Bedside tracheostomy in the intensive care unit.

OBJECTIVE: To prove that tracheostomy performed at the bedside in the intensive care unit is a safe, cost-effective procedure. DESIGN: Retrospective review of all adult patients undergoing elective bedside tracheostomy in the intensive care unit between January 1983 and December 1988. Two hundred four patients were identified. SETTING: A private 1200-bed tertiary care center with a 120-bed critical care facility. MAIN OUTCOME MEASURES: Major and minor perioperative complications, cost savings, and comparison of risk between bedside tracheostomy and that performed in the operating room. RESULTS: There were six major complications (2.9%): one death due to tube obstruction, two bleeding episodes requiring reoperation, one tube entrapment requiring operative removal, one nonfatal respiratory arrest, and one bilateral pneumothorax; and seven minor complications (3.4%): five episodes of minor bleeding, one tube dislodgement in a tracheostomy with a well-developed tract, and one episode of mucus plugging. One late complication (tracheal stenosis) was identified. CONCLUSIONS: Bedside tracheostomy in the intensive care unit can be performed with morbidity and mortality rates comparable to operative tracheostomy. In addition, it provides a significant cost savings for the patient.

Gastrocolic fistula caused by benign gastric ulcer in the patient who has not had prior operation. Case reports and review of the literature.

Gastrocolic fistula caused by benign gastric ulcer is an intriguing condition when it occurs in the patient who has not had prior operation. Four such cases are presented here and similar past cases are reviewed. The authors recount the history of surgical thought concerning this disorder and make recommendations for the preoperative and intraoperative approach to these patients.

The resectional reoperation rate for Crohn's disease in a general community hospital.

The severity of Crohn's disease has not been objectively estimated for patients treated at community hospitals. During an 11-year period, 105 patients underwent initial intestinal resection for Crohn's disease at a large community hospital. Follow-up data were actuarially analyzed. The overall resectional reoperation rate was 4.0 per cent per year the first seven years after initial resection and 1.9 per cent per year for the next ten years. Patients with small-bowel disease had a better prognosis than did patients with ileocolic disease. Patients who were less than 30 years of age at initial resection needed a second resection more often than did older patients. The 81 patients with initial resection after 1970 have had the lowest resectional reoperation rate yet reported: 2.8 per cent per year for ten years. The resectional reoperation rate for patients with Crohn's disease treated at this community hospital compares favorably with reoperation rates reported for patients at referral centers.