Computed tomography in blunt abdominal trauma.

Emergency abdominal computed tomography (CT) has been performed in more than 200 cases of acute blunt abdominal trauma. Computed tomography was highly sensitive and specific for a wide variety of intraperitoneal and retroperitoneal traumatic lesions. There were no false-positive or false-negative CT interpretations, except for a single case in which residual peritoneal lavage fluid was mistaken for intraperitoneal blood. Computed tomobraphy has major advantages over otherradiologic techniques, including angiography, and may obviate peritoneal lavage and explo4atory laparatomy in some circumstances.

Effect of donor-disseminated intravascular coagulation in liver transplantation.

It is not known whether disseminated intravascular coagulation, present in a large percentage of organ donors, affects patient outcome after liver transplantation. We reviewed our first 55 liver transplantations and identified 10 donors with disseminated intravascular coagulation. We compared the perioperative courses of the 10 recipients of these transplanted livers with those of 10 matched controls whose donors did not have disseminated intravascular coagulation. Disseminated intravascular coagulation recipients did not require more blood products during or after surgery; their hepatic enzyme levels and prothrombin times after surgery were not statistically significantly higher than those of the controls. There was no difference in hospital stay, number of episodes of rejection, retransplantations, or deaths. The presence of disseminated intravascular coagulation in donors did not adversely affect graft function or patient outcome and should not be a sole criterion for rejecting a liver for transplantation.

Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure.

OBJECTIVE: To determine whether prevention of the abdominal compartment syndrome after celiotomy for trauma justifies the use of absorbable mesh prosthesis closure in severely injured patients. DESIGN: Retrospective analysis of case series from July 1, 1989, to July 31, 1996. SETTING: University-based level I trauma center. PATIENTS: Seventy-three consecutive trauma patients requiring celiotomy who received absorbable mesh prosthesis closure and 73 control patients matched for injury severity and trauma type who received celiotomy without a mesh prosthesis closure. INTERVENTIONS: Absorbable mesh prosthesis closure was used in cases of excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic defect, or planned reoperation. MAIN OUTCOME MEASURES: Demographics, Injury Severity Score, Abdominal Trauma Index, highest abdominal Abbreviated Injury Scale score, number of abdominal/pelvic injuries, highest head Abbreviated Injury Scale score, shock, indication for mesh closure, complications, number of operations and time required for closure, days in the intensive care unit, length of stay, and mortality were determined. The highest abdominal Abbreviated Injury Scale score was multiplied by the number of abdominal/pelvic injuries to calculate the abdominal pelvic trauma score. RESULTS: Group 1 consisted of 47 patients who received mesh at initial celiotomy, and group 2, 26 patients who received mesh at a subsequent celiotomy. These 2 groups were statistically similar in demographics, injury severity, and mortality. However, group 2 had a significantly higher incidence of postoperative abdominal compartment syndrome (35% vs 0%), necrotizing fasciitis (39% vs 0%), intra-abdominal abscess/peritonitis (35% vs 4%), and enterocutaneous fistula (23% vs 11%) compared with group 1 (P < .001). Group 1 patients with preoperative abdominal compartment syndrome had more abdominal/ pelvic injuries and higher abdominal trauma index than matched controls (P < .05). There was a trend toward higher abdominal pelvic trauma score in patients who developed abdominal compartment syndrome. The Pearson coefficient of correlation between the abdominal trauma index and the more easily calculated abdominal pelvic trauma score was 0.91 (P < .001). CONCLUSION: The use of absorbable mesh prosthesis closure in severely injured patients undergoing celiotomy was effective in treating and preventing the abdominal compartment syndrome.

Selective nonoperative management of blunt liver injury using computed tomography.

