Assessment of skeletal muscle viability by PET.

UNLABELLED: We investigated the use of [18F]fluoro-2-deoxyglucose (FDG) PET scanning for assessment of skeletal muscle viability in patients with peripheral vascular disease and in patients following free-flap skeletal muscle transfer for closure of open wounds. METHODS: We obtained 32 FDG-PET scans from 30 patients, either at the time of admission for peripheral vascular disease (n = 16) or between 1 and 15 days after surgery for skeletal muscle transfer (n = 16). Ratios between injured and contralateral limb FDG tracer activity uptake were correlated with clinical outcome at 1 mo to 3 yr follow-up. RESULTS: Viable muscle uptake ratios ranged from 0.47 to 7.88 (mean: 2.26 +/- 1.81; n = 26), while nonviable muscle uptake ratios ranged from 0.12 to 0.46 (mean: 0.27 +/- 0.12; n = 6; p < 0.02). After skeletal muscle transfer, two patients with viable tissue, as documented by PET, required amputation due to osteomyelitis, and one patient with peripheral vascular disease who showed viable tissue by PET required amputation 3 mo after the PET scan because of recurrent ulcers. CONCLUSION: FDG-PET scanning can determine skeletal muscle viability in patients with peripheral vascular disease and in patients following free-flap transfer.

Pneumogastrography in the diagnosis of perforated peptic ulcer.

During the 5 year period ending December 1982, 57 patients underwent operation for perforated peptic ulcer. Pneumogastrography was utilized in nine patients who were suspected of having perforation but who had equivocal physical findings and normal findings on initial roentgenographs. All patients with initial pneumoperitoneum or pneumoperitoneum after gastric insufflation were operated on within 6 hours of admission for a combined mortality rate of 9.7 percent. Patients without free air, initially equivocal examinations, and in whom pneumogastrography was omitted, experienced an average delay of 27 hours. The overall mortality rate in these patients was 28 percent. We conclude that pneumogastrography enhances the sensitivity of plain diagnostic roentgenography in confirming the diagnosis of perforated gastric or duodenal ulcer. Gastric insufflation is recommended whenever perforated peptic ulcer is considered in the differential diagnosis and initial films are inconclusive.

General surgical complications following cardiac surgery.

During the five-year period ending July 1981, 3,200 patients underwent cardiac surgery requiring cardiopulmonary bypass at the Medical College of Virginia. Twenty-five patients (0.8%) experienced general surgical complications. Gastrointestinal bleeding was the most common complication encountered. The overall mortality of 24% compares favorably with other reported series. General surgical complications following cardiac surgery are serious and may be caused by aggravation of pre-existing disease, hypoperfusion, stress, or a combination of all three. Although intensive nonoperative therapy may be effective, early reoperation is recommended when nonoperative measures fail.

The segmental rectus abdominis free flap for ankle and foot reconstruction.

The reconstruction of soft-tissue defects of the ankle and foot usually requires free-tissue transfer. Although certain local flaps have been described for the reconstruction of these injuries, their utility may be compromised by significant crush injury or the size and location of the defect. Part of the rectus abdominis muscle, the segmental rectus abdominis free flap, is ideally suited for this use because of the muscle's versatility, reliability, and negligible donor deformity when harvested through a low transverse abdominal incision. Seven patients reconstructed with this flap are presented, and the technique is discussed. All patients have been successfully reconstructed with preservation of the ankle and foot. At present, all patients are fully or partially weight-bearing. The segmental rectus abdominis free flap is recommended for the reconstruction of such wounds.

Primary Kaposi's sarcoma of an intraparotid lymph node with AIDS.

A case of Kaposi's sarcoma of an intraparotid lymph node in a patient with previously undiagnosed AIDS is presented. In patients at risk for AIDS who present with undiagnosed head and neck tumors, the diagnosis of epidemic Kaposi's sarcoma should be considered. Although transmission of AIDS to health care workers is exceedingly rare, proper precautions should be exercised when working with these patients.

Free rectus abdominis muscle flap: advantages in lower extremity reconstruction.

Major soft tissue losses of the distal portion of the leg usually require free tissue transfer for reconstruction. We have recently treated seven patients with free rectus abdominis muscle flaps. The rectus abdominis has several advantages over other muscles; these advantages simplify such reconstructions. Elevation of this muscle can be done simultaneously with recipient vessel dissection without the need for patient repositioning. The deep inferior epigastric vessels provide a reliable pedicle of one large artery and two veins of sufficient length to accomplish microvascular anastomosis outside the zone of injury without the use of vein grafts. The size and shape of the muscle conforms well to the defects of many wounds in the leg. There is no functional deficiency from the use of one muscle, and the donor site scar is relatively inconspicuous since the rectus abdominis is harvested through a midline abdominal incision. There have been two complications in this series, one intraoperative flap failure, and one case of recurrent osteomyelitis. There has been no donor site morbidity. We recommend the free rectus abdominis muscle flap for the reconstruction of many complex wounds of the distal portion of the leg.

Impact of early recognition on outcome in nonpenetrating wounds of the small bowel.

During a recent ten-year period, 20 patients were treated for nonpenetrating, small-bowel trauma requiring resection. Despite the relative infrequency of this injury, jejunoileal trauma must be suspected in all patients sustaining blunt force to the abdomen. Physical signs suggesting major intra-abdominal wounds usually occur at admission or immediately thereafter, provided the patient is alert. Patients with altered sensorium or equivocal findings should undergo diagnostic peritoneal lavage. Laboratory investigation is not helpful in detecting small-bowel wounds. Plain roentgenography is indicated, but was diagnostic in only 20% of patients in this series. The high incidence of associated injuries accounts for the substantial morbidity (70%) in this series. Early operation improves survival.

