Spontaneous rupture of the liver upon revascularization during transplantation.

Spontaneous rupture of the liver has been described in association with many benign and malignant conditions. We report, to our knowledge, the first case of spontaneous rupture of the liver upon revascularization, requiring total hepatectomy and portocaval shunt, followed by successful retransplantation. Routine pathological examination of the explanted liver failed to reveal the etiology of the rupture. However, electron microscopy demonstrated abnormal collagen in the hepatic arterial wall compatible with a collagen disorder such as Ehlers-Danlos type IV disease. We conclude that the donor liver had a previously undiagnosed collagen disorder. Review of the literature does not preclude the use of livers from donors with a history of connective tissue disorders. Based on our experience one should exercise caution when using livers from such donors. With a history of connective tissue disorder in an immediate family member, further tests should be performed in the donor to rule out a subclinical connective tissue disorder. In addition, a review of all patients reported thus far to have undergone total hepatectomy and portocaval shunt, followed by liver transplantation as a two-stage procedure is presented.

Overuse of splenic scoring and computed tomographic scans.

BACKGROUND: As the most commonly injured abdominal organ in blunt trauma, the management of splenic injury has undergone evolution. The risk of blood transfusions administered in an attempt to save the spleen has lowered the threshold for operation and also expanded the limits for nonoperative management. An in-depth analysis was carried out of risk factors on patients requiring immediate surgery and those who fail non-operative management based on organ injury scaling grading by computed tomographic (CT) scan and operation. The application of nonoperative management in the elderly population and the use of follow-up CT scanning and sonography in the outpatient setting was also examined. METHODS: Between January of 1991 and June of 1996, 226 consecutive blunt splenic trauma, injured patients at a Level I trauma center were evaluated. All subsequent CT scans and sonograms in the inpatient and outpatient setting were analyzed. The Student's t test, Pearson chi2 analysis with Yates correction, and analysis of variance were used to compare between and among groups. RESULTS: There were 153 men (67.7%), an average age of 34.8 years, an average Injury Severity Score of 24.4, and 28 deaths (12%). There was a significant difference with respect to Injury Severity Score, Glasgow Coma Scale score, Revised Trauma Score, units of packed red blood cells transfused, length of stay, intensive care unit length of stay, mean splenic injury grade, and cost between patients observed initially and those operated on initially. There was no significant difference in age between the two groups. Of 170 patients, 37 patients (22%) who had an initial CT scan underwent immediate exploratory laparotomy. The remaining 133 patients (78%) had nonoperative management; however, 15 patients (11%) failed the period of observation. Five in this group had a laparotomy secondary to other causes and another six were operated on within 24 hours of their injury for their splenic injury. Thus, only four of the nonoperative management patients (3%) actually failed nonoperative splenic management after 24 hours of injury. There were 100 second CT scans obtained. Three of these patients, who had developed hemodynamic instability, required operation for a bleeding spleen. The subsequent CT scan was confirmatory in these three patients who resided in the intensive care unit. All other CT scans and sonograms for clinically unremarkable patients failed to yield any alteration in care based on the scans. CONCLUSION: Blunt splenic injured patients can be safely observed; however, there are certain risk factors in those requiring immediate surgery and those failing nonoperative management. The CT scan underestimates injury, possibly related to a progression of bleeding found at the time of operation. No outpatient studies altered the course of management. Age also did not influence outcome. Thus, in the dedicated trauma center, nonoperative management of blunt splenic injury patients does not lead to undue morbidity or mortality. Once discharged, follow-up radiographs in asymptomatic patients are not necessary.

Effect of MTP on TNF-alpha in perfused rat liver after bacteremia and ischemia/reperfusion.