Computed tomographic (CT) scans are used to evaluate victims of blunt trauma for abdominal injury when reasons for immediate laparotomy are not present. Twenty-four patients whose CT scans showed liver injuries that were small parenchymal lacerations or intrahepatic hematomas were managed without laparotomy. Intra-abdominal blood was absent or estimated to be less than 250 mL in volume. None of the patients were in shock; six patients required transfusions, none for acute abdominal bleeding. None of these patients subsequently required laparotomy or showed hepatobiliary problems at a follow-up examination less than one year later. Five follow-up scans showed varying degrees of resolution. Two patients died of severe head injury, but the liver injury did not contribute to the cause of death. Other patients with more severe blunt liver injury who were treated nonoperatively developed significant complications that required delayed surgery. It seems that patients with limited liver injury diagnosed by CT scan and selected by strictly applied criteria can be managed safely without laparotomy in a setting where rapid evaluation and treatment of any potential complication is available.

The utility of polyglycolic acid mesh for abdominal access in patients with necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis is a poorly understood process that has been treated by a variety of surgical approaches. Despite advances in operative interventions and critical care, this disease often requires prolonged resource allocation and continues to cause substantial morbidity, with mortality rates ranging from 11% to 40%. We report on our recent series of patients with necrotizing pancreatitis and our experience with the use of an absorbable mesh in a subset of these patients to facilitate their surgical care. STUDY DESIGN: From 1985 to 1994, 40 patients with culture-proved necrotizing pancreatitis underwent operative debridement and drainage. Surgical outcomes were compared among patients who underwent a single debridement and drainage, those requiring multiple procedures, and those having placement of polyglycolic acid mesh. RESULTS: The overall hospital mortality rate was 30%. The mean length of hospital stay was 35 days. The rate of infected pancreatic necrosis was 60%, with a mortality rate of 45% in patients having infected pancreatic tissue at surgery. Patients without infected pancreatic tissue at surgery had a mortality rate of 6% (p = 0.03). Eleven patients requiring multiple operations had placement of absorbable polyglycolic acid mesh. Clinic followup was possible in five of six survivors who underwent mesh closure. Abdominal-wall hernias developed in two patients and were repaired electively, and three patients had spontaneous closure by granulation without abdominal-wall hernias. The average number of operations for debridement and drainage was 2.5 (range, 1-15). Patients with limited pancreatic necrosis required a single operative debridement and drainage, and this was associated with improved outcomes. CONCLUSIONS: Necrotizing pancreatitis remains an important challenge in surgical care. It requires prolonged hospitalization, costly resources, and causes substantial morbidity and mortality. Our patients with infected pancreatic necrosis or clinical deterioration underwent open staged necrosectomy and debridement. Those patients requiring repeat laparotomy often had placement of polyglycolic acid mesh. This provided open drainage of the abdominal cavity and simplified further care by allowing easy abdominal access for repeat drainage procedures, often performed in the intensive care unit. These patients had a high rate of fistula formation, which may be decreased by changes in wound care. Polyglycolic acid mesh is a useful adjunct in the surgical care of selected patients with necrotizing pancreatitis.

Long-term outcome of completion gastrectomy for nonmalignant disease.

Between 1989 and 1995 we performed completion gastrectomy for non-malignant disease in 21 patients (11 men and 10 women, mean age 48.4 years). These patients had undergone a total of 48 prior gastric operations. Indications for completion gastrectomy in this group were anastomotic ulceration with stricture in eight patients, alkaline reflux gastritis and/or esophagitis in eight, postsurgical gastroparesis in two, gastroesophageal necrosis in two, and gastrocutaneous fistula in one. Major preoperative symptoms included nausea and vomiting in 16 cases, abdominal pain in 15, dysphagia in 14, heartburn in seven, and weight loss in five. Following completion gastrectomy, five patients (24%) had serious complications and there was one postoperative death (5%). Five patients were lost to follow-up. For the remaining 15 patients, mean follow-up has been 30 months with a range of 1 to 70 months. These patients were all interviewed and eight (53%) report significant improvement, two (13%) report moderate improvement, and four (27%) report no improvement; one patient (7%) has had worsening of symptoms since undergoing completion gastrectomy. The average body weight index was essentially unchanged after completion gastrectomy. We conclude that completion gastrectomy with Roux-en-Y esophagojejunostomy results in a favorable outcome in the majority of selected patients with diseases of the foregut who are unresponsive to less radical treatment.

