Tracheo-innominate artery erosion: Successful surgical management of a devastating complication.

Successful management of a patient with tracheo-innominate artery erosion requires the rapid institution of specific resuscitative and operative measures. Ten patients seen at the Charity Hospital of Louisiana in New Orleans and 127 documented cases from the world literature were analyzed regarding predisposing factors, diagnostic features, resuscitative measures and operative treatment. Diagnoses associated with abnormal neck positioning were seen in 48% of patients with tracheo-innominate erosions. In 69% of 96 instances, the site of erosion was located at the cannula end and implicates excessive anterior pressure. Caution is recommended in those patients with abnormal neck positions, low placed tracheostomy stomas and individuals with asthenic habitus. Resuscitative measures were highly successful when the tracheal ballon was inflated or when the method of retrosternal finger pressure was used. All personnel providing care for patients with tracheostomies should be aware of the initial measure of ballon inflation. Operative measures which permanently interrupted the innominate artery in the area of possible future erosion were the most successful. Of the 22 cases in which the innominate artery was sacrificed, only one had evidence of cerebral ischemia. Timely institution of proper measures can result in salvage of an unexpected number of these otherwise dramatic fatalities.

Acute post-traumatic coarctation of the abdominal aorta.

An unusual case of coarctation of the abdominal aorta following trauma in reported. The resultant supratenal aortic constriction was associated with severe hypertension and elevated plasma renin concentration. Gradual aortic dilation at the suture site was accompanied by remission of hypertension and return of plasma renin concentration to normal. Correlation of laboratory and hemodynamic changes resulting from this unusual case of abdominal coarctation is discussed.

A half-century of experience in the management of colon injuries: changing concepts.

A total of 773 patients who sustained colon injuries during the period 1927-1974 at Charity Hospital of Louisiana in New Orleans was reviewed. For purposes of comparison the patients were grouped into three 15-year periods. The first period (1927-1942) represented patients treated in the pre-antibiotic era exclusively with exteriorization. The second period (1943-1958) included patients in whom a program of selective surgical treatment of colon injuries was instituted, and included the advent of antibiotics and improved resuscitation. The final period (1959-1974) represented the increased use of primary repair of colon injuries. In comparing the three consecutive periods there was a marked increase (106%) in the frequency of colon injuries, primarily due to gunshot wounds in young males. The average age of our patients during this last 15-year period was 27 years. The transverse colon was the most frequent site of the injury (37%) followed by the left colon (31%) and the right colon (20%). From 60 to 75% of the patients also had associated intra-abdominal or other injuries. The mortality from colon injuries has declined steadily from 67.5% in the initial period to a low of 9.2% during the past 15 years. This drop in mortality occurred despite the fact that a larger number of patients sustained associated injuries. When comparing the three methods of therapy, primary repair, repair with proximal colostomy, and exteriorization was used less frequently during the past 15 years. It was the exclusive form of therapy in all patients treated before 1942. With the advent of selective management and antibiotics we have seen a transition from exteriorization to primary repair without colostomy. During the past 15 years primary repair was used in 44% of the patients; repair with a proximal decompressive procedure was utilized in 22%; exteriorization was carried out in 33% of the patients. The selective use of primary repair has been associated with lower mortality, fewer complications, and a shorter hospital stay, despite the increasing incidence of multiple associated injuries in this latter group of patients. Based on these studies, a plea is made for the selective use of primary repair of colon injuries of patients in good general condition when the local injury to the colon appears to warrant such an approach=

Hemodynamics of the interposition mesocaval shunt.

Eighty interposition mesocaval shunts, using a knitted Dacron large diameter prosthesis, have been performed during the past five and one-half years. Patients were evaluated from the standpoint of protection from recurrent esophageal hemorrhage, shunt patency, encephalopathy and cumulative survival analysis. In a selected group of patients, hemodynamic measurements were also obtained in the pre, intra, and postoperative periods. These included measurements of wedged hepatic vein pressure, superior mesentric venous blood flow, and residual superior mesenteric, hepatic sinusoidal and inferior vena cava pressures following the shunt procedure. Additionally, direct shunt flow measurements utilizing a square wave of electromagnetic flowmeter were also performed. Results indicate that the shunt patency is 95%; adequate decompression of the portal system was accomplished; recurrent variceal hemorrhage did not occur if the shunt remained patent; the incidence of encephalopathy was low (11%); and the operative mortality for the entire series was 9%. Continued perfusion of the liver was documented in 44% of patients and appears to be a function of the residual total portal resistance largely controlled by inferior vena caval pressure at the level of graft replacement. Life survivhat the interposition mesocaval shunt appears to be an effective technique for the control of variceal hemorrhage, has important hemodynamic advantages and can be applied to most patients for the control of variceal hemorrhage due to portal hypertension.

Cardiac contusion: a capricious syndrome.

Cardiac contusions are being recognized with frequency. Among 507 patients with non-penetrating chest injuries, 210 had serial electrocardiograms sufficient to evaluate the heart. Forty-five of these 210 patients (21%) had cardiac contusions. These 45 patients and 3 others who were confirmed to have cardiac contusions at necropsy, comprise the 48 patients in this series. Life-indangering cardiac complications occurred in 14 (29%) of the 48 patients, and 4 patients died. The development of cardiac complications following cardiac contusions appears to have a significant relationship to the presence of shock, hypoxia and to factors related to the severity of multiple injuries. These observations have therapeutic implications in management of patients with cardiac contusions through prevention of hypovolemia and hypoxia and avoidance of fluid overload as well as treatment of specific cardiac complications.