INTRODUCTION: Muramlytripeptide phosphatidylethanolamine (MTP) stimulates synthesis of cytokines by hepatic Kupffer cells. We have shown in a perfused rat liver model that secondary ischemia/reperfusion (I/R) downregulates tumor necrosis factor alpha (TNF-alpha) expression after Escherichia coli (EC) bacteremia. Here, we tested the hypothesis that pretreatment with MTP restores cytokine response after sequential bacteremia and I/R. METHODS: Thirty-eight livers were studied in eight groups after intraportal injection of 10(9) live EC or normal saline (NS): (1) normoxic EC; (2) EC + I/R (ischemia began 30 min after EC followed by 2 h of reperfusion); (3) normoxic NS controls; and (4) NS + I/R. Four groups of rats received 300 micrograms of MTP i.v. 24 h prior to liver harvesting; (5) MTP + EC; (6) MTP + EC + I/R; (7) MTP + NS; and (8) MTP + NS + I/R. Bioactive and antigenic TNF-alpha, PGE2 and bacterial clearance were assessed. RESULTS: MTP increased bioactive TNF-alpha response to EC (MTP + EC vs EC controls: 685 +/- 255 U/ml vs 250 +/- 180 U/ml, P < 0.02). I/R did not downregulate TNF-alpha in animals treated with MTP (MTP + NS vs MTP + NS +I/R, P = 0.83). Pretreatment with MTP restored TNF-alpha after I/R MTP + EC + I/R vs EC + I/R: 671 +/- 215 U/ml vs 27 +/- 14 U/ml, P < 0.001) to levels similar to those found in the MTP + EC group (MTP + EC + I/R vs MTP + EC: 671 +/- 215 U/ml vs 685 +/- 255 U/ml, P = 0.75). Finally, bacterial clearance was increased in groups which received MTP. CONCLUSION: In vivo administration of MTP increases hepatic TNF-alpha response to intraportal EC bacteremia by a PGE2 independent mechanism. This response is maintained even after subsequent ischemia and reperfusion.

Civilian colon trauma: factors that predict success by primary repair.

BACKGROUND: Primary repair has become the most common method of treatment for civilian injuries of the colon. However, colostomy may still be required in selected patients. AIMS: This study was undertaken to identify factors for the performance of colostomy in patients with colon injuries. METHODS: During a 60-month period, all penetrating injuries to the colon treated at Saint Louis University Hospital were evaluated. All patients underwent an operation within six hours of injury. Rectal injuries were excluded. RESULTS: One hundred thirty consecutive patients with injuries to the colon were identified. Primary repair was performed in 81 patients (62 percent). Fecal diversion was used in 49 patients (38 percent). No deaths occurred related to colon injury. Complications related to colon injury included wound infections in 22 patients (17 percent) and intra-abdominal complications in 16 patients (abscess, 14; fecal fistula, 1). Wound complications were most closely related to whether the skin was closed primarily or left open (22 vs. 8 percent). Intra-abdominal complications occurred in 7 percent of patients in whom the colon injury was closed primarily and in 20 percent of patients in whom a stoma was created (P > 0.05). Patients chosen for colostomy had significantly greater blood loss, more associated injuries, and higher scores on the Abdominal Trauma Index (ATI) and Colon Injury Scale (CIS) and were more likely to have gross contamination (P < 0.05). Stepwise regression analysis of 13 factors revealed that only gross contamination and ATI predicted the occurrence of intra-abdominal complications and that CIS most closely predicted either wound or intra-abdominal complications. Stratification of patients based on an ATI of > or =30 and a CIS of > or =4 revealed no difference in outcome between primary repair and colostomy in either the low-risk or high-risk groups. However, severity of injury was greater in patients treated with colostomy. CONCLUSIONS: Primary repair can be accomplished with low morbidity in the majority of civilians with penetrating injuries to the colon. Colostomy may be required in high-risk patients as defined by an ATI of > or =30 in association with a CIS of > or =4.

Outcome and utility of scoring systems in the management of the mangled extremity.

BACKGROUND: The role of scoring systems as predictors of amputation and functional outcome in severe blunt extremity trauma was examined. METHODS: All severe extremity injuries treated over a 10-year period were scored retrospectively using four scoring systems: Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and Limb Salvage Index (LSI). RESULTS: Twenty-three upper (UE) and 51 lower extremity (LE) injuries were evaluated. Sensitivity and specificity, respectively, were MESI 100% and 50%, MESS 79% and 83%, PSI 96% and 50%, and LSI 83% and 83%. For each system, there were no differences between patients with good and poor functional outcomes. CONCLUSION: All of the scoring systems were able to identify the majority of patients who required amputation. However, prediction in individual patients was problematic. None of the scoring systems were able to predict functional outcome.

Management of selected rectal injuries by primary repair.

BACKGROUND: Diversion of the fecal stream with or without primary repair has been the mainstay of therapy for rectal injuries. Because primary repair has replaced colostomy as the treatment of choice for most colon injuries, we reviewed our experience with primary repair of rectal injuries in order to determine if primary repair without diversion is a feasible option in selected patients. MATERIALS AND METHODS: All traumatic rectal injuries over the past 48 months were reviewed for mechanism of injury, diagnosis, treatment, and outcome. RESULTS: Thirty consecutive patients with extraperitoneal rectal injuries were identified. Six of the 30 patients underwent primary repair without diversion. Five were repaired transanally, and 1 was repaired at celiotomy. There was no morbidity related to the rectal repair in patients who underwent primary repair without diversion, and there were no deaths. CONCLUSIONS: Based on a small number of patients, these data suggest that primary repair of rectal injuries in selected patients may be feasible. Further prospective investigation is needed to determine which patients may be successfully treated in this fashion.