Acute and chronic pancreatic pseudocysts are different.

Our experience supports the concept that acute and chronic pancreatic pseudocysts differ and require different plans of management. Patients who present with a chronic pseudocyst should be scheduled for operation promptly; internal drainage is almost always possible, spontaneous resolution is extremely rare, and delay only runs the risk of complications. Patients who are found to have an acute pseudocyst that develops during an attack of acute pancreatitis should be managed expectantly for 4 to 6 weeks; in them, spontaneous resolution may occur and surgical therapy is more satisfactory if the pseudocyst wall is allowed to mature enough that internal drainage is possible.

Management of variceal hemorrhage in the potential liver transplant candidate.

The increased utilization of liver transplantation raises new issues regarding the management of bleeding esophageal varices in patients who are or may become transplant candidates. Since December 1982, 53 patients were referred from a university hospital to distant liver transplant centers for transplantation. Transplants were performed in 37 patients; at last follow-up, 6 died before transplantation, 7 were awaiting transplantation, and 3 were declined. Of the 53 patients referred for transplantation, 22 (42 percent) had a history of variceal hemorrhage. Sclerotherapy was required in nine patients and portosystemic shunt in four patients. Variceal hemorrhage contributed to the deaths of three of the six patients who died before transplantation could be performed. Endoscopic sclerotherapy has become the mainstay of invasive therapy in most patients with bleeding esophageal varices. If sclerotherapy is unsuccessful in the arrest or control of variceal hemorrhage, the decision must be made whether to proceed with urgent liver transplantation or portosystemic shunt. Factors which influence this choice include the ability to stabilize an acutely bleeding patient, the hepatic reserve and general clinical stature of a patient, and the availability of a liver transplant center.

Oriental cholangitis.

Oriental cholangitis is a poorly understood syndrome consisting of intrahepatic pigment stone formation with chronically recurrent exacerbations and remissions. Endemic to Asia, it is being encountered more frequently in the United States due to increased immigration of asians. Twenty-one patients with oriental cholangitis (9 men and 12 women), 19 to 84 years of age, all of whom immigrated from asian countries, were treated between 1970 and 1983. All had histories of episodic abdominal pain, most with jaundice, chills, and fever. Laboratory results were nonspecific but frequently included leukocytosis and hyperbilirubinemia. All patients were operated on with 15 having cholecystectomy, common duct exploration, and a bilioenteric anastomosis. E. coli was cultured from specimens obtained from the biliary tracts of all patients, and 13 patients had more than one organism. Four patients had a previous history of parasitic infection, and four different patients had parasites identified in the biliary tract intraoperatively. Early recognition and appropriate operation will decrease morbidity and mortality.

Colorectal foreign bodies and perforation.

Although most rectal foreign bodies can be removed safely in the emergency room, some require removal in the operating room. Good results can be achieved if basic principles in the management of colorectal injuries in general are applied to colorectal perforations by foreign bodies. Although rectal foreign bodies and colorectal perforations from non-medical rectal instrumentation have been a medical curiosity for many years, especially in metropolitan general hospitals, there can be little doubt that the frequency of such problems is increasing. We expect that community hospitals, will see more of these problems in years to come, if they are not already.

Pancreatic abscess: impact of computerized tomography on early diagnosis and surgery.

Pancreatic abscess continues to be a lethal complication of acute pancreatitis, with mortality rates of 40 percent in recent surgical series. A major factor contributing to this high mortality has been delay in diagnosis. When combined with diagnostic needle aspiration, computerized tomographic scanning has greatly enhanced the early detection of pancreatic abscesses. In a 4 year period at our institutions, 21 patients with proved pancreatic abscesses were evaluated early in their clinical course by computerized tomography. On follow-up ranging from 7 months to 3 1/2 years, there were only four deaths for a mortality rate of 19 percent. Many of the surviving patients had a long and protracted clinical course (mean length of hospitalization was 56 days) and reoperation for recurrent abscess or gastrointestinal complications was required in eight patients (38 percent). Computerized tomography proved to be of considerable value in localizing the site of de novo or recurrent pancreatic abscess and in detecting postoperative complications. An aggressive approach encompassing early computerized tomographic scanning with diagnostic needle aspiration appears to be a factor in the improved survival rate of these patients.

