The Journal of surgical research
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To retrospectively evaluate the diagnostic performance and clinical utility of magnetic resonance imaging (MRI) in pregnant patients suspected of having acute appendicitis, when an ultrasound study generated an inconclusive result. ⋯ MRI represents a useful diagnostic test for acute appendicitis in pregnant women, and decreases the need for an emergency operation. Its high negative predictive value makes MRI useful for ruling out appendicitis in pregnant patients who have an inconclusive ultrasound. However, the low sensitivity observed in this study suggests that MRI, like other imaging modalities, is not perfect, and may miss an acute appendicitis diagnosis. Thus, future prospective clinical study of MRI as a diagnostic test for the evaluation of women who present with acute abdominal pain and possible appendicitis during pregnancy is warranted.
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Comparative Study
Despite the increasing use of nonoperative management of firearm trauma, shotgun injuries still require aggressive operative management.
The energy dissipation between gunshot and shotgun blasts is very different. Injuries from shotgun blasts vary depending on the distance of the victim from the shooter, the choke of the shotgun, the pellet load, and the wad of the ammunition. We postulated that gunshot and shotgun blasts create different injury patterns that dictate different treatment plans. ⋯ Although the injury severity was similar, injuries from shotguns required more operations and resource utilization. Shotgun blasts can create impressive superficial injuries as well as significant deep organ damage. An aggressive operative approach to managing shotgun trauma is advantageous.
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Comparative Study
Noncitrated whole blood is optimal for evaluation of postinjury coagulopathy with point-of-care rapid thrombelastography.
Progressive postinjury coagulopathy has become the fundamental rationale for damage control surgery, and the decision to abort operative intervention must occur prior to overt laboratory confirmation of coagulopathy. Current coagulation testing is most commonly performed for monitoring anticoagulation therapy, the results are delayed, and the applicability of these tests in the trauma setting is questionable. Point-of-care (POC) rapid thrombelastography (r-TEG) provides real time analysis of thrombostatic function, which may allow for accurate, goal directed therapy. The test differs from standard thrombelastography (TEG) because the clotting process and subsequent analysis is accelerated by the addition of tissue factor to the whole blood sample, but is limited by the requirement that the analysis be performed within 4 min of blood draw to prevent clot formation. Consequently, citrated specimens have been proposed to obviate this time limitation. We hypothesized that the speed of r-TEG analysis following tissue factor addition to citrated blood might compromise accurate determinations compared with noncitrated whole blood. Additionally, we sought to compare the use of r-TEG with conventional coagulation tests in analysis of postinjury coagulopathy. ⋯ POC r-TEG is superior when performed with uncitrated versus citrated whole blood for evaluation of postinjury coagulation status. As a real time measure of total thrombostatic function, our preliminary data suggest that r-TEG may effectively guide transfusion therapy and result in reduced FFP administration compared with conventional coagulation tests.
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Very few quality indicators of care exist for surgical procedures. These may be used to both score the quality of care received, and as a method of improving the quality of care delivered (quality improvement initiatives). ⋯ This Delphi process has used the best available evidence, along with a consensus methodology employing the opinion of experts in the field, to identify 18 quality indicators for patients undergoing hepatic resection for metastatic colorectal cancer. These indicators will provide a means for benchmarking quality of care among surgeons, institutions, and health regions.
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Comparative Study
The role of laparoscopy in the management of malrotation.
Malrotation is currently treated via the Ladd's procedure. Many surgeons feel this operation should be performed using the open approach to facilitate adhesion development, thus decreasing the risk for volvulus. However, little comparative data exist on the relative merits of laparoscopy for this operation. Therefore, we have analyzed our experience with the open and laparoscopic Ladd's procedure. ⋯ A laparoscopic Ladd's procedure should be the initial approach in patients with malrotation in the absence of volvulus. We encourage a low threshold for conversion to an open approach if there is any concern about volvulus/orientation. This may decrease morbidity for patients who are found at operation to have a low risk of recurrent volvulus.