Operative and Perioperative Pulmonary Emboli.

Intraoperative and perioperative massive pulmonary emboli remain an unusual but well-established cause of death. Improved outcomes rely on a high index of suspicion, prompt recognition, and aggressive intervention. Surgical embolectomy outcomes have improved drastically since its inception as a technique at the turn of the previous century and should be used without hesitation during an intraoperative crisis in which pulmonary embolism has been determined to be the cause. There is an emerging trend toward a more aggressive approach.

The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds.

BACKGROUND: To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW). METHODS: Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes). RESULTS: Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%). CONCLUSIONS: We find no role for DL in the evaluation of ASW patients solely to determine PV.

Routine follow-up imaging is unnecessary in the management of blunt hepatic injury.

BACKGROUND: Nonoperative management of hemodynamically stable patients with blunt hepatic injuries has become the standard of care over the past decade. However, controversy regarding the role of in-hospital follow-up computed tomographic (CT) scans as a part of this nonoperative management scheme is ongoing. Although many institutions, including our own, have advocated routine in-hospital follow-up scans, others have suggested a more selective policy. Over time, we have perceived a low yield from follow-up studies. The hypothesis for this study is that routine follow-up imaging of asymptomatic patients is unnecessary. METHODS: All patients selected for nonoperative management of blunt hepatic injury were evaluated for utility of follow-up CT scans over a 4-year period. RESULTS: There were 530 stable patients with hepatic injury on admission CT scans in which follow-up scans were obtained within a week of admission. All injuries were classified according to the revised American Association for the Surgery of Trauma Organ Injury Scale: 102 (19.2%) grade I, 181 (34.1%) grade II, 158 (29.8%) grade III, 74 (13.9%) grade IV, and 15 (2.8%) grade V. Follow-up scans showed that most injuries were either unchanged (51%) or improved (34.7%). Only three patients underwent intervention based on their follow-up scans: two patients had arteriography (one with therapeutic embolization) and one had percutaneous drainage. Each of those patients had clinical signs or symptoms that were indicative of ongoing hepatic abnormality. CONCLUSION: These data demonstrate that, regardless of injury grade, routine in-hospital follow-up scans are not indicated as part of the nonoperative management of blunt liver injuries. Follow-up scans are indicated for patients who develop signs or symptoms suggestive of hepatic abnormality.