The use of oxygen consumption and delivery as endpoints for resuscitation in critically ill patients.

OBJECTIVE: Oxygen consumption (VO2I) and delivery (DO2I) indices have been stated to be superior to conventional parameters as endpoints for resuscitation. However, another interpretation of published data is that inability to increase VO2I/DO2I given adequate volume resuscitation reflects inadequate physiologic reserve and poor outcome. DESIGN: Fifty-eight critically ill patients were randomized to two groups. In group 1 (27 patients) attempts were made to maintain VO2I > or = 150 or DO2I > or = 600 mL/min/m2. If DO2I was > 600, no attempt was made to increase VO2I even if it was < 150. Group 2 (31 patients) was resuscitated based on conventional parameters. Volume resuscitation protocols and goals for pulmonary capillary wedge pressure were the same in both groups. VO2I/DO2I were recorded in group 2, but physicians were blinded to this data. Age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation (APACHE II) score were not different between groups. MAIN RESULTS: Three patients in group 1 and two patients in group 2 died of organ failure (OF). One additional patient in group 2 died of refractory shock within 24 hours. Two of the patients in group 1 who died failed to meet VO2I/DO2I goals within 24 hours despite maximal resuscitation. Mortality was not different between the groups even with exclusion of the group 1 patients who failed to meet VO2I/DO2I goals (p = 0.66). After exclusion of the patient in group 2 who died of refractory shock, OF occurred in 18 of 27 (67%) in group 1 and in 22 of 30 (73%) in group 2 (p = 0.58). Length of ventilator support, intensive care unit stay, and hospital stay were not different between groups. When all patients were assessed, no difference was found in the incidence of OF between patients who attained the VO2I goal and those who did not. OF occurred in 20 of 34 (59%) patients who maintained a mean DO2I > or = 600 during the first 24 hours of the study and in 21 of 24 (88%) of those who did not (p < 0.02). CONCLUSIONS: No difference was found in the incidence of OF or death in patients resuscitated based on oxygen transport parameters compared to conventional parameters. These data suggest that given adequate volume resuscitation, oxygen-based parameters are more useful as predictors of outcome than as endpoints for resuscitation.

Selective management of embolized intracardiac missiles.

Intracardiac projectiles are occasionally found in stable patients who have sustained penetrating trauma. These missiles may arise from embolization from a peripheral injury site. We describe 3 patients with embolized intracardiac projectiles. The diagnosis was suggested by the presence of a foreign body within the cardiac silhouette on chest roentgenograms and was confirmed using fluoroscopy, echocardiography, or computed tomography. The management of embolized intracardiac missiles should be individualized to each patient. All of our patients had fixed intracavitary right-sided missiles and were successfully managed expectantly.

Multiple organ failure: is it disappearing?

The incidence of multiple organ failure (MOF) during the last decade has been reported variously as 2% to 25%, depending on the patient population examined. The mortality rate from this devastating complication ranges from 40% to 80%. Although the incidence has not changed during the last decade, it does not mean that there has been no progress. Tertiary centers are now seeing trauma and nontrauma patients who have more significant underlying disease and injuries. Likewise, a higher percentage of our trauma patients are now referred from outside institutions where there may not be the facilities to administer the complex, rapid resuscitation these patients require. Prevention of MOF remains its best treatment. Rapid, adequate volume resuscitation, adequate nutrition, appropriate antibiotic usage, and aggressive pulmonary management are important for preventing the downward physiologic spiral that leads to MOF and death. Once MOF has occurred, it is not clear that these same measures are as effective in altering outcome.

Clinical trials of new and novel therapeutic agents.

Throughout this issue of World Journal of Surgery are recommendations and descriptions of therapy to prevent the development of multiple organ failure (MOF). The subjects include advances in monitoring; circulatory, pulmonary, and gut support; blood treatment; immune modulation; and control of the inflammatory process. Additional methods of organ support include recommendations for resuscitation and initial care and for early definitive operations. New therapeutic agents such as growth factors, glucan, ketaconazole, and antithrombin III are described. Finally, methods to support organ function before it fails (circulation, lungs, and kidneys) are described.

The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture.

