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Query: UMLS:C0032285 (pneumonia)
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Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.
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PMID:Abdominal aortic aneurysm repair. 1156 37

Splenectomy is frequently required in children with various hematologic disorders. The reported advantages of laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis. This report evaluates the outcome of children undergoing LS at a single children's facility. One hundred twelve children underwent LS by the lateral approach between August 1995 and February 2001. Indications for LS were hereditary spherocytosis in 58, idiopathic thrombocytopenic purpura in 21, sickle cell disease in 19, and other conditions in 14. LS alone was completed in 89 children and LS and cholecystectomy (LSC) in 20. Three required conversion to open splenectomy. Accessory spleens were identified in 19. Complications included ileus (four), acute chest syndrome (four), bleeding (two), pneumonia (one), and diaphragm perforation (one). There was no mortality. An accessory spleen was missed in one child with recurrent anemia. Average operative time for LS was 106 minutes and for LSC 135 minutes. Operative time for LS decreased with experience but the difference was not significant. Average length of stay was 1.51 days (range 1-11) and was longer in sickle cell disease (2.47 days) versus hereditary spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude that LS is safe and effective in children with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay.
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PMID:Laparoscopic splenectomy has become the gold standard in children. 1189 57

This review describes the microbiology and management of meningitis and shunt infections caused by anaerobic bacteria in children. The predominant anaerobes recovered in meningitis are Bacteriodes spp., Bacteriodes fragilis, Fusobacterium spp., and Clostridium spp. Peptostreptococcus, Veillonella, Actinomyces, Propionibacterium acnes, and Eubacterium are less commonly isolated. The predisposing conditions for meningitis are acute or chronic middle-ear infection, sinusitis, pharyngitis, and pulmonary infections. In newborn and preterm infants the predisposing conditions are rupture of membranes, amnionitis, fetal distress, necrotizing enterocolitis, gastric perforation and subsequent ileus followed by bacteremia, aspiration pneumonitis and septicemia, infected ventriculoperitoneal or ventriculoatrial shunt, and complicating dermal sinus tract infections. Shunt infection with Propionibacterium spp. has been reported in children, especially in association with ventriculoauricular and ventriculoperitoneal shunts. Clostridium perfringens has been recovered from infants with a ventriculoperitoneal shunt. Multiple-organism meningitis was reported as a complication of ventriculoperitoneal and lumboperitoneal shunts that perforated the gastrointestinal tract. Early recognition and effective therapy are essential to recovery. Management of meningitis includes the use of antimicrobials effective against anaerobes that penetrate the blood-brain barrier. These include metronidazole, chloramphenicol, the combination of a penicillin and a beta-lactamase inhibitor, and carbapenems. The treatment of shunt infection includes antimicrobial therapy and removal of the shunt.
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PMID:Meningitis and shunt infection caused by anaerobic bacteria in children. 1189 73

We review our two-team operative technique and results of anterior retroperitoneal lumbosacral spine exposure for diskectomy, partial corpectomy, and spinal instrumentation. Seventy-two patients with lumbar spondylosis and associated symptomatic radiculopathy had this exposure between January 1, 2000 and January 1, 2002. A single disc space was isolated in 54 patients. Multilevel exposure was achieved in 18 patients. Main outcome measures included intra- and postoperative complications, blood transfusion requirements, duration of ileus, incidence of erectile/sexual dysfunction, and length of hospital stay. A single small bowel enterotomy and iliac vein laceration, both repaired primarily, were the only intraoperative complications. Perioperative blood transfusions were required in 13 patients (18%). Mean length of postoperative ileus was 3.5 days and average length of hospital stay was 5 days. Postoperative complications occurred in 7 patients (9.7%). These included erectile dysfunction (2), transient unilateral lower extremity paresis (1), acute acalculous cholecystitis (1), femoral vein thrombosis (1), pneumonia (1), and acute myocardial infarction (1). There were no genitourinary or other major vascular injuries. A two-team approach for lumbosacral spine instrumentation via anterior retroperitoneal exposure capitalizes on unique specialty-specific surgical skills. This paradigm facilitates safe lumbosacral spine surgery and major perioperative complications are rare.
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PMID:Anterior retroperitoneal lumbosacral spine exposure: operative technique and results. 1261 53

We describe the whole cohort of patients operated on laparoscopically for ventral hernias at our institution. Information on early results, complications, and long-term follow-up was collected prospectively. Of 90 operations attempted, five (5.8%) required conversion. Of the remaining 85 patients, 65 (76%) had an incisional hernia, while 20 (24%) had primary defects. Three trocars were routinely employed (Hasson and two 5-mm). The prosthetic mesh used was ePTFE inserted through the first trocar and fixed using helicoidal staplers. Patients were periodically followed in the outpatient clinic for at least 12 months postoperatively and contacted at the time of this review. Mean operative time was 101 min. We had three small bowel injuries repaired laparoscopically. Postoperative pain was limited. Bowel movements, deambulation, and discharge were prompt. We had six (7%) urinary retentions, eight (9%) seromas, three (3.5%) cases of pneumonia, two (2%) cases of postoperative vomiting, and one (1%) prolonged ileus, which resolved spontaneously on postoperative day 2. Mean postoperative stay was 4 days. One patient was readmitted after 4 weeks with incomplete obstruction, resolved conservatively. There were three recurrences (3.5%), which developed within 1 year of the operation, and a trocar-site herniation (1%). The technique appears safe and efficacious.
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PMID:Recurrences after laparoscopic ventral hernia repair: results and critical review. 1471 70

