Surgical salvage of failed radiocephalic arteriovenous fistulae: techniques and results in 29 patients.

From August 1987 through February 1995 we performed 42 surgical procedures in 29 patients with occluded or stenotic radiocephalic arteriovenous fistulae. Operations were designed to preserve native veins for cannulation (Group I) or to preserve access in the same forearm, bypassing the failed fistula (Group II). For 27 procedures in 22 Group I patients, cumulative primary patency was 70%, 57%, and 47% at 6, 12, and 18 months, respectively. A subgroup of patients was identified, however, in whom excellent results could be reliably predicted. Among 19 hemodynamically stable patients with mature fistulae amendable to more proximal arteriovenous anastomoses, cumulative primary patency was 100%, 81%, and 67% at 6, 12, and 18 months, respectively. Secondary patency for 17 such patients was 100%, 89% and 89% for these same intervals. In Group II only two of ten patients required use of other access sites (9 1/2, 18 1/2 months). We believe that all occluded or stenotic radiocephalic arteriovenous fistulae should be considered for surgical salvage. Excellent results can be predicted for (1) hemodynamically stable patients with (2) mature fistulae that (3) fail near the arterial anastomosis and are (4) amendable to new more proximal arteriovenous anastomoses.

Repair of a post-traumatic common iliac arteriovenous fistula.

The management of a patient with a post-traumatic common iliac arteriovenous fistula which was repaired surgically is reported. The current use of less-invasive endoluminal techniques is reviewed.

ICU scoring systems do not allow prediction of patient outcomes or comparison of ICU performance.

Recent revisions of the major ICU scoring systems have broadened their database markedly and increased their statistical accuracy. For a specific patient, however, the systems cannot be accurate enough to direct management decisions. Significant questions remain about the reliability of these systems for comparing different ICUs and different patient populations, especially in surgical and trauma patients. Current scoring systems, therefore, cannot be used reliably in either the management of the individual patient or in the making of quality comparisons between ICUs.

Benefits of early admission to a comprehensive trauma center for patients with spinal cord injury.

Patients with spinal cord injury may be admitted directly to a trauma center with a dedicated rehabilitation unit or transferred there days or weeks later. This study analyzed the relationship between time of transfer to a Level I Trauma Center with a spinal cord injury service and efficacy of subsequent rehabilitation. We examined the records of all patients admitted to the service between September 1981 and August 1983 and followed at least one year. There were 197 patients, 102 quadriplegics and 95 paraplegics, aged 15 to 77 years (average = 29.4 years). Median time from injury to admission was 11 days for quadriplegics and 21 days for paraplegics; this was used to define early and late groups. The early quadriplegic group began rehabilitation 2.94 days postinjury; the late quadriplegic group, 74.87 days (p less than .01). Time in rehabilitation did not differ (128.22 days, early; 122.61, late), but total hospitalization--from injury to discharge--was 131.16 days for the early quadriplegic group and 197.27 for the late quadriplegic group (p less than .01). Average duration of prerehabilitation care for the paraplegic groups was 6.19 days (early) and 58.58 days (late) (p less than .01). Time in rehabilitation was the same for both paraplegic groups, but total hospitalization was shorter for early admissions (82.91 days vs 125.90 days, p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal injuries missed by computed tomography.

Isolated intestinal injuries are frequently difficult to diagnose using only physical examination and routine laboratory studies. Between 1980 and 1988, ten patients were identified who had intestinal injuries and had computed tomographic (CT) scans before operation. For none of these scans was the initial reading considered diagnostic of intestinal injury. All patients came to laparotomy from 2 hours to 3 days following injury, and no patient died because of missed intestinal injury. Retrospective review of the scans revealed two to be diagnostic of intestinal perforation with free intraperitoneal air or extravasated contrast. The remaining eight scans had findings suggestive of injury. However, six additional patients had similar suggestive findings and had no evidence of intestinal injury. One patient with missed duodenal injury had not been given gastrointestinal contrast. Computed tomographic findings of intestinal trauma may be subtle or nonspecific and require optimal technique and care in interpretation. The timely treatment of this injury continues to rely on a high index of clinical suspicion and serial examinations by an experienced surgeon.

