The endovascular management of penetrating carotid artery injuries: long-term follow-up.

OBJECTIVES: To review a single-centre experience with stent-graft treatment of penetrating carotid artery injuries and long-term follow-up. METHODS: All stable patients with carotid artery injuries presenting between August 1998 and February 2009 were considered for endovascular treatment. Patients were selected based on clinical and radiological criteria and data were prospectively collected. Follow-up was conducted clinically, angiographically and by telephonic contact. Endpoints were stroke, death and any other stent-graft-related complications. RESULTS: A total of 128 patients were treated, of whom only 19 were selected for endovascular management. The recorded technical success rate was 100%, with one early stroke and one non-stent-graft-related procedural death. A further four patients were lost to follow-up. The remaining 14 patients had a mean follow-up of nearly 4 years. No stent-graft-related late deaths, strokes or other complications were reported, although one instance of late stent-graft occlusion was documented. CONCLUSION: Endovascular management of penetrating carotid artery injuries is safe and the long-term outcomes justify a more liberal application of this technique in selected patients.

Surgical and endovascular management of penetrating innominate artery injuries.

OBJECTIVE: To review our management of penetrating innominate artery injuries by open and endovascular techniques. METHODS: Data regarding patient demography, clinical presentation, investigations, associated injuries, pathology, management, complications and mortality, were collected on patients treated at a single centre over 18 years. RESULTS: 39 innominate artery injuries were treated. There were 36 men and three women, with a mean age of 27 years (range 18-49). Thirty-eight injuries were due to stabwounds and one was the result of a gunshot wound. The most common clinical presentations were shock (47%) and haematoma(42%). Twenty-three patients had associated injuries. The most common pathology was false aneurysm in 21 patients followed by 13 actively bleeding injuries, 4 arteriovenous fistulas and 1 arterial occlusion. Thirty-four patients underwent surgical and five endovascular repair. Overall survival was 79%. The stroke rate for surviving patients was 6%. Patients treated with endovascular stenting had shorter hospital and intensive care unit stays than those treated with surgery. CONCLUSIONS: Innominate artery injuries have high rates of morbidity and mortality. A vascular surgical approach with pre-operative angiography, when possible and careful surgical planning by a dedicated team promotes better surgical results. Endovascular and hybrid procedures can become the method of choice when treating stable patients.

Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a serious complication of sepsis that is associated with a high mortality. OBJECTIVES: Using the adapted International Society on Thrombosis and Haemostasis (ISTH) diagnostic scoring algorithm for DIC, we evaluated the treatment effects of high-dose antithrombin (AT) in patients with severe sepsis with or without DIC. PATIENTS AND METHODS: From the phase III clinical trial in severe sepsis (KyberSept), 563 patients were identified (placebo, 277; AT, 286) who did not receive concomitant heparin and had sufficient data for DIC determination. RESULTS: At baseline, 40.7% of patients (229 of 563) had DIC. DIC in the placebo-treated patients was associated with an excess risk of mortality (28-day mortality: 40.0% vs. 22.2%, P < 0.01). AT-treated patients with DIC had an absolute reduction in 28-day mortality of 14.6% compared with placebo (P = 0.02) whereas in patients without DIC no effect on 28-day mortality was seen (0.1% reduction in mortality; P = 1.0). Bleeding complications in AT-treated patients with and without DIC were higher compared with placebo (major bleeding rates: 7.0% vs. 5.2% for patients with DIC, P = 0.6; 9.8% vs. 3.1% for patients without DIC, P = 0.02). CONCLUSIONS: High-dose AT without concomitant heparin in septic patients with DIC may result in a significant mortality reduction. The adapted ISTH DIC score may identify patients with severe sepsis who potentially benefit from high-dose AT treatment.

Traumatic abdominal wall hernia--four cases and a review of the literature.

OBJECTIVE: To review blunt traumatic abdominal wall hernias (TAWHs) in our institution. METHOD: Retrospective review of blunt abdominal trauma cases over a 6-month period. RESULTS: Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery. CONCLUSION: This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.

Traumatic abdominal wall hernia - four cases and a review of the literature : trauma

Objective. To review blunt traumatic abdominal wall hernias (TAWHs) in our institution. Method. Retrospective review of blunt abdominal trauma cases over a 6-month period. Results. Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions; and 1 had been assaulted with a large stone. All were diagnosed on presentation; 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies; and 1 was repaired after 4 months. The 4th patient refused surgery. Conclusion. This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential

Endovascular management of traumatic cervicothoracic arteriovenous fistula.

