Association of time-to-surgery with outcomes in clinical stage I-II pancreatic adenocarcinoma treated with upfront surgery

Background

Time-to-surgery from cancer diagnosis has increased in the United States. We aimed to determine the association between time-to-surgery and oncologic outcomes in patients with resectable pancreatic ductal adenocarcinoma undergoing upfront surgery.

Implementation of an academic half day in a vascular surgery residency program improves trainee and faculty satisfaction with surgical indications conference

Background

The Accreditation Council for Graduate Medical Education mandates scheduled didactics for residency programs but allows flexibility in implementation. Work-hour restrictions, patient care duties, and operative schedules create barriers to attendance for surgical trainees. We explored vascular surgery trainees and faculty perceptions on trainees operative preparation and participation, and overall fund of knowledge after implementing an academic half day conference (AHD) schedule.

Predicting ICU readmission among surgical ICU patients: Development and validation of a clinical nomogram

Background

Unplanned intensive care unit readmission within 72 hours is an established metric of hospital care quality. However, it is unclear what factors commonly increase the risk of intensive care unit readmission in surgical patients. The objective of this study was to evaluate predictors of readmission among a diverse sample of surgical patients and develop an accurate and clinically applicable nomogram for prospective risk prediction.

The Influence of IPPB,CPAP, and IPPB with CPAP during Cardiopulmonary Bypass on Postbypass and Postoperative Pulmonary Function

Pulmonary compliance and shunt (

_S/

_T) were employed to determine the optimal method for maintaining the lungs during cardiopulmonary bypass in 100 calves. The calves were divided into four groups with respect to pulmonary maintenance during bypass: nonventilation with the lungs collapsed (Group 1); nonventilation with the lungs exposed to 5 cm H₂O of continuous positive airway pressure (CPAP) (Group 2); intermittent positive-pressure breathing (IPPB) without CPAP (Group 3); and IPPB with 5 cm H₂O of CPAP (Group 4). All groups had similar compliance preoperatively and sustained significant decreases 30 minutes after bypass. Lung compliance returned to preoperative levels two hours postoperatively in Groups 1 and 2 but was still reduced in Groups 3 and 4. The

_S/

_T was markedly higher postoperatively in Groups 3 and 4 than in Groups 1 and 2.These data demonstrate that ventilation during bypass reduces early postoperative lung compliance and increases

_S/

_T and they suggest that static pulmonary inflation during bypass offers no advantages over allowing the lungs to remain collapsed.     

The role of biofeedback and relaxation therapy in arterial occlusive disease

Eleven patients with chronic arterial occlusive disease and intermittent claudication were treated with biofeedback-relaxation therapy in an attempt to increase walking time by improving peripheral blood flow. Criteria for admission to the study included (1) participation in an exercise program without improvement in symptoms (2) a maximal treadmill walking time (MWT) of <5 min and (3) an ankle blood pressure of <60 mm Hg immediately postexercise. Patients were randomized into two groups: Group I entered biofeedback training immediately, and Group II served as controls for 3 months prior to undergoing the same treatment protocol as Group I. Patients were taught EMG and skin temperature feedback during 30 1-h training sessions over a 13-week period. Following biofeedback therapy all patients in Group I significantly increased their MWT (P < 0.001) while patients in the control Group (II) showed minimal improvement in MWT. After undergoing biofeedback therapy, Group II also improved their MWT. At the completion of the study, 9 of 11 patients walked >8 min. The improved MWT was associated with a fall in resting (P < 0.05) and exercise (P < 0.01) arm systolic blood pressure. Both the exercise ankle blood pressure (P < 0.05) and exercise ankle/arm blood pressure ratio (P < 0.01) increased significantly following biofeedback therapy, suggesting a reduction in resistance around the site of occlusion. Our findings indicate that biofeedback training may be an effective nonoperative treatment for selected patients with arterial occlusive disease and intermittent claudication.     

Basilic elevation transposition may improve the clinical outcomes for superficialization of basilic arteriovenous fistula veins

Objective

Basilic vein arteriovenous fistulas are an important and common option for hemodialysis access and require superficialization before use. Various superficialization techniques have been employed, such as basilic tunnel transposition (BTT), basilic elevation, and basilic elevation transposition (BET). Each technique may have advantages and disadvantages, and there have been few reports directly comparing the outcomes of these techniques. This report compares the clinical outcomes of BET vs BTT performed by a single operator and discusses some technical considerations derived from this study and the literature.

