Simultaneous mesenteric and renal bypass for visceral ischemia and renovascular hypertension.

Severe visceral ischemia and uncontrollable hypertension in a patient with previous aortofemoral and right aortorenal bypasses underwent surgical correction for stenosis of the celiac, superior mesenteric and left renal arteries. A Dacron jump graft from the junction of the aorto-celiac trunk to the superior mesenteric artery artery alleviated the mesenteric ischemia. A nonreversed vein graft connected the side of the Dacron prosthesis to the end of the left renal artery improved the renovascular hypertension. This modified, simple surgical approach, successfully corrected visceral ischemia and renovascular hypertension and avoided using the severely calcified aorta for celiac and mesenteric bypasses.

Blunt trauma to the liver. Analysis of management and mortality in 323 consecutive patients.

This study represents a 6 year 4 month experience with blunt trauma to the liver of patients from the Maryland Institute for Emergency Medical Services Systems, a major regional trauma center. The significance of this study is that it describes a large, relatively homogeneous population and analyzes what the state of the art for liver trauma has been in a center dedicated solely to trauma that has a full-time staff of trained traumatologists. Three hundred twenty-three consecutive patients with blunt liver trauma are presented, representing 3.5% of 9271 patients admitted to the institute over the period of this study. Ninety per cent had associated traumatic injuries requiring operative intervention. A mortality rate of 31% (101 patients) was noted; 41.5% of the deaths, due primarily to liver injury, occurred intraoperatively during the initial operation following admission. The use of simple suture techniques and resectional debridement to control hemorrhage are advocated. Anatomic lobectomy, intracaval shunting, and hepatic artery ligation were uniformly unsuccessful. The use of drains was associated with a significantly increased incidence of infectious complications (p less than 0.00002).

Gastric carcinoma in the young.

Thirty-eight cases of gastric carcinoma in patients 35-years-old and younger, occurring in the period 1948 to 1983, are reviewed. They comprised 2.2% of 1710 cases in all ages for the same 35 year period at the Charity Hospital. Women were afflicted as commonly as men. Blacks outnumbered whites 2.9:1.0. Obstruction, pain, and weight loss of relatively short duration were prominent symptoms. Tumors tended to be located distally in the stomach, and scirrhous in appearance. Histologically, diffuse type lesions were more common than intestinal or other type tumors. Radiographic evidence of disease was usually present in patients undergoing upper gastrointestinal series. Endoscopy with biopsy was a valuable diagnostic tool. Resectability in this group was not less than that achieved for all ages, however, only one patient has survived for five years. Advanced stage lesions predominated and were associated with poor survival. Earlier stage lesions in this age group appear to bear a more favorable prognosis.

Splenic conservation after multiple trauma in adults.

The traditional management of splenic injuries is undergoing serious challenge. During the four year period from 1980 to 1983, 60 of 230 patients with injured spleens operated upon at the Maryland Institute for Emergency Medical Services' Shock Trauma Center have had splenic salvage. Motor vehicle accidents accounted for 57 of the 60 injuries (95 per cent). Fifty-eight patients (97 per cent) had major associated extra-abdominal injuries (average 1.9 injuries per patient) requiring additional operative procedures. Concurrent intra-abdominal injury was present in 37 patients (62 per cent). The mean operating time was 106 minutes; 98 minutes for those patients with isolated splenic injuries and 115 minutes for those with associated minor intra-abdominal injuries. The average amount of blood transfused during celiotomy was 3.5 units of packed red blood cells per patient. As familiarity and confidence with the techniques have accrued, the number of splenic preservation procedures has steadily increased from approximately 10 per cent to more than 50 per cent. Complications related to splenorrhaphy per se were few. The mortality was 10 per cent; all deaths were secondary to associated injuries. Criteria for and contraindications to splenic salvage in patients with multiple trauma are presented and discussed.

Blunt intestinal trauma. A modern-day review.

During the 5-year period from January 1978 through December 1982, 196 patients with blunt trauma to the small bowel, colon, or mesentery were treated at the Maryland Institute for Emergency Medical Services Systems (MIEMSS) Shock Trauma Center. More than 80% of these patients were the victims of motor vehicle accidents and therefore commonly had multisystem injuries. Sixty of these patients suffered 83 major injuries in the form of perforation or mesenteric injury resulting in ischemic bowel. This group accounted for 6.9% of the 870 patients who had celiotomy for blunt trauma during this period. Several significant observations were made. All injuries, except one, were diagnosed by peritoneal lavage. Only two duodenal injuries were present. Perforations involving the jejunum and ileum were distributed throughout the entire length of the small bowel. Colon injuries comprised one-fourth of the major injuries, with most occurring in the ascending and sigmoid colon. There were 16 deaths, 6 of which occurred as a result of complications from the bowel injury.