Abdominal trauma.

Abdominal trauma continues to be the major cause of morbidity and mortality in this country. Unnecessary deaths and complications can be minimized by improved resuscitation, evaluation, and treatment. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of unneeded surgery is an important goal of evaluation. However, most avoidable deaths result from failure to resuscitate and operate on surgically correctable injuries. When the diagnosis is in doubt and clinical judgment suggests surgery, exploration provides definitive treatment as well as diagnosis; moreover, the risks of negative exploration have become acceptable. The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however, still depend on experience and clinical judgment for application and determination of the best care for the injured patient.

Dose effects of raw soybean flour on pancreatic growth.

Raw soya flour (RSF) feeding to rats produces pancreatic hypertrophy and hyperplasia, and, if sufficiently prolonged, the spontaneous development of pancreatic neoplasms and the potentiation of pancreatic carcinogens. With continuous exposure to RSF the threshold dose for pancreatic growth is approximately 20% RSF, but the threshold for the other effects has not been defined. If 100% RSF is fed for less than 24 weeks continuously the effects on the pancreas are completely reversible, but feeding for longer than this leads to irreversible progression to pancreatic adenoma and carcinoma over the next 50-70 weeks. Repeated alternation of the diet between 100% RSF and rat chow for prolonged periods leads to effects on the pancreas at least as marked as those seen with continuous RSF feeding. This occurs with RSF feeding for periods as short as 2 days out of 7. The effects seen in the rat must be applied to human nutrition with caution, but it is suggested that infants fed soya based milk substitutes and fad dieters who frequently radically alter dietary composition may be more susceptible to spontaneous or carcinogen-induced pancreatic neoplasms.

Rapid changes in pancreatic DNA, RNA and protein in the rat during pancreatic enlargement and involution.

Pancreatic weight, nucleic acid content and protein content were measured on the involuting rat pancreas after its initial enlargement from a raw soy bean flour (RSF) diet. Rats were fed an RSF diet for four weeks and then changed to an inhibitor-free diet of either heated soy bean flour (HSF) or rat cubes for 1, 2, 7 or 14 days. Control rats were fed cubes continuously from weaning or cubes followed by HSF for two weeks. There was no significant difference in the body weights of rats in any of the test or control groups. After four weeks on RSF the wet weight of the pancreas was double that of the control animals and the protein content and nucleic acid content were also significantly greater. After RSF-fed animals were changed to cube or HSF diets, pancreatic parameters rapidly reverted to normal. The most striking change was in pancreatic DNA which returned to control values within 2 days of changing to cubes or HSF. Pancreatic weight, RNA and protein reverted to control values within 7 days of the change of diet. The rapid increase and decrease in the size of the rat pancreas after diet alterations suggest that pancreatic growth may be more labile than previously thought. If rapid changes in pancreatic cell number occur in rats fed alternating cube and RSF diets, then these animals may be more susceptible to pancreatic carcinogens.

Breast biopsies on outpatients.

One hundred and three excisional biopsies of breast masses were done on an outpatient basis under local anesthesia. The criteria for selecting patients were such that only two malignant tumors were found, and 101 unnecessary hospital admissions were avoided. A large majority of patients responding to our survey accepted or even preferred the outpatient, local anesthetic technique. Thirteen of 16 patients who had previous inpatient biopsies under general anesthesia preferred biopsy as an outpatient under local anesthesia. This idea is not new, but new economic and social conditions as well as developing diagnostic techniques now increase its potential value.

The effect of long-term feeding of soya-bean flour diets on pancreatic growth in the rat.