OBJECTIVE: There is no gold standard for early and reliable diagnosis of traumatic diaphragmatic rupture (TDR). The purpose of this study is to correlate CT scans, chest radiographs, and intubation on the ability to diagnosis traumatic diaphragmatic rupture. MATERIALS AND METHODS: Twenty patients with blunt trauma induced diaphragmatic rupture were identified from a five year review of a Level 1 Trauma Registry. RESULTS: Ten of the 20 (50%) patients had TDR on initial chest X-ray, all on the left side. Twelve patients had both chest X-rays and a chest and abdominal CT scan; however, only five (42%) of the CT scans were diagnostic. Of the 12 patients initially intubated, TDR was diagnosed in only four (33%) patients on initial chest X-ray and in one (14%) of seven patients having chest and abdominal CT scans and being intubated. CONCLUSION: The early diagnosis of blunt traumatic diaphragmatic rupture, especially in intubated patients, continues to be a diagnostic dilemma. There is a significantly better possibility of identifying left over right-sided TDR (P < or = 0.05). Diagnosing TDR is also facilitated by extubation. If the suspicion exists, a post extubation chest radiograph should be performed to evaluate for TDR.

Evaluation of the thoracic and lumbar spine after blunt trauma.

BACKGROUND: Routine performance of thoraco-lumbar (TL) spinal radiology in patients with blunt trauma is controversial. PATIENTS AND METHODS: To establish indications for radiologic screening of the TL spine, a retrospective review of 344 patients who had radiologic evaluation of the spine was performed. RESULTS: Forty-seven patients had abnormalities detected on radiologic evaluation. One hundred eighty-six patients had at least one clinical finding suggestive of injury. Thirty-two had abnormal radiographs. Thirteen of these abnormalities represented old or minor fractures and were not treated. Nineteen patients had injuries requiring treatment. Two patients were treated with activity restriction, 12 with a back brace, 4 with operative fixation, and 1 patient died prior to operation. Of the 129 patients who were awake, alert, and without clinical evidence of injury, 10 had abnormal radiologic studies. Three patients had old fractures, 4 had transverse process fractures, and 3 had spondylolisthesis. None of these patients required treatment. Twenty-nine patients had equivocal clinical examinations primarily due to altered levels of consciousness. Five patients had abnormal radiologic studies, 3 of whom required treatment. Three factors associated with the occurrence of TL spine injury were identified: an Injury Severity Score > or = 15, a positive clinical examination, and a fall of > or = 10 feet. CONCLUSIONS: These data suggest that patients who are awake, alert, and with no clinical evidence of injury do not require radiologic study of the TL spine. Patients with equivocal or positive clinical findings or with altered levels of consciousness should have complete TL spine evaluation.

Trauma management in the 21st century.

Predicting the future can be interesting but difficult, particularly because of the exciting developments in the science of injury, inflammation, sepsis, and shock. Considering what has happened between 1895-1995, it is difficult to contemplate what will happen in the next 100 years. Will change accelerate in the 21st century? So far, our scientific knowledge and capability have exceeded the ability to care for injured and operated patients. Much of the future will depend upon society's ability to control violence and prevent injury. Most of the factors resulting in death after injury are beyond the control of those caring for patients or those studying patient problems. Thus the major risk factors for death after trauma are injury severity, the age of the patient, the problems of shock, and end-stage organ injury. If we are to decrease mortality from injury, we must work to prevent injury and decrease the severity of injury while improving our capabilities to care for the injured. New rapid diagnostic procedures, immediate therapy at the scene of the injury, portable or flying resuscitative and therapeutic units, and better understanding of the need for the inflammatory response in contrast to the disaster produced by an overwhelming inflammatory response will help. The major hazard for predicting the future in the management of injured patients could be predicting that something cannot be done. We recognize now that almost anything can be done if we learn enough and understand the problems sufficiently well. The Shock Society is dedicated to that purpose.

Computed tomography as a screening exam in patients with suspected blunt aortic injury.

BACKGROUND: Chest computed tomography (CT) screening of patients with blunt trauma for thoracic aortic injury is controversial. This study was undertaken to determine whether CT could exclude aortic injury and be used to select patients for aortography. METHODS: Computed tomography and aortography were used to evaluate 155 patients with blunt trauma. Computed tomography scans were reviewed separately by four attending radiologists who were unaware of the patients' clinical course and angiographic findings. RESULTS: Eight of 155 patients had aortic injuries requiring operation. Computed tomography scans in five patients were read as positive by all reviewers. One scan was read as positive by three reviewers and as negative by one. Two scans were read as positive by two radiologists and as negative by two. After poor scans were excluded, the combined sensitivity of CT for detecting aortic injury was 88%, specificity was 54%, positive predictive value was 9%, and negative predictive value 99%. CONCLUSIONS: The sensitivity of CT scan for indicating the need for aortography is observer dependent. As CT manifestations of aortic injury are often subtle, CT does not reliably exclude aortic injury.

