Penetrating trauma to the diaphragm: natural history and ultrasonographic characteristics of untreated injury in a pig model.

HYPOTHESIS: Recent use of minimally invasive techniques to evaluate the chest and abdomen in patients with penetrating thoracoabdominal trauma has led to the discovery of many occult diaphragm injuries. Surgical repair of these injuries is relatively straightforward. However, diagnosis can be difficult, and the natural history of these injuries is controversial. By developing a penetrating diaphragm injury model, the ultrasonographic characteristics and natural history of this injury can be better understood. SETTING: Surgical laboratory of a tertiary care hospital. SUBJECTS: Seven pigs (Sus scrofa), weighing between 55 and 80 kg, received a 3-cm right-sided (n = 3) or left-sided (n = 4) diaphragm injury via thoracoscopy. INTERVENTIONS: Thoracoabdominal x-ray and ultrasonographic examinations were performed preoperatively; at 2, 4, 8, and 12 weeks postoperatively; and when symptoms related to the diaphragm injury occurred. At 12 weeks, or at the time of earlier death, a postmortem thoracoabdominal examination was performed. MAIN OUTCOME MEASURES: x-Ray and ultrasonographic characteristics, and evidence of wound healing, in a penetrating diaphragm injury model. RESULTS: Perioperative recovery occurred in all pigs. No pigs had radiographic evidence of immediate postoperative herniation. Pigs in the right-sided injury group died early (

The role of laparoscopy in the management of suspected recurrent pediatric hernias.

BACKGROUND: This report examines recurrent pediatric groin hernias and the role of diagnostic laparoscopy in the management of these recurrences. METHODS: A chart review of 19 children presenting with recurrent hernias was performed, analyzing the type of primary hernia, nature of recurrence, preexisting medical conditions, surgical complications at primary repair, and time to recurrence. Diagnostic laparoscopy (DL) was used during the remedial repair of the last nine patients. RESULTS: Seventeen indirect hernias were repaired during the primary repair, and 1 femoral hernia was identified. In one child, no inguinal hernia was identified at the initial operation. Overall, 11 recurrences were found to consist of indirect sacs, and 4 were found to have attenuation of the inguinal floor. Four additional recurrences were found to be femoral hernias. In only 1 patient was a wound factor (infection) thought to play a role in the recurrence. Diagnostic laparoscopy in 9 patients found 4 (44%) to have unsuspected intraoperative findings. Four femoral hernias were identified (3 with unsuspected contralateral femoral hernias). Additionally, 1 unsuspected recurrence of an indirect sac was identified. CONCLUSIONS: Laparoscopy accurately identifies the nature of the defect in children with recurrent groin hernias, detecting unsuspected contralateral indirect, direct, or femoral hernias in 44% of those undergoing laparoscopy.

Isolated transient loss of consciousness is an indicator of significant injury.

OBJECTIVE: To determine if isolated transient loss of consciousness is an indicator of significant injury. SETTING: University-based level I trauma center. DESIGN AND PATIENT: Phase 1 retrospective case series of all patients with trauma admitted directly from the emergency department to the operating room or an intensive care unit who had transient loss of consciousness as their only trauma triage criterion. Phase 2 prospective case series of all trauma patients transported by emergency medical system personnel with transient loss of consciousness as their only trauma triage criterion. MAIN OUTCOME MEASURES: Emergency operation and intensive care unit admission. RESULTS: Phase 1: From January 1, 1992, to March 31, 1995, we admitted 10255 patients with trauma. Three hundred seven (3%) met the enrollment criteria and were admitted to the operating room (n = 168) or intensive care unit (n = 139). Of these, 58 (18.9%) were taken to the operating room emergently to manage life-threatening injuries: 11 (4%) had craniotomies and 47 (15%) had non-neurosurgical operations. Phase 2: From July 1 to December 31, 1996, 2770 trauma patients were transported to our facility; 135 (4.9%) met the enrollment criteria. Forty-one (30.4%) of these required admission, and 6 (4.4%) were taken emergently to the operating room from the emergency department (1 [1%] for a craniotomy, 3 [2.2%] for intra-abdominal bleeding, and 2 [1.5%] for other procedures). Two (1.5%) of the 135 patients died. CONCLUSIONS: Patients with isolated transient loss of consciousness are at significant risk of critical surgical and neurosurgical injuries. These patients should be triaged to trauma centers or hospitals with adequate imaging, surgical, and neurosurgical resources.

Autocatabolism of surface macromolecules shed by human melanoma cells.

The fate of cell surface macromolecules released by human melanoma cells in vitro was studied. Labeled surface macromolecules released by lactoperoxidase-radioiodinated melanoma cells were incubated cells. It was found that some of these macromolecules were autocatabolized to acid-soluble fragments by the cells which had released them. Degradation did not occur in the absence of cells, was almost completely inhibited at 4 degrees, and was partially suppressed by cytochalasin B (10 micrograms/ml) and by some inhibitors of energy production, i.e., iodoacetamide (10(-4) M) and a combination of 2-deoxyglucose (18 mg/ml) and 2,4-dinitrophenol (10(-4) M). Radioiodinated surface macromolecules were degraded much more rapidly than radioiodinated serum proteins. Thus, degradation required the presence of cells, was in part an active process, and was selective. These results suggest that one of the pathways for the turnover of surface macromolecules on tumor cells is shedding followed by autocatabolism of the shed material by the cells which they have released.