardbase excess, lactate, anion gap, strong ion difference, andstrong ion gap) and biochemical markers (Na+, K+, Ca+, Cl+, 相似文献
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J E McGillicuddy 《Neurosurgery Clinics of North America》1991,2(1):137-150
In the not too distant past brachial plexus injuries were considered to have a poor, almost hopeless, prognosis, and a conservative approach of waiting for any spontaneous recovery was advocated. The development of microtechniques for nerve grafting and repair combined with precise electrophysiologic testing of nerve continuity by SSEP and NAP techniques have changed this outlook completely. An aggressive approach to plexus injuries can now be advocated. This approach must be grounded in a thorough knowledge of the internal and external anatomy of the plexus and a careful analysis of each injured element. The type, location, and degree of injury to each area of the plexus are the critical factors in determining the proper course of action in these injuries. Organization of these data, derived from serial clinical and electrical examinations, provides the framework for clinical decisions in brachial plexus injuries. Classification of the many aspects of a plexus injury will simplify the decision making in what may initially seem to be a hopelessly complicated problem. 相似文献
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Evidence-based medicine (EBM) is an important advance in health care. The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S), the Royal Australasian College of Surgeons, has been at the forefront of promoting EBM in surgery by developing systematic reviews and managing surgical audits. In EBM, uptake of evidence is just as important as establishing the evidence. The prospective, long-term data collection of surgical audits on treatment processes and outcomes often have a high patient and surgeon coverage and make them extremely valuable as a tool for assessing the uptake of evidence. Surgical audits can be used: (i) to assess practice trends and the impact of systematic reviews or clinical guidelines on treatment practice, (ii) to identify the disparities in the uptake of evidence, and (iii) to promote further research on how to bridge evidence-practice gaps and to overcoming possible barriers for the evidence uptake. The information gathered through the audit data assessment on evidence-uptake can be used to improve evidence dissemination and identify possible barriers to the uptake of evidence. 相似文献
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