Hepatocellular adenoma and nodular regenerative hyperplasia of the liver in a young man.

A 26-year-old man had a massive intraabdominal hemorrhage from a hepatocellular adenoma (HCA). The tumor arose within a liver that demonstrated generalized nodular regenerative hyperplasia. The patient had no factors predisposing to either HCA or nodular regenerative hyperplasia (NRH) of the liver. Although rare, HCA should be included in the differential diagnosis of spontaneous intraperitoneal hemorrhage even in young men. The coexistence of HCA and NRH of the liver in this patient may indicate a common pathogenesis.

Patterns of trauma care costs and reimbursements: the burden of uninsured motorists.

UNLABELLED: In today's rapidly changing medical-economic environment, hospitals must continually reexamine their services to determine which are cost efficient. We used a database system to analyze our financial experience with motor vehicle accident victims discharged between July 1982 and June 1983. We found that motor vehicle accidents accounted for 2.1% of discharges, but 6.6% of patient-days. The average length of stay was 23.8 days, more than three times the hospital average (7.4 days). Charges averaged +723 per day, essentially identical with the hospital average. In terms of patient-days, 51% of accident victims were covered by private insurance, 39% by Medi-Cal (California's Medicaid), and 3% by Medicare; 7% were uninsured and unsponsored. Hospital charges related directly to patient-days and were identical for the four financial categories. Overall reimbursement for these patients was 80.3% of charges, approximately equal to our estimated costs. Reimbursement as a percentage of charges varied greatly according to the category of sponsorship: private insurance, 90%; Medicare, 78%; and unsponsored, 15%. Medi-Cal paid a fixed confidential per diem rate. CONCLUSIONS: Caring for victims of motor vehicle accidents was a break-even proposition for our institution in 1982-1983. Uninsured and unsponsored patients produced a large deficit which of necessity had to be made up by cost shifting to privately insured patients or by direct tax subsidies. Motor vehicle insurance per se made only a modest contribution to our reimbursement for the care of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Computed tomography in thoracoabdominal trauma.

UNLABELLED: This study evaluates our experience with CT scanning in thoracic and abdominal trauma. It was designed to analyze the accuracy and usefulness of CT with regard to: a) type of trauma, b) location of injury, c) timing of scanning, d) timing of operative intervention, e) confirmatory findings, and f) ultimate patient outcome. Between 1978 and 1983, 2,069 CT scans were performed for trauma in our institution, of which 122 were abdominal and ten thoracic, in 98 patients. Thirty-one of these patients had operation or autopsy confirmation of the findings; for 11 patients subsequent CT was available. Abdominal scanning was positive in 48 patients. The organs most commonly injured were spleen (17 patients), pancreas (nine), kidney (11), and liver (eight). Two pancreatic scans were initially interpreted as negative, but in retrospect definite abnormalities were present. CONCLUSIONS: 1) Thoraco-abdominal CT scanning documents injury to the liver, spleen, kidney, and retroperitoneum with a high degree of accuracy. 2) CT is most useful in stable trauma patients without obvious indications for laparotomy but with abnormal findings requiring explanation. 3) CT scanning is useful in evaluating patients for delayed complications following trauma. 4) Attention to details of technique and clinical correlation are essential to avoid misinterpretation of thoracoabdominal CT scans, especially of the pancreas. 5) Use of CT scans may assist in the safe, nonoperative management of selected patients with injury limited to solid organs.

Therapeutic thoracoscopy.

