Daniel Cuadrado

A comparison of open versus closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery.

BACKGROUND Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. PURPOSE The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. METHODS From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. RESULTS Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. CONCLUSION Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

Care of the Postoperative Pulmonary Resection Patient

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.

Thoracic Trauma: a Combat and Military Perspective

Purpose of ReviewThis article reviews the finer points of thoracic trauma seen during combat and provides parallels to the civilian sector for potential implementation.Recent FindingsLessons learned during recent conflicts in Iraq (Operation Iraqi Freedom), Afghanistan (Operation Enduring Freedom) as well as the ongoing military actions targeting the Islamic State (ISIS) have equipped combat surgeons with a breadth of knowledge concerning the management of complex thoracic trauma. The unique environment provided by war inherently fosters the development of innovation. Management of combat injuries has become more crucial to all trauma surgeons, as high-velocity weaponry and global terrorism can produce similar injury patterns in the civilian trauma setting.SummaryThis review focuses on unique injuries seen in austere war-time environments with focus on thoracic trauma. Applications to civilian trauma are highlighted throughout the article with the hope that the experience gained by combat surgeons may aide in the advancement of trauma care.

Diagnosis and Management of Penetrating Cardiac Injury

During the wars in Iraq and Afghanistan, thoracic injuries accounted for 10% of combat casualties with truncal hemorrhage reported as the main cause of preventable death in 47–67% of cases. The mechanisms for cardiac injury in the civilian trauma environment are typically from stab wound and low-velocity gunshot wounds. While these also exist in the combat environment, there is the additional threat from improvised explosive devices (IEDs) and high-velocity weapons. Recent terrorist attacks in Paris and the United States show that these injuries are possible on large scale in the civilian environment. Patients present on a spectrum from benign in appearance to lifeless, occasionally with rapid progression. Evaluation for these patients must be rapid and diligent, with immediate treatment before the development of pericardial tamponade.