Major mediastinal injury from crossbow bolt.

We treated a 26-year-old male who sustained a self-inflicted injury to the mediastinum with a crossbow bolt. Injuries involved penetration of the sternum 1 cm below the sternomanubrial joint, right lung, pericardium, ascending aorta, right pulmonary artery, esophagus, and azygos vein. He was treated successfully with cardiopulmonary bypass and hypothermia. Exposure was achieved with a combination of a sternotomy and right thoracotomy.

Cardiac assessment with thallium scanning prior to aortic aneurysm repair.

Coronary artery disease occurs commonly in patients with aortic aneurysms and is a major cause of morbidity and mortality. The role of screening and intervention for cardiac disease prior to aneurysm repair is controversial. The outcome after cardiac screening with thallium scanning and/or angiography in 102 consecutive patients undergoing aortic aneurysm repair was documented. Significant coronary artery disease was found in 34 (33%) patients and two patients had either coronary artery bypass or angioplasty prior to aneurysm repair. There was no cardiac mortality after aneurysm repair and the overall mortality on an intention-to-treat basis was 2%. There was good correlation between prior history of cardiac events, electrocardiography (ECG) and the results of screening with thallium scanning and angiography. There was no correlation between cardiac history, ECG and the incidence of cardiac events in the postoperative period. Significant coronary artery disease was found in 33% of patients without a cardiac history or abnormal ECG. Cardiac screening with thallium scanning confirmed a high incidence of significant coronary disease in patients with aortic aneurysm. In this study, cardiac intervention followed by expedient aneurysm repair in 20 patients was associated with zero mortality. The short-term benefit of such a policy is difficult to prove and its main advantage may be better long-term survival.

Impact of femoro-distal bypass on major lower limb amputation rate.

BACKGROUND: Limb salvage is one of the cardinal aims of vascular surgery, but the influence of distal bypasses on amputation rates has been difficult to demonstrate. METHODS: The incidence and indications for major limb amputations and infrapopliteal bypass during two consecutive 16-month periods were analysed. RESULTS: There was a decrease in the number of major amputations from 34 during the first period to 13 in the second, while the number of bypasses to the infrapopliteal arteries increased from four in the first period to 21 in the second. CONCLUSIONS: An increase in the incidence of bypasses to the infrapopliteal arteries was matched by a decrease in the number of major amputations. Factors that may have contributed to the increase in the incidence of distal bypass and the decrease in the number of amputations include the availability of digital subtraction angiography, and a change in referral patterns within the hospital so that, except for trauma, all patients who were considered to be candidates for major amputation were assessed by a vascular surgeon.

Injuries to the bile duct resulting from laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has now become the treatment of choice for symptomatic gall stones. There does, however, appear to be an increased incidence of bile duct injuries. In this article, experience with eight patients who sustained a bile duct injury and were referred to the Hepatobiliary Service at Westmead Hospital, between 1990 and 1992, is reported.

Laparoscopic rectopexy.

A 74-year-old female suffering from recurrent rectal prolapse underwent laparoscopic rectopexy. A modified sling rectopexy was performed with excellent results. The authors believe that this is the first report of this technique.

Prevention of prosthetic vascular graft infection by rifampicin impregnation of a protein-sealed Dacron graft in combination with parenteral cephalosporin.

Antibiotic-impregnated prosthetic vascular grafts have been shown to be highly resistant to bacterial contamination in animal models. The aim of this study was to assess if graft infection in an animal model challenged with local bacterial contamination could be reduced further by the use of rifampicin soaking of a protein-sealed Dacron graft in addition to the prophylaxis provided by perioperative intravenous cephalosporin. Of 20 Merino sheep given cefoxitin intravenously before the induction of anaesthesia, ten had a rifampicin treated Dacron graft implanted into the common carotid artery (group 1), and ten received an untreated Dacron graft (group 2). Before wound closure the grafts were inoculated with 1 ml of 10(8) colony forming units per ml of Staphylococcus aureus. After three weeks the grafts were removed and cultured. Group 1 sheep had fewer graft infections (two of 10) compared to group 2 (six of eight survivors), this difference being statistically significant (p = 0.03; Fisher exact test). It is concluded that rifampicin treatment of protein-sealed Dacron grafts combined with intravenous cefoxitin provides more protection from contaminating Staphylococcus aureus than intravenous cefoxitin alone in this animal model.

The incidence of recurrent carotid stenosis after carotid endarterectomy and its relationship to neurological events.