Prevention of extensor lag after indicis proprius tendon transfer.

An experiment on fresh cadaver hands showed that a longitudinal incision of the hood did not affect index extension when traction was made on the common extensor tendon, but that excision of a portion of the hood containing the indicis proprius caused an extensor lag. The lag was eliminated by repair of the hood, providing that the closure was not too tight to prevent normal excursion of the hood. These findings were correlated with findings in patients who had undergone indicis proprius tendon transfer. Extensor lag after indicis proprius transfer is not caused by removal of the force of the tendon per se, but by factors which cause either disruption of normal hood function or tethering of its normal excursion.     

Acute acalculous cholecystitis: a complication of hyperalimentation.

In a 5 year period, eight patients in whom acute acalculous cholecystitis developed during intravenous hyperalimentation are reviewed with emphasis on factors contributing to pathogenesis. Gallbladder distention, biliary stasis, and bile inspissation, thought to be important in the pathogenesis of this disease, are enhanced with the use of hyperalimentation, and this potential complication is being seen with increasing frequency in seriously ill or injured patients who are being fed parenterally. In addition to hyperalimentation, sepsis, hypotension, multiple transfusions (more than 10 units), prolonged fasting, and ventilatory support were frequent common denominators. Typical findings of pain, tenderness, and a mass in the right upper abdominal quadrant are infrequent, and the diagnosis rests on a high index of suspicion and ultrasonography. This syndrome may be preventable by the stimulation of gallbladder emptying with intermittent fat ingestion or parenteral infusion of cholecystokinin.     

Feasibility of Closed-Chest Left Ventricular Bypass Using Unilateral Retrograde Transpulmonary Flow

A method for closed-chest left heart bypass using retrograde unilateral transpulmonry blood flow originating from the left atrium and retrieved by a cuffed cannula wedged in a pulmonary artery branch is described. Technical feasibility and physiological implications were tested in 12 anesthetized sheep and 4 awake calves. Retrograde transpulmonary flow showed a curvilinear relationship to the left atrial pressure, with the highest rate of rise occurring when left atrial pressure approached levels of pulmonary edema (25 to 35 mm Hg); at this point retrograde transpulmonary flow became equal to control cardiac output. The intervention and the bypass were well tolerated for short periods by these healthy animals. The possible advantages of the method are discussed, with emphasis on self-regulation of bypass flow by the filling resistance of the left ventricle.     

Ligation of the Patent Ductus Arteriosus in the Newborn Intensive Care Unit

During a two-year period, 21 premature infants (weight at birth, 680 to 2,340 gm) had operative closure of patent ductus arteriosus (PDA). The first 6 infants had ligation performed in the operating room (OR); the subsequent 15 had ligation in the Newborn Intensive Care Unit. There were no immediate postoperative deaths. Two infants died from problems present preoperatively within 30 days postoperatively. There were no infections. Technique in the unit utilizes an open warmer with local anesthesia and a paralyzing agent. By eliminating transportation to the OR one avoids problems with thermoregulation, loss of lines, malfunction of monitors, poorly controlled ventilation, and fluid overload. Additional advantages to ligation in the unit are that the infant is already monitored, intubated, and on a respirator, and that venous and usually umbilical arterial lines are in place. At the conclusion of operation, management is returned to the neonatologists for optimal continuity of care.     

Selective operative approach for variceal hemorrhage

Since 1978, the operation chosen for patients with variceal hemorrhage has been based on preoperative hemodynamic and clinical factors. One hundred sixteen consecutive patients were managed with the following operations: distal splenorenal shunt (75 patients), nonselective shunts (33 patients), and nonshunting operation (8 patients). Emergency surgery was required in 19 percent of patients. The selection criteria used resulted in the majority of high risk patients receiving nonselective shunts. This selective operative approach resulted in an overall operative mortality of 12 percent, a median survival of 3 years, and postoperative encephalopathy, ascites, and recurrent variceal hemorrhage in 20, 23, and 11 percent of patients, respectively. Operative mortality for the total group was closely related to Child's class. Whereas encephalopathy was most frequent after nonselective shunts, ascites was more common after the distal splenorenal shunt. Recurrent hemorrhage rarely occurred after a shunting procedure, but was a frequent complication of nonshunting operations. Neither the type of procedure selected nor the cause of liver disease influenced long-term survival.