Spectrum of general surgery in rural America.

OBJECTIVES: To define the types of surgery performed by rural surgeons, to compare their experience to that of graduating US surgical residents and to document rural surgical mortality. DESIGN: Prospective registry of consecutive cases recorded by 7 rural general surgeons working in one department of surgery from December 31, 1994, through March 30, 1996. Comparison with the 1995 Report C (Resident Operative Logs) of the Residency Review Committee. National survey of surgical residency programs regarding formal gynecology experience. SETTING: Nine rural community hospitals in the Midwest. PATIENTS: Patients undergoing surgery in 9 cities with populations of fewer than 10000. MAIN OUTCOME MEASURES: Type of surgery and postoperative (30-day) mortality. RESULTS: Two thousand four hundred twenty procedures were performed by 7 surgeons practicing in 9 cities with populations of 1500 to 8000. There were 6 (0.25%) postoperative deaths. Case types are as follows: endoscopy, 686 (28.3%); gynecology, 498 (20.6%); hernia, 241 (10%); colorectal, 194 (8%); biliary, 183 (7.6%); cesarean sections, 130 (5.4%); breast, 129 (5.3%); orthopedic, 115 (4.8%); carpal tunnel, 63 (2.6%); otolaryngology, 35 (1.4%); and endocrine, 1 (0.4%); for a total of 2420 (100%). Report C indicated 1995 graduating chief residents averaged 8 obstetric and and gynecologic and 5.3 orthopedic cases during their residency. Of 204 surgical residency programs surveyed, 106 (52%) offered no obstetrics and gynecology rotation. CONCLUSIONS: A large volume of surgery was performed with low mortality by 7 rural general surgeons. The operative experience of 1995 residency graduates differed from our rural surgeons. We recommend a rural surgical track in selected training programs to prepare graduates better for rural practice. Senior level rotations in endoscopic, gynecologic, obstetric, and orthopedic surgery and mentorship with rural surgeons would be optimal.

Rural trauma care: role of the general surgeon.

BACKGROUND: Care of the patient injured in the rural setting poses many unique challenges. This report profiles the experience of a solo, rural general surgeon with patients with multiple injuries during a 7-year period. METHODS: Emergency department (ED) contact sheets for 43,308 patients treated from September 1, 1988 through August 31, 1995 were reviewed. Eighty-four patients met selection criteria based on injuries with Abbreviated Injury Scale score > or = 3 in a single body region or > or = 2 in two or more body regions. Prehospital and hospital records were reviewed. RESULTS: Injury Severity Score ranged from 8 to 43 (mean, 16). Four patients died in the ED, 54 (64%) were transferred to a referral trauma center, and 26 (31%) were admitted to the community hospital. CONCLUSIONS: Roles of the general surgeon in the management of multiple trauma in the rural hospital are: (1) to coordinate trauma care in the community, including educational and organizational efforts; (2) to perform the necessary techniques in the ED to achieve optimal resuscitation and stabilization; (3) to rationally prioritize patients for transfer to a referral trauma center based upon assessment of patient injuries and institutional capabilities; and (4) to provide definitive care for a subset of patients with no need for subspecialty intervention.

Gastric rupture after the Heimlich maneuver.

Since 1975, the Heimlich maneuver has been widely applied to relieve upper airway obstruction caused by aspirated material. Life-threatening complications have been documented following this simple procedure. We report two cases of gastric rupture after use of the Heimlich maneuver. Both patients experienced pulmonary and abdominal symptoms. The diagnosis was confirmed in each case by the demonstration of free intraperitoneal air on an upright chest roentgenogram. Full-thickness gastric rupture along the lesser curvature of the stomach was repaired in both patients; one patient died. Abdominal pain or persistent abdominal distention despite nasogastric suction after the Heimlich maneuver should prompt evaluation for possible gastric rupture.

Blunt myocardial disruption: report of an unusual case and literature review.

Blunt cardiac injury is frequently noted among trauma patients. They may demonstrate few signs and symptoms or may be in profound shock. A unique case of left ventricular disruption in a young soldier who sustained blunt torso trauma is reported. A paucity of clinical findings led to a delay in diagnosis. He ultimately underwent successful repair 12 days after injury.

Surgical treatment of renal cell carcinoma involving the inferior vena cava.

Renal cell carcinoma extends into the inferior vena cava in 5% of patients undergoing exploratory surgery for this malignancy. If the tumor is left unresected, death within 1 year is certain. In addition, caval occlusion may result in massive lower extremity edema, ascites, hepatic failure, and pulmonary embolus. During the past 17 years, 12 patients with renal cell carcinoma extending into the inferior vena cava were treated at a single institution by radical nephrectomy and caval tumor extraction. There were 10 men (83%) and ages ranged from 50 to 78 years (mean 63 years). There was one operative death (8%) caused by refractory coagulopathy. Long-term follow-up was achieved for all survivors. One- and 3-year survival rates by life-table method were 73% and 27%, respectively. Mean survival time after resection was 32 months. Careful preoperative planning is essential. The optimal approach for venacaval tumor extraction or resection is dictated by the cephalad extent of tumor seen on preoperative thoracoabdominal CT scan, ultrasound, or inferior venacavography. Disease limited to the infrahepatic vena cava is best approached with a thoracoabdominal incision through the eighth intercostal space. Extension of tumor to the hepatic veins or right atrium requires median sternotomy in combination with an abdominal incision for complete removal. An ellipse of vena cava around the origin of the renal vein is excised with the specimen. The resultant incision is closed by lateral phleborrhaphy. Late sequelae of the mild caval narrowing were not observed. An aggressive multispecialty surgical policy for caval extraction and resection of renal cell carcinoma resulted in extended patient survival and excellent palliation.

Acute gastric dilatation after trauma.

During a 2-year period, 248 consecutive patients were admitted with multiple trauma. Acute gastric dilatation was documented in 67 (27%) patients by review of all admission roentgenograms. There were 51 (76%) males and 16 females. Ages ranged from 2 to 80 years (mean, 29.2 years). The incidence of acute gastric dilatation in children was 44% vs. 25% for adults (p less than 0.05). The mechanism of injury was motor vehicle accident in 45 (67%), agricultural accident in 8 (12%), fall in four (6%), bicycle accident in four (6%), and miscellaneous in six (9%). There were 38 orthopedic, 35 craniocerebral, 34 abdominal, 31 thoracic, 27 maxillofacial, and 14 spinal injuries. Injury Severity Scores ranged from 4 to 66 (mean, 23.5). Thirteen (19%) patients presented in shock and there were four (6%) hospital deaths. No death was attributable to gastric dilatation. Nasogastric tubes were placed in 41 (61%) patients and 26 were managed without tube placement. Complications associated with acute gastric dilatation included pulmonary aspiration in three (4%) patients, gastric hemorrhage in three (4%), gastrointestinal perforation in one (1%), and prolonged ileus in 12 (18%). In addition, gastric dilatation rendered abdominal examination difficult and delayed peritoneal lavage. Acute gastric dilatation after trauma is frequent in our rural trauma center. Early placement of a nasogastric tube in the absence of a clear contraindication is strongly supported in the management of multiply injured patients.