Acute acalculous cholecystitis in the critically ill.

Acute acalculous cholecystitis, inflammation of the gall-bladder without evidence of calculi, accounts for 2 to 15% of all cases of acute cholecystitis. The incidence of acute acalculous cholecystitis in adults undergoing cholecystectomy may be as high as 15 per cent and up to 32 per cent in the pediatric population. During the past 10 years, 22 patients who were being treated in the intensive care unit for other reasons underwent cholecystectomy for acute acalculous cholecystitis. Eighteen (82%) of the patients were male, the average age was 61 years, and patients spent an average of 19 days in the intensive care unit prior to cholecystectomy. The most common clinical findings were right upper quadrant tenderness and pain. Fifteen (68%) of the patients had a previous operative procedure. HIDA scans were positive in all 12 patients in which they were performed. Ultrasounds were positive in 13 of 17 (76%) patients, and CT scans 7 of 9 (78%). Nine (41%) patients died. Early diagnosis with rapid intervention is crucial in managing this disease if outcome is to be improved. Gangrene and/or necrosis of the gallbladder was present in 13 (59%) of patients, suggesting that cholecystectomy may be the best approach to management.

Right coronary artery occlusion secondary to blunt trauma.

The heart lies in a vulnerable position when the chest is subjected to direct blunt trauma. Acute occlusion of a coronary artery from blunt chest trauma is rare, with occlusion of the right coronary artery at its origin recorded only twice in the English literature. A young male unrestrained driver sustained an acute deceleration injury with significant chest trauma when he crashed, crushing the steering wheel against his chest. Creatine phosphokinase isoenzymes were initially 2% of the total and 8% 12 h later. There were marked electrocardiographic changes, and an echocardiogram revealed abnormal left ventricular systolic function with an akinetic inferior-posterior wall and right ventricular enlargement. A wide mediastinum and mechanism of injury led to the performance of aortography which failed to disclose a right coronary vessel. Subsequently coronary angiography confirmed acute occlusion of the proximal right coronary artery. Because of other associated injuries, nonoperative medical management was successfully utilized.

Traumatic train injuries.

Train accidents involving motor vehicles and pedestrians can be devastating. Approximately 1,234 fatalities were recorded in the United States in 1989. The literature from the United States is sparse, prompting a 7-year review of 23 consecutive train accident victims. Twenty (87%) were male, with an average age of 30.6 years. Sixteen (70%) were intoxicated at the time of the accident, and the average Injury Severity Score was 21.4. There was a total of eight traumatic amputations occurring in the 11 (48%) patients involved as pedestrians. Two of these were railroad workers, and nine were trespassers. Fourteen (61%) accidents occurred between the hours of 2300 and 0700. Three (14%) patients died. Although alcohol use occurred in 16 (70%), there was no significance between alcohol use and amputation. Thus, non-railroad employed pedestrians, because of a lack of protection, are more prone to traumatic amputations, primarily of the lower extremities, than those involved in motor vehicle accidents.

Management of blunt hepatic injuries.

Sixty-three consecutive patients with blunt hepatic trauma were examined. Twenty-four patients underwent immediate operation, and 39 patients were evaluated by computed tomography (CT), of whom 17 underwent operation. Ten patients had no hepatic abnormalities on CT and had operations for associated injuries. Liver injuries were noted in the remaining seven patients, but CT underestimated the injury in four patients. A large hemoperitoneum was present in all seven patients by CT, and the average transfusion was 10 U during initial resuscitation. Twenty-two patients with grade I to III injuries and a small to moderate hemoperitoneum were managed nonoperatively. Six of these patients had transfusions during resuscitation. Only one patient received more than 2 U. There were no deaths and no major complications related to the liver injury. Most patients had repeat CT at 1 week, which demonstrated stable or improving injuries. CT may underestimate the degree of liver injury. Nonoperative management is appropriate in stable patients with grade I to III injuries and a small to moderate hemoperitoneum. These patients should require no more than 2 U of blood, and repeat scans should demonstrate a stable injury.

Stress gastritis revisited.

In current ICU populations, overt bleeding from stress gastritis occurs in 10% to 20% of patients. Bleeding rates may be reduced to about 3% in patients receiving prophylactic therapy. Although patients with bleeding have higher mortality rates than other critically ill patients, it is not clear that the mortality rate is improved with prophylactic therapy, as most patients die from their underlying disease. As new complications of prophylactic therapy are identified, better definitions of the population at risk to develop complications of stress gastritis will be necessary to select those patients who will benefit most from prophylactic therapy.