Vascular trauma in infants and children.

A 20-year retrospective evaluation of vascular trauma in infants and children was undertaken. The study included 53 cases of blunt and penetrating vascular injuries in pediatric patients. There were 36 males and 17 females ranging in age from 24 days to 14 years (average, 10 years). The most frequently encountered sites of arterial trauma were the brachial or superficial femoral artery, and of venous trauma the inferior vena cava. Any patient presenting to the Emergency Center with an injury in proximity to a major vessel, hematoma formation, audible bruit, or palpable thrill underwent prompt arteriography or immediate operative exploration of the injury sit. All patients in the series were managed operatively. There were 41 major arterial and 32 major venous injuries. No patient required a major amputation. Most injuries were repaired by primary closure or segmental resection and end-to-end anastomosis; interposition vein grafts and substitute conduits were used in four patients with more extensive injuries. A 13% operative mortality was encountered: the most frequent cause of death was intraoperative exsanguinating hemorrhage. The triad for successful management of vascular trauma in pediatric patients is: 1) a high index of suspicion, 2) performance of aggressive diagnostic studies when indicated, and 3) prompt surgical intervention.

Surgical management of penetrating injuries of the esophagus.

Although well protected and infrequently injured, penetration of the esophagus has a reported mortality of 10 to 30 per cent. The results of the management of seventy-seven patients with noniatrogenic penetrating injuries of the esophagus were reviewed. The region of esophageal injury was cervical in forty-five patients, intrathoracic in twenty-one patients, and intraabdominal in eleven patients. Gunshot wounds accounted for 75 per cent of the injuries. The overall mortality was 23 per cent. The highest morbidity and mortality was among patients with intrathoracic injuries, due to both difficulty in exposure and complexity of associated injuries. Because of the high incidence of late complications in intrathoracic injuries, cervical diversion and tube gastrostomy or complete esophageal exclusion must be considered early. Fundoplastic procedures were used in four patients with distal esophageal injuries. Although the overall mortality from truncal penetrating wounds has improved in recent years, the mortality from esophageal injuries remains high, reflecting a need for advancement in initial operative management.

Necrotizing fasciitis: a persistent surgical problem.

Necrotizing fasciitis is a rare but specific clinical entity which, if not diagnosed early and treated aggressively, is rapidly fatal. The disease was first described during the Civil War and continues to be associated with a 50% mortality. The infectious process is diagnosed by the presence of a widespread fascial necrosis with extensive undermining of the adjacent tissues. The initial mechanism of injury as well as the location and etiologic agent of the suppurative fasciitis may vary. A review of 41 cases of necrotizing fasciitis occurring over a 22-year period disclosed an overall mortality of 39%. Most often, the mortality was related to the severity of the associated diseases and a failure to recognize the disease process promptly. The rate may be lowered by early recognition and prompt surgical intervention coupled with intensive supportive therapy.

Surgical management of colon atresia.

Colon atresia is a rare cause of intestinal obstruction in the neonate and requires early diagnosis and prompt surgical treatment. It is impossible in the neonate to differentiate colon atresia from other forms of obstruction at the time of initial presentation. The diagnosis is confirmed roentgenographically, including views of the abdomen and contrast barium enema series. Lesions proximal to the splenic flexure are treated with initial resection of the atretic segment and a primary anastomosis. Those lesions distal to the splentic flexure are managed initally with a diverting loop colostomy with subsequent staged resection and anastomosis.

Unimpaired renal, myocardial and neurologic function after cross clamping of the thoracic aorta.

Twelve patients who had sustained trauma presented at the emergency department with either asystole or profound hypotension. All underwent thoracotomy and temporary cross clamping of the descending thoracic aorta as part of the resuscitative measures; all received massive amounts of fluids and cold blood and underwent prompt surgical intervention. In none of these patients was there evidence of myocardial, peripheral nerve, neurologic or renal damage. One patient had residual cortical blindness. Measures were taken to preserve renal function before, during and after aortic cross clamping. These included the avoidance of nephrotoxic antibiotics, limit of clamping time to the minimum effective period, intermittent release of the aortic clamp, and intraoperative administration of osmotic diuretics or furosemide, or both. Other factors which may have contributed to these results were the youth of these patients, the absence of cardiac, renal or metabolic diseases and the hypothermia resulting from the administration of large amounts of cold blood. We concluded that temporary cross clamping of the descending thoracic aorta should be performed only for patients with massive exsanguine trauma who have cardiac arrest or who do not respond to other intensive resuscitative measures.

Management of 1,590 consecutive cases of liver trauma.

Between 1939 and 1974, more than 1,500 patients have been treated for penetrating or blunt liver trauma at our institution. Gunshot wounds and major blunt trauma have increased, stab wounds decreased, as percent of total. In most cases techniques other than partial hepatic resection were used, although this was performed in 49 instances. Choledochostomy was infrequently employed. Intracaval shunts were useful in 15 selected patients with massive hepatic, concomitant suprarenal vena caval, or hepatic vein injuries. The overall mortality of this group was 13.1%. The improvement in mortality from liver injuries is attributable to (1) early exploration for suspected intra-abdominal traumatic injury, (2) a conservative approach to the liver injury, and (3) the limitation of lobar resection, vascular cannulae, and afferent vascular compression to highly selected cases.

In situ preservation of cadaver kidneys for transplantation: laboratory observations and clinical application.

Many kidneys obtained from cadaver donors undergoing sudden cardiac arrest cannot be transplanted due to the long periods of warm ischemia from the moment of arrest to nephrectomy. A double-ballon-triple-lumen catheter for the rapid in situ preservation of cadaver kidneys has been designed. Used in combination with equipment routinely found in any hospital, it can cool human kidneys in situ to 10-15 C and maintain this temperature until nephrectomy can be performed. Kidenys preserved with this catheter have functioned after transplantation into suitable recipients. This report describes the design and laboratory evaluation of this new device, its clinical effectiveness and technique of insertion.

Improving the efficiency of wound drainage catheters.

We have modified the most commonly utilized wound drainage system to further reduce the incidence of postoperative accumulation of fluid under the skin flaps. This modification allows more efficient removal of debris, loose tissue fragments, and clots from the wound catheters and insures a constant negative pressure in the system. These maneuvers lengthen the usefulness and improve the efficiency of the catheters and have reduced the incidence of fluid accumulation.