1. Pancreatic growth was measured in rats by changes in pancreatic weight, nucleic acid content and protein content after feeding diets of heated soya-bean flour (HSF), raw soya-bean flour (RSF), 200 g raw soya-bean flour + 800 g heated soya-bean flour/kg (80 HSF) and 400 g raw soya-bean flour + 600 g heated soya-bean flour/kg (60 HSF) for periods up to 36 weeks. Control rats of comparable age to soya-bean flour-fed rats were continued on rat cubes during the 36-week study. 2. Cube-fed rats remained significantly heavier than rats fed on soya-bean flour diets. Analysis of variance showed rats fed on HSF were significantly heavier than RSF-fed rats and rats fed on 80 HSF significantly heavier than those fed on 60 RSF. 3. Pancreatic indices in HSF-fed rats were similar to comparable control rats. 4. Hypertrophy was found in rats fed on the RSF-containing diets with the extent of enlargement corresponding to the RSH content. Hyperplasia was also found in rats fed on RSF and 60 HSF. 5. The greatest pancreatic growth was seen in RSF-fed rats with all the indices peaking at 8 weeks followed by a decline and then a rise again at 36 weeks. 6. The fall in pancreatic indices in rats fed on RSF for 12 and 24 weeks is most likely an effect of general malnutrition due to the multiple deficiences in amino acids which occur in animals fed on RSF. The rise at 36 weeks may reflect increased body growth or the beginning of adenomatous changes.

Colostomy closure after colon injury: a low-morbidity procedure.

One justification for expanding the indications for primary repair of colonic injuries is the high morbidity classically associated with colostomy closure. Our impression that this morbidity is overstated prompted us to review our experience with closure of colostomies constructed for treatment of colon trauma for the 5-year period 1979-1984. During this period 75 colostomies created for treatment of colorectal injuries were closed. Complications were frequent after colostomy creation, but few could be attributed to the colostomy. Following colostomy closure, however, complications were infrequent (5%) and generally minor. If morbidity of colostomy closure is cited as a factor justifying expanded indications for primary repair of colon injuries, current morbidity rates should be borne in mind.

The effect of fasting on enzyme levels in the enlarged and involuting rat pancreas.

1. The effect on pancreatic digestive enzyme levels of fasting and changes from a diet containing trypsin inhibitor (raw soya-bean flour, RSF) to diets free of trypsin inhibitor (heated soya-bean flour, HSF, or commercial rat chow) was studied in rats for up to 7 d. 2. In RSF-fed rats killed without fasting, enzyme levels were low, but after fasting for 24 h before killing there was a marked increase in all enzyme levels. Histological studies showed that pancreatic acinar cells from RSF-fed rats killed without fasting were devoid of zymogen granules, but following a 24 h fast there was a marked accumulation of zymogen granules which extend into the basal cytoplasm. Fasting either produced no change or a fall in enzyme levels in rats fasted after feeding HSF or chow continuously. 3. If animals fed on RSF were changed to HSF and either fed or fasted for 24 h up to the time of killing there was an increase in amylase (EC 3.2.1.1), trypsin (EC 3.4.21.4), lipase (triacylglycerol lipase; EC 3.1.1.3) and protein 1 d after the change, followed by a fall over the next 6 d to levels similar to those seen in rats fed on HSF continuously. 4. Animals changed from RSF to chow showed similar effects as far as trypsin, lipase and protein were concerned, but amylase rose, to reach the level seen in rats fed on chow continuously (about ten times that seen in soya-bean-fed rats), after 2 d. 5. These results suggest that in the rats fed on RSF, pancreatic enzyme synthesis is rapid but secretion is equally rapid and intracellular enzyme levels are low. When these animals are fasted or changed to a diet free of trypsin inhibitor the rate of secretion falls but the high rate of synthesis continues for at least 24 h and enzymes accumulate in the pancreas. In studies of pancreatic enzyme levels in rats fed on trypsin inhibitor the extent of fasting before killing the animal is therefore an important variable. Such animals should probably not be fasted before study.