Indications for early thoracotomy in the management of chest trauma.

Trauma to the thorax represents a significant portion of injuries seen in an inner-city emergency room. Although most of these patients may be successfully managed without thoracotomy, a certain percentage require operative intervention either immediately or within several hours. The records of more than 380 patients with major chest trauma seen in recent years have been reviewed. Three hundred twenty-one of these patients (84%) required only good supportive measures such as correction of hypovolemia, temporary ventilatory support, tube thoracostomy, and careful observation. Forty-four additional patients (12%) required immediate operation following preliminary resuscitative treatment. Indications included hemorrhage, cardiac tamponade, injury to a great vessel, and rupture of the diaphragm. There were 10 deaths in this group. In 15 other individuals (4%) delayed operation was undertaken following careful reappraisal of initial injuries by continued examination, monitoring of vital signs, and appropriate roentgenographic and laboratory studies. Indications for delayed operation included continued or recurrent bleeding, widening of the mediastinum, hemoptysis, and recurrent hemothorax. There was only 1 death in this group. Thus, although it may be clear which patients require immediate operation, only careful and continuous monitoring can identify those who initially appear to be in stable condition but eventually will require exploration.

Intestinal bypass in morbid obesity: long-term metabolic sequelae.

A review of 51 patients undergoing jejunoileal bypass for morbid obesity is presented. There were two postoperative deaths; the 49 remaining patients have been followed for up to five years. Weight loss has been acceptable, the complications for the most part being transient and easily controlled. We believe that jejunoileal bypass for morbid obesity is a useful treatment modality in carefully selected patients.

Clinical effects of membrane lung support for acute respiratory failure.

Extrapulmonary support in respiratory failure has become possible for prolonged periods with clinical application of the membrane lung oxygenator. The membrane lung may be perfused in a venovenous circuit, in which case it functions by prepulmonary venous oxygenation, or it may be pumped in venoarterial perfusion as partial or total cardiopulmonary bypass. Four patients were placed on venovenous membrane lung (GE-Peirce) perfusion for periods ranging from 6 to 112 hours. In oxygenating blood flows of less than 50% of the cardiac output, a viable PaO2 (mean, 52 mm Hg) was obtained in 2 patients with 60% FIO2, including 1 survivor who was weaned from the membrane lung. The remaining 2 patients had heart failure and insufficient venovenous membrane lung flows to improve systemic oxygenation (mean PaO2, 45 mm Hg on 100% FIO2). Four other patients were placed on venoarterial membrane lung (GE-DuaLung) bypass for 18 to 110 hours. With 40 to 85% of the cardiac output bypassed through the membrane oxygenator, immediate improvement was seen in systemic oxygenation (mean PaO2, 75 mm Hg), effective compliance (mean increase of 75%), and reduction in pulmonary hypertension (mean decrease, 15 mm Hg). These changes during bypass allowed the lungs to be put at rest with a decrease in FIO2 and positive end-expiratory pressures. This clinical experience indicates that venoarterial membrane lung bypass may be both supportive and therapeutic, decompressing the pulmonary circuit and maintaining systemic oxygenation. Membrane lung supported by either mode of perfusion has been shown to be clinically effective in patients suffering acute respiratory failure.

Transduodenal sphincteroplasty for biliary tract disease.

Transduodenal sphincteroplasty is an efficient and easy method for dealing with benign biliary tract disease. With it a permanent wide-open stoma is created between the common bile duct and the duodenum, which is established only by complete division of the muscular sphinteric mechanism. Specific indications for sphincteroplasty include multiple common duct stones or "sludge", primary biliary calculi, unremovable intrahepatic stones, impacted ampullary stones, or stenosis of the sphincter of Oddi. Conditions unrelieved by sphincteroplasty include biliary dyskinesia "post-cholecystectomy syndrome", and relapsing pancreatitis with biliary disease. Sixty-five patients are presented who underwent transduodenal sphincteroplasty for benign biliary tract disease in various categories. Satisfactory results were obtained in 53 patients. Coincident pancreatic disease was associated with the least satisfactory results.