BACKGROUND: This study evaluated a single-centre experience with endovascular repair of traumatic arteriovenous fistula in the cervicothoracic region. METHODS: Endovascular repair of 27 traumatic cervicothoracic arteriovenous fistulas was attempted between August 1998 and December 2001. Patients with active bleeding or end-organ ischaemia were excluded. Follow-up was accomplished with clinical, duplex Doppler and arteriographic evaluation after 1 month and then every 3 months. RESULTS: Twelve patients with a major vessel injury were treated by stent-graft placement. Vessels involved were the subclavian (eight), common carotid (three) and internal carotid (one) arteries. Subclavian artery side branches were embolized in three of the eight patients. Four patients developed early type 4 endoleaks but all resolved. Treatment with stent-grafts was ultimately successful in all 12 patients. Three patients were lost to follow-up. During mean follow-up of 21 (range 3-36) months, one of the remaining patients developed a graft stenosis. Fifteen patients with minor vessel injuries were treated with arterial embolization. Vessels embolized were subclavian artery branches (four), external carotid artery and branches (seven) and vertebral arteries (four). Successful embolization was accomplished in ten of 15 patients. CONCLUSION: Endovascular therapy is a promising alternative to surgery for selected patients with cervicothoracic arteriovenous fistula.

Laparoscopic versus open surgical exploration in premenopausal women with suspected acute appendicitis.

OBJECTIVES: To assess the utility of laparoscopic versus conventional surgical exploration in premenopausal women with suspected acute appendicitis. METHOD: Female patients aged 15-45 years in whom an independent decision to undertake surgical exploration had been made, were randomised to laparoscopic or open procedures. Comparison of patient groups was conducted on an intention-to-treat basis. RESULTS: Eighteen patients underwent laparoscopic exploration, with 1 procedure requiring conversion to lower midline laparotomy. Open surgical exploration was performed primarily in 16 patients. Postoperative complications (3 patients versus 1 patient) and diagnostic errors (5 patients versus 1 patient) were more frequent in patients undergoing open surgical procedures. Laparoscopic procedures tended to be of longer duration than open operations, but were generally associated with slightly more favourable indices of postoperative recovery (analgesic requirement, postoperative hospitalisation, return to normal activity, return to work). In patients found not to have acute appendicitis, the difference in mean postoperative hospitalisation following laparoscopic intervention (2.6 days) and conventional surgery (3.4 days) approached statistical significance (p < 0.1). CONCLUSIONS: Laparoscopy may carry some diagnostic advantage over open surgery in premenopausal women with suspected acute appendicitis. Patients found not to have acute appendicitis have a marginally shorter period of hospitalisation after laparoscopic intervention. The outcome following laparoscopic appendicectomy for confirmed acute appendicitis is at least equivalent to that achieved with conventional appendicectomy. Laparoscopic exploration is an acceptable option in premonopausal women requiring surgery for suspected acute appendicitis.

Endovascular repair of occluded subclavian arteries following penetrating trauma.

PURPOSE: To describe the endovascular repair of 2 subclavian arteries occluded due to penetrating trauma. CASE REPORTS: Two male patients were admitted with zone-I neck stab wounds. Both were hemodynamically stable and had absent pulses in the ipsilateral upper limb with decreased Doppler pressures. There were no signs of critical ischemia or active bleeding. On arteriography, complete occlusion of the second segment of the left subclavian arteries in both patients was demonstrated. Stent-graft repair and embolectomy under local anesthesia were successfully performed. No procedure-related complications occurred, and both patients were discharged after 2 days. At 1-year follow-up, stent-graft patency was demonstrated in both patients. CONCLUSIONS: Endovascular repair is a feasible and safe option in the management of occluded subclavian arteries due to penetrating trauma. This may represent another indication for stent-grafting in the expanding role of this technique.

Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial.