Simultaneous posterior pharyngeal flap and tonsillectomy.

Posterior pharyngeal flap (PPF) construction in patients with hypertrophied tonsils raises a significant concern for adequate airway maintenance. Most often, tonsillectomy, as a separate procedure, is done first. The authors have preferred to do both the PPF and the tonsillectomy simultaneously. Twenty consecutive cases are reviewed retrospectively to determine whether this has increased morbidity. All patients underwent posterior pharyngeal flaps for correction of velopharyngeal incompetence (VPI). Postoperative fevers that resolved without specific treatment occurred in four patients. Three patients experienced postoperative bleeding problems, but only two were of tonsillar origin. No patient developed immediate airway obstruction, although a single patient was observed overnight in the intensive care unit. Another developed sleep apnea several months after the operation, which required that the posterior pharyngeal flap be taken down. This patient had an unusual amount of hypertrophic scar in the nasopharyngeal area, but not in the oropharynx. No other operative or postoperative complications were experienced. The average hospitalization was 4.2 days. It is concluded that simultaneous tonsillectomy and PPF construction may be performed safely in patients who need both procedures.

Patterns of maxillofacial injuries in restrained and unrestrained motor vehicle crash victims.

Safety belts reduce the frequency and severity of injuries sustained in motor vehicle crashes. Since the head and face are the most frequently injured anatomic regions in motor vehicle crash victims, the use of active restraints should lessen these injuries. This study was undertaken to examine the ability of safety belts to prevent and alter the pattern of maxillofacial injuries. During a 6-month period beginning February 1, 1987, 613 motor vehicle crash victims presented alive to the Trauma Center at the University of Tennessee Medical Center at Knoxville and were entered into this study. There were 254 restrained victims (R), 290 unrestrained (UR), and 69 who were excluded for lack of sufficient data regarding restraint usage. Unrestrained victims tended to be younger (mean age: UR = 27.9, R = 31.7; p less than 0.03), and more often male (UR = 65% vs. R = 51%; p less than 0.03). Irrespective of position within the vehicle, the mean number of facial lacerations per person was less in the restrained group (R = 0.31, UR = 0.76; p less than 0.03). This injury reduction was more pronounced in front seat occupants (R = 0.27, UR = 0.82; p less than 0.03). Furthermore, a smaller proportion of the lacerations in the restrained group were categorized as complex, i.e., involving more than skin and subcutaneous tissue (R = 5.0%, UR = 15.9%; p less than 0.03). The pattern of skeletal injuries was also significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

Injury and cost comparison of restrained and unrestrained motor vehicle crash victims.

The use of active motor vehicle restraints is a topic of current public and legislative debate. To better define the effects of restraint systems on injury severity, the following study was undertaken. Parametric statistical tests were used for data analyses. For a 6-month period beginning February 1, 1987, all motor vehicle crash victims treated in the emergency unit were entered into the study (n = 613). There were 290 unrestrained subjects (UR), 254 restrained subjects (R), and 69 were excluded because restraint usage information was unobtainable. Unrestrained victims were younger (mean age, UR = 28, R = 32; p less than 0.05), and were more often male (UR = 65%, R = 51%; p less than 0.05). Hospitalization was more frequently required for unrestrained crash victims (UR = 59%, R = 26%; p less than 0.05). Length of hospital stay (LOS), including ICU confinement, was also extended (mean LOS, UR = 13, R = 10), but this difference did not reach statistical significance. Injury Severity Scores (ISS) and Abbreviated Injury Scales (AIS) were tabulated and compared. Mean ISS was significantly higher for unrestrained victims (UR = 8.28, R = 4.44; p less than 0.05), and a higher proportion of unrestrained victims had scores greater than 15 (UR = 20%, R = 7%; p less than 0.05). Mean AIS was higher in all regions, although the difference did not consistently reach statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

The tertiary trauma survey: a prospective study of missed injury.

The Advanced Trauma Life Support Course defines a primary and a secondary survey to rapidly identify life-threatening and associated injuries, respectively, in multiple trauma patients. However, circumstances during resuscitation, including multiple casualties, emergent operation, unconsciousness, etc., may interfere with this process. An initial review of our trauma registry data yielded a modest 2% incidence of missed injuries in a 90% blunt trauma population. In order to determine the true incidence of missed injuries, a tertiary survey was performed prospectively on all injured patients (N = 399) admitted during a recent 3-month period. After completion of the primary and secondary surveys (including appropriate roentgenographs), all injuries were listed in the trauma admission record. Patients were later reexamined immediately before ambulation or, in head-injured patients, upon regaining consciousness. All missed injuries were documented, including site and type of injury, reason missed, how identified, and attendant morbidity. Forty-one missed injuries were found in 36 patients (9%). These included: 21 extremity fractures, five spinal fractures, two facial fractures, five thoracic injuries, six abdominal injuries (including five splenic lacerations), and two vascular injuries. The most common reason for injuries to be missed was altered level of consciousness due to head injury or alcohol. Other reasons included severity of injury and instability requiring immediate operation, lack of symptoms at admission, technical problems, and low index of suspicion by the examiner. None of the missed injuries resulted in death. However, one missed injury caused serious disability and seven required operative correction.(ABSTRACT TRUNCATED AT 250 WORDS)