A retrospective review was done on 501 patients who had bilateral sequential one-stage total knee replacements from September 1995 to April 2000 to evaluate perioperative (inhospital) morbidity. One thousand two knee replacements were done with the patients receiving regional anesthesia, on 286 women and 215 men with an average age of 66 years. The average transfusion requirement was 2.8 units of blood per patient. There were no deaths, myocardial infarctions, or cerebrovascular accidents. The mean length of hospital stay was 7.2 days. One hundred forty-four perioperative complications were observed in 109 patients (21.8%). These complications included 27 arrhythmias (5%), one congestive heart failure (0.2%), 65 lower extremity deep venous thromboses (13%), 14 fat emboli (3%), and two pulmonary emboli (0.4%). Other major complications were pneumonia (1%), acute renal failure (0.4%), ileus (2%), and mental status changes (2%). Wound complications included two deep infections (0.4%), three hematomas (0.6%), and five delayed wound healings (0.9%). According to the current study the perioperative morbidity and mortality is acceptable if the procedure is used for selected patients. Patients with significant comorbidities should have a staged bilateral total knee replacement.
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PMID:Perioperative morbidity in bilateral one-stage total knee replacements. 1512 41

Laparoscopic appendectomy (LA) is safe and effective in cases of peritonitis, perforation, and abscess. We investigated our conversion rate and clinical outcomes in this patient population, as well as preoperative factors that predict operative conversion. A retrospective nonrandomized cohort of 92 patients underwent LA for acute appendicitis with peritonitis, perforation, or abscess at our institution between 1997 and 2002. Thirty-six of the 92 were converted to open appendectomy (OA), yielding a conversion rate of 39 per cent. The presence of phlegmon (42%), nonvisualized appendix (44%), technical failures (8%), and bleeding (6%) were reasons for conversion. Preoperative data had no predictive value for conversion. CT scan findings of free fluid, phlegmon, and abscess did not correlate with findings at the time of surgery. Total complication rates were 8.9 per cent in the LA group as compared to 50 per cent in the converted cohort. Postoperative data showed LA patients stayed 3.2 days versus 6.9 days for converted patients (P = 0.01). LA patients had less pneumonia (P = 0.02), intra-abdominal abscess (P = 0.01), ileus (P = 0.01), and readmissions (P = 0.01). LA is safe and effective in patients with appendicitis with peritonitis, perforation, and abscess, resulting in shorter hospital stays and less complication.
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PMID:Efficacy of laparoscopic appendectomy in appendicitis with peritonitis. 1575 49

Living donor liver transplantation evolved in response to donor shortage. Current guidelines recommend potential living donors (LD) have a body mass index (BMI) <30. With the current obesity epidemic, locating nonobese LD is difficult. From September 1999 to August 2003, 68 LD with normal liver function test (LFTs) and without significant comorbidities underwent donor hepatectomy at our center. Post-operative complications were collected, including wound infection, pneumonia, hernia, fever, ileus, biliary leak, biliary stricture, thrombosis, bleeding, hepatic dysfunction, thrombocytopenia, deep venous thrombosis, pulmonary embolism, difficult to control pain, depression and anxiety. Complication rates for LD with BMI >30 (n = 16) and BMI <30 (n = 52) were compared. The incidence of wound infection increased with BMI, 4% for nonobese and 25% for obese LD (p = 0.024). There were no statistically significant differences for all other complications. No LD died. Recipient survival was 100% with obese LD and 80% with nonobese LD (p = 0.1). Select donors with a BMI >30 may undergo donor hepatectomy with acceptable morbidity and excellent recipient results. Updating current guidelines to include select LD with BMI >30 has the potential to safely increase the donor pool.
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PMID:Select utilization of obese donors in living donor liver transplantation: implications for the donor pool. 1630 13

To overcome the barrier of size match, right lobe graft has been widely used in living donor liver transplantation (LDLT). We assessed donor outcome, with a focus on remnant liver volume (RLV) after right hepatectomy based on the experiences of 2 LDLT centers, as a means of guiding the establishment of safe RLV limits for donor right hepatectomy. Between January 2002 and December 2003, a consecutive 146 liver donors who underwent right hepatectomy with at least 12 months of follow-up were enrolled in this study. Donors were grouped into 2 groups according to RLV: group 1 (n = 74), <35% (range, 26.9-34.9) and group 2 (n = 72), > or = 35% (35.0-46.8). No donors died or suffered a life-threatening complication. Mean peak serum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (IU/L) levels were 219.5 +/- 79.9 and 231.5 +/- 83.3 in group 1 and 210.3 +/- 81.6 and 225.8 +/- 93.0 in group 2 (P = 0.497 and 0.699), respectively. Mean peak serum total bilirubin (TB) (mg/dL) level in group 1 (3.4 +/- 1.6) was higher than in group 2 (2.8 +/- 1.4; P = 0.023). Overall 23 (15.8%) major morbidities, 10 in group 1 (13.5%) and 13 in group 2 (18.1%), occurred according to Clavien's system (P = 0.939). These included bleeding (n = 3 in group 1 and n = 6 in group 2; P = 0.282), ileus (n = 3 and 1; P = 0.324), biliary leakage (n = 4 and 4; P = 0.968), and pneumonia (n = 0 and 2; P = 0.149). Minor morbidities were also comparable in the 2 groups. In conclusion, the outcome of donors with an RLV of <35% was not different from that of donors with an RLV of > or = 35%, with the exception of transient cholestasis. Therefore, a remnant RLV of <35% does not appear to be a contraindication for right liver procurement in living donors.
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PMID:Outcome of donors with a remnant liver volume of less than 35% after right hepatectomy. 1644 1

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.
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PMID:Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity. 1705 44


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