CONTEXT: Activation of the coagulation system and depletion of endogenous anticoagulants are frequently found in patients with severe sepsis and septic shock. Diffuse microthrombus formation may induce organ dysfunction and lead to excess mortality in septic shock. Antithrombin III may provide protection from multiorgan failure and improve survival in severely ill patients. OBJECTIVE: To determine if high-dose antithrombin III (administered within 6 hours of onset) would provide a survival advantage in patients with severe sepsis and septic shock. DESIGN AND SETTING: Double-blind, placebo-controlled, multicenter phase 3 clinical trial in patients with severe sepsis (the KyberSept Trial) was conducted from March 1997 through January 2000. PATIENTS: A total of 2314 adult patients were randomized into 2 equal groups of 1157 to receive either intravenous antithrombin III (30 000 IU in total over 4 days) or a placebo (1% human albumin). MAIN OUTCOME MEASURE: All-cause mortality 28 days after initiation of study medication. RESULTS: Overall mortality at 28 days in the antithrombin III treatment group was 38.9% vs 38.7% in the placebo group (P =.94). Secondary end points, including mortality at 56 and 90 days and survival time in the intensive care unit, did not differ between the antithrombin III and placebo groups. In the subgroup of patients who did not receive concomitant heparin during the 4-day treatment phase (n = 698), the 28-day mortality was nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo group (43.6%) (P =.08). This trend became significant after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo group; P =.03). In patients receiving antithrombin III and concomitant heparin, a significantly increased bleeding incidence was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001). CONCLUSIONS: High-dose antithrombin III therapy had no effect on 28-day all-cause mortality in adult patients with severe sepsis and septic shock when administered within 6 hours after the onset. High-dose antithrombin III was associated with an increased risk of hemorrhage when administered with heparin. There was some evidence to suggest a treatment benefit of antithrombin III in the subgroup of patients not receiving concomitant heparin.

Consented testing of newborns and childbearing women for human immunodeficiency virus through a newborn metabolic screening program.

OBJECTIVE: In this program a postpartum woman could consent to receive her newborn's human immunodeficiency virus test result from the New York State Newborn Screening Program. STUDY DESIGN: By state regulation each postpartum woman was counseled and offered her newborn's human immunodeficiency virus test result. With the mother's consent, newborn human immunodeficiency virus antibody test results from the Newborn Screening Program were sent to the baby's pediatrician; otherwise, test results were blinded. Data were analyzed for births from August 1, 1996, to January 31, 1997. RESULTS: Overall, 92.5% of women offered newborn human immunodeficiency virus testing consented to receive the result. Among 444 human immunodeficiency virus-positive women offered newborn testing, consented testing resulted in a 21.4% increase in knowledge of human immunodeficiency virus status from 72.3% (n = 321) at delivery to 93.7% (n = 416) after newborn testing; 6.3% (n = 28) of human immunodeficiency virus-positive women delivered of infants who did not consent apparently remained unaware of their human immunodeficiency virus status. CONCLUSION: Combined prenatal and consented newborn testing identified 94% of human immunodeficiency virus-positive mothers and exposed newborns, allowing early entry into care. Such testing may provide an opportunity for women not previously tested for the human immunodeficiency virus to learn their status but is not a substitute for universal prenatal human immunodeficiency virus counseling and consented human immunodeficiency virus testing.

Endovascular treatment of penetrating thoracic outlet arterial injuries.

OBJECTIVES: to establish the feasibility of stent-graft treatment of penetrating thoracic outlet arterial injuries. DESIGN: prospective study. MATERIALS AND METHODS: forty-one patients with penetrating injuries to the carotid, subclavian and proximal axillary arteries admitted between August 1998 and May 1999 were studied. Patients requiring urgent surgical exploration for active bleeding (n=26) were excluded. Remaining patients underwent arteriography to assess suitability for stent-graft placement. After successful stent-graft treatment clinical and sonographic follow-up were done at 1 month and thereafter 3-monthly. RESULTS: of the 15 patients considered, 10 patients qualified for stent-graft treatment (seven male, three female, mean age 27 years). The vessels involved were subclavian artery (seven), carotid artery (two) and axillary artery (one). Seven had arteriovenous fistulae and three, pseudoaneurysms. Stent-graft treatment was successful in all 10 patients with no procedure-related complications. On mean follow-up of 7 months no complications were encountered. CONCLUSION: endovascular treatment shows promise as a treatment modality for thoracic outlet arterial injuries. Long-term follow-up is required for comparison to the results of standard surgical repair.

Acute acalculous cholecystitis--a clinical-pathological disease spectrum.

OBJECTIVE: To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). DESIGN: Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape. PATIENTS: Fifty-seven consecutive patients with AAC treated over a 9-year period. MAIN OUTCOME MEASURES: Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. RESULTS: Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. CONCLUSION: The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.

Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus.