We have studied the incidence of postoperative recurrent stenosis and occlusion in 286 patients, following 320 carotid endarterectomies, all of whom were commenced on low dose aspirin postoperatively. Two hundred and thirty patients (242 procedures) were examined clinically and by duplex scanning on at least two occasions at a minimum of six months apart. The crude incidence of significant recurrent carotid disease was 9.1% (22 out of 242). Seven of 22 vessels had recurrent disease detected within 24 months of operation, representing a crude incidence of 2.9% and a cumulative incidence of 4.2% at two years. The remainder developed recurrent disease after this time. Multivariate analysis of risk factors for recurrent carotid disease following carotid endarterectomy showed that a history of hypertension was significant (p = 0.001). The incidence of ipsilateral neurological events was 7.4% and was related to the presence of recurrent carotid disease (p less than 0.001).

Laser angioplasty for superficial femoral and proximal popliteal artery occlusion.

A prospective study of percutaneous laser assisted thermal angioplasty for superficial femoral and proximal popliteal artery occlusions was performed on 93 consecutive patients with a mean length of occluded segment of 7.6 cm. Technical success was achieved in 78 patients (84%). Subsequent patency or occlusion has been confirmed by duplex ultrasound scanning or arteriography. The crude patency rate for successfully recanalised vessels was 48% during a mean follow-up period of 18 months. Subsequent femoropopliteal bypass or amputation was required in 20% of these patients. Factors predictive of reocclusion were a length of occluded segment greater than 8 cm (p = 0.05) and less than two patent vessels below the knee (p = 0.005).

Wound infiltration with 0.25% bupivacaine not effective for postoperative analgesia after cholecystectomy.

The instillation of local anaesthetic agents into surgical wounds has been reported to be an effective method of reducing pain and narcotic requirements, using both local injection and topical application techniques. We performed a double-blind trial to test the value of the long-acting local anaesthetic, bupivacaine, in this role. Eighty patients undergoing elective cholecystectomy were entered into the study. They were divided into 2 groups of 40 patients to compare a local injection technique with a topical application technique. For each route of application, 20 patients received a test solution containing 0.25% plain bupivacaine, and 20 received 0.9% NaCl as a control. Postoperative analgesia in the form of intramuscular pethidine (1-1.5 mg/kg) was made available to all patients on request. The degree of postoperative pain was assessed using three criteria: the time from operation to the first request for analgesia, the total dose of postoperative pethidine required during the first 3 postoperative days and the patient's rating of pain on a 10 cm linear analogue scale at 24 h and 72 h. There was no statistically significant difference between the degree of postoperative pain experienced by patients receiving bupivacaine and those receiving NaCl, when assessed by any criterion. There was also no significant difference found between patients receiving bupivacaine by local infiltration and those receiving the drug topically. It is concluded that the local application of bupivacaine to the wound is not an effective analgesic technique following laparotomy for cholecystectomy.

Rifampicin impregnation of a protein-sealed Dacron graft: an infection-resistant prosthetic vascular graft.

A gelatin-sealed knitted Dacron vascular graft was prepared by passive impregnation with rifampicin and implanted in the common carotid artery of 10 merino sheep. Another 10 merino sheep had an untreated graft inserted. The graft was topically inoculated with 1 mL of 10(8) colony forming units per mL of Staphylococcus aureus before wound closure. The grafts were harvested at 3 weeks and cultured. All untreated grafts and surrounding tissues became infected. One of the 10 grafts treated with rifampicin became infected (P = 0.0002) and 4 sheep with rifampicin-treated grafts had surrounding tissue infection. No bacteria cultured from the rifampicin-treated sheep developed resistance to rifampicin.

Gallstone formation after major abdominal surgery.

84 patients underwent multiple abdominal ultrasound examinations over a median of 36 months (range 6-140). 11 had gallstones at their first ultrasound examination, and were excluded from further analysis. Of the remaining 73 patients, 12 of 47 who underwent major abdominal surgery had gallstones within 14-36 months of operation, compared with 0 of 26 who did not undergo such surgery. The cumulative prevalence of new gallstones within 3 years of major surgery was 28%; no new gallstones were seen from 36 to up to 140 months postoperatively. By univariate and logistic regression analysis, age and major abdominal surgery were the only significant clinical determinants for the appearance of gallstones during follow-up. The findings of this retrospective study indicate that major abdominal surgery may accelerate the development of gallstones in some patients. If confirmed in a prospective study, it may be possible to define groups at high risk of gallstones after surgery and to institute prophylactic measures.