Surgical Management of Delayed Brachial Plexopathy After Clavicle Nonunion.

SUMMARY: Brachial plexopathy after conservative therapy or surgical treatment of clavicular fractures is an uncommon, yet serious complication that is associated with compression of the brachial plexus or the subclavian artery and vein because they traverse through the thoracic outlet. Surgical decompression of the brachial plexus is the recommended treatment if this condition is to occur. Although there are multiple reports of these cases in the literature, at present, there are no clear guidelines for their management. We are highlighting an institutional management algorithm, illustrated by a small retrospective case series, that uses a multidisciplinary approach in an effort to minimize complications associated with the management of clavicle nonunion.

Acidosis augments myogenic constriction in rat coronary arteries.

The myogenic response is a process by which blood vessels autoregulate vascular smooth muscle tone in response to changes in transmural pressure. It is characterized by vessel contraction or dilation with increased or decreased pressure, respectively. We sought to identify whether acidosis impacts the myogenic response in rat coronary resistance arteries. Ventricular septal arteries were isolated from male Sprague-Dawley rats and mounted on a pressure myograph. The myogenic response was assessed by measuring the arterial diameter at pressures of 10-120 mm Hg. The fluorescence indicators 2',7'-bis-(carboxyethyl)-5(and-6)-carboxyfluorescein and Fura-2 were utilized to measure intracellular pH (pH(i)) and intracellular free calcium concentration ([Ca(2+)](i)), respectively. A decrease in the extracellular pH (pH(o)) from 7.4 to 6.9 produced a fall in pH(i) and an increase in the myogenic response. Under nominally HCO (3) (-) /CO(2)-free conditions at a constant pH(o), blockade of the sodium-hydrogen exchanger with HOE694 also resulted in a fall in pH(i) and a similar enhancement of myogenic activity. Concentration response curves were constructed to measure the potencies of the HOE694 effects: the EC(50) was 34 microM for the pH(i) change and 19 microM for vessel constriction. Apparent [Ca(2+)](i) remained unchanged during HOE694-induced intracellular acidification. Furthermore, in the presence of HCO (3) (-) , HOE694 did not markedly affect pH(i) and vascular tone remained unaltered. Our data demonstrate that acidosis augments myogenic constriction of rat coronary arteries. These effects are due to a fall in pH(i) consequent upon the reduction in pH(o) and may reflect an increased myofilament [Ca(2+)](i) sensitivity within vascular smooth muscle cells.

Intra-abdominal complications after surgical repair of small bowel injuries: an international review.

BACKGROUND: The ideal method of repairing serious small bowel injuries remains unknown. Prior reports suggest a higher rate of enteric anastomotic-related complications (EACs) with stapled posttraumatic bowel anastomosis but did not specifically focus on the small bowel or clarify fully the actual anastomotic construction. METHODS: This was a retrospective review of patients requiring surgical repair of small bowel perforations at a Level I urban American center (Detroit Receiving Hospital [DRH]) and a Canadian provincial trauma center (Vancouver Hospital and Health Sciences Center [VHHSC]). All patients requiring a primary repair and/or resection were included. Anastomoses were hand-sewn, stapled, or combined stapling and sewing with mucosal inversion. Leaks, anastomotic fistulae, and intra-abdominal abscesses were considered specific EACs. A sample size of 53 per group was obtained to detect a 17% difference at alpha = 0.05 (one-sided) and beta = 0.2. RESULTS: Full-thickness small bowel injuries were repaired in 232 patients (DRH, 165; VHHSC, 67). Injuries were penetrating at DRH (91.5%) and blunt at VHHSC (65.7%). Anastomotic repairs in 127 patients (158 anastomotic repairs [DRH, 113; VHHSC, 55]) were 64 (40.5%) stapled, 38 (24.1%) hand-sewn, and 56 (35.4%) combined. Also, 105 patients had 349 primary closures of an injury. Overall, there were 24 EACs. After anastomosis, there were 11 intra-abdominal abscesses: 6 after stapling, 3 after being sewn, and 2 after a combined construction. There were four small bowel anastomotic fistulae: three after stapled-only anastomosis and one after hand-sewing. After enteroenterostomy, the EAC rate was 10.2% per patient, or 8.4% per anastomosis. After primary repairs, one patient had an anastomotic fistula, which closed spontaneously, and 11 had intra-abdominal abscesses, yielding an EAC rate of 10.6% per patient or 3.4% per repair. A primary repair was significantly less likely to be associated with an EAC than any anastomosis (p = 0.035). No method of anastomosis was statistically safer in relation to EACs, whether analyzed by patient, by anastomosis, or by considering primarily either the use of a linear stapler or the principle of inverting the mucosal approximation. Only damage control procedures and associated pancreaticoduodenal injuries were identified as statistically significant predictors using multiple logistic regression analysis. CONCLUSION: Anastomotic complications after enteroenterostomy or primary repair for trauma are uncommon regardless of the technique, but surgeons must be especially cautious during or after damage control. Primary repairs are desirable, but when anastomosis is unavoidable, the method of repair should reflect that with which the surgeon is the most comfortable.