BACKGROUND: The Pediatric AIDS Clinical Trials Group Protocol 076 reported a reduction in the rate of perinatal transmission of the human immunodeficiency virus (HIV) from 25.5 percent to 8.3 percent with a three-part regimen of zidovudine given ante partum, intra partum, and to the newborn. We examined the effects of abbreviated zidovudine regimens on perinatal HIV transmission using data from the HIV polymerase-chain-reaction (PCR) testing service of the New York State Department of Health. Pregnant women who received abbreviated regimens rather than the recommended regimens did so because of limited prenatal care or by choice. METHODS: The requisition form used by the PCR testing service included information on the demographic characteristics of the infants and the timing of any perinatal treatment with zidovudine. We also analyzed data on the timing of zidovudine prophylaxis collected by chart review in a subgroup of 454 infants as a means of validating the results in the entire cohort. RESULTS: From August 1, 1995, through January 31, 1997, specimens from 939 HIV-exposed infants who were 180 days of age or younger were submitted for PCR testing. The rates of perinatal HIV transmission varied depending on when zidovudine prophylaxis was begun. When treatment was begun in the prenatal period, the rate of HIV transmission was 6.1 percent (95 percent confidence interval, 4.1 to 8.9 percent); when begun intra partum, the rate was 10.0 percent (3.3 to 21.8 percent); when begun within the first 48 hours of life, the rate was 9.3 percent (4.1 to 17.5 percent); and when begun on day 3 of life or later, the rate was 18.4 percent (7.7 to 34.3 percent). In the absence of zidovudine prophylaxis, the rate of HIV transmission was 26.6 percent (21.1 to 32.7 percent). CONCLUSIONS: These results confirm the efficacy of zidovudine prophylaxis and suggest that there are reductions in the rates of perinatal transmission of HIV even with the use of abbreviated regimens that are begun intra partum or in the first 48 hours of life.

Toxic epidermal necrolysis in a burn patient complicated by acute pancreatitis.

This report concerns a previously healthy patient who presented with 8% total body surface area burn wounds to his face and neck. Even though his burn wounds healed quickly, his course was complicated by the development of toxic epidermal necrolysis affecting 60% total body surface area due to a drug reaction. During the recovery period he subsequently developed jaundice and pancreatitis -- a rare and interesting course that is not well described in the literature.

Carcinoma of the gallbladder--a possible regional predisposition in the western Cape and northern Cape.

An analysis of 19 patients with confirmed carcinoma of the gallbladder who were treated over a period of 68 months emphasised known clinical features of the disease, i.e. nonspecific symptomatology, late presentation and poor prognosis. Comparison with 883 patients undergoing surgery for benign calculous biliary tract disease during the same period identified a more advanced mean age (67.0 v. 55.3 years), larger mean maximum stone diameter (20.3 v. 11.9 mm) and a higher proportion of patients resident in the Cape interior and west coast region (57.8% v. 11.8%) as features associated with carcinoma of the gallbladder. Further investigation of the regional predisposition suggested by this study may identify new factors linked to the development of gallbladder cancer.

Antibiotic monotherapy with meropenem in the surgical management of intra-abdominal infections.

In an open, multicentre, randomised study, the efficacy and safety of meropenem monotherapy as adjuvant antibiotic therapy in the surgical management of intra-abdominal infection was compared with that of the combination of cefotaxime and metronidazole. A total of 160 hospitalised adult patients with intra-abdominal infection requiring surgery were treated intravenously with either meropenem 1 g every 8 h (by bolus injection or infusion; n = 77) or cefotaxime 2 g and metronidazole 500 mg every 8 h (n = 83). Clinical and bacteriological responses to antibiotic therapy were assessed at the end of treatment and at 2-4 weeks' follow-up after treatment. The clinical response rates at the end of treatment and follow-up were 91% and 96%, respectively, for meropenem and 100% and 97%, respectively, for cefotaxime plus metronidazole. The bacteriological response rates were 90% and 93%, respectively, for meropenem and 92% at both time points for cefotaxime plus metronidazole. Both treatments were well tolerated. In this study, meropenem monotherapy was effective and as well tolerated as cefotaxime plus metronidazole. Meropenem monotherapy should, therefore, prove a useful alternative to standard combination therapy for the empirical treatment of intra-abdominal infections.

A survey of South African endoscopic surgical practice.

To coincide with the first annual meeting of the South African Society of Endoscopic Surgeons (SASES), a postal survey of the endoscopic surgical practices of 98 registered specialist surgeons was undertaken. A response rate of 73.5% was achieved, and 94.5% of respondents had personally performed endoscopic surgical procedures. Cholecystectomy (4,557) was the most commonly performed endoscopic surgical procedure and was associated with a postoperative mortality rate of 0.13% and morbidity of 3.5%. Twelve bile duct injuries were reported (0.26%). In descending order of frequency, other procedures reported were diagnostic laparoscopy (1,404), dorsal sympathectomy (412), appendicectomy (396), inguinal hernia repair (146), anti-reflux procedures (83) and diagnostic thoracoscopy (51). No postoperative deaths were recorded and complication rates varied from zero for diagnostic thoracoscopy to 4.8% for inguinal hernia repair and anti-