Thoracoscopy was originally devised for diagnostic purposes but has subsequently come to have several therapeutic applications as well. This report reviews our experience with 13 patients in whom thoracoscopy was used in a therapeutic capacity. In three patients intrapleural foreign bodies (segments of polyethylene catheters) were removed endoscopically. In two patients open postpneumonectomy empyema cavities were explored and debrided thoracoscopically. In the remaining eight patients thoracoscopy was used to facilitate chemical pleurodesis in the treatment of effusions or pneumothoraces, after resectable disease had first been ruled out. Our conclusions are as follows: (1) Thoracoscopy can serve therapeutic as well as diagnostic functions. (2) Excellent exposure can be obtained during general anesthesia by use of one-lung ventilation. (3) Thoracoscopy is a safe, simple, and effective means of removing intrapleural foreign bodies. (4) Thoracoscopy allows chemical pleurodesis to be applied selectively to patients who will not require future thoracotomy; i.e., those with proved incurable malignant disease or with recurrent pneumothoraces without gross abnormalities of the pulmonary parenchyma. (5) Chemical pleurodesis is facilitated by this technique, which assures uniform exposure of all pleural surfaces to the sclerosing agent. (6) Pleurodesis is less painful when the sclerosing agent is introduced during general anesthesia. (7) Thoracoscopy allows safe, complete, visually guided débridement of open postpneumonectomy empyema cavities.

Lateral thoracotomy and one-lung anesthesia in patients with morbid obesity.

Between May, 1980, and October, 1981, 22 morbidly obese patients ranging in weight from 93.4 to 236.8 kg (average, 145.2 kg) underwent transthoracic gastric stapling. Fourteen of these operations were performed using endobronchial intubation and selective collapse of the left lung to facilitate surgical exposure. The patients were compared with 22 consecutive patients treated by trans-abdominal gastric stapling during the same period. None of the 44 patients had evidence of chronic alveolar hypoventilation (pickwickian syndrome). In terms of operating time, blood loss, duration of intubation, and hospital stay, the two groups did not differ significantly. Despite marked shunting during one-lung ventilation, satisfactory arterial oxygen tension (PaO2) could be demonstrated on 100% oxygen for all thoracotomy patients (PaO2 range, 67 to 230 torr; mean, 132.3 torr). In fact, except for a lower PaO2 during one-lung anesthesia, the thoracotomy patients were indistinguishable from the laparotomy patients in terms of perioperative respiratory function. Pain, sedation, and positioning led to significant decreases in vital capacity and one-second forced expiratory volume in both groups on the first post-operative day, and in the thoracotomy group on the second day. There were only two wound infections in the thoracotomy group, as opposed to six infections with two dehiscences in the laparotomy group. It is concluded that lateral thoracotomy with or without one-lung anesthesia can be performed safely in massively obese patients--at least in those without preexisting alveolar hypoventilation syndrome.

Prognosis and management of victims of near-drowning.

Between 1972 and 1981 40 victims of near-drowning were admitted to the Santa Clara Valley Medical Center. Hospital records were reviewed with regard to: 1) the circumstances of submersion and rescue; 2) the patient's condition upon arrival at the emergency room; 3) treatment, hospital course, and ultimate outcome. There were ten hospital deaths, 23 patients recovered completely, and seven were discharged with incapacitating neurologic disability. Three of the neurologically impaired patients died between 1 and 13 months after discharge. All patients who arrived with a beating heart were eventually discharged neurologically intact. Of the 21 patients who required in-hospital cardiopulmonary resuscitation, ten died, seven remained comatose, and four recovered without serious neurologic deficits. The use of hypothermia, steroids, and barbiturate coma was not randomized, but did not appear to influence ultimate outcome. Intracranial pressure was monitored in five patients and was never elevated during the first 24 hours. The complete recovery of nearly 20% of apparently lifeless individuals justifies aggressive resuscitation and support of all victims of near-drowning.

Lye ingestion. Clinical patterns and therapeutic implications.

Conventional treatment of caustic esophagitis consists of early endoscopy to the first site of injury followed by antibiotic and steroid therapy, with early mechanical dilatation to prevent stricture formation. The failure of this approach in two recent patients led us to review our overall experience with the management of patients who had ingested lye or other caustic substances. Of 42 patients treated at the Santa Clara Valley Medical Center between 1970 and 1980, seven sustained severe esophageal burns. All had intractable strictures despite steroids, antibiotics, and, in three cases, attempts at dilatation. We conclude that patient survival should not be jeopardized by overly aggressive attempts to salvage an extensively damaged esophagus. Such attempts will probably prove both futile and dangerous, and effective re-establishment of oral-intestinal continuity is now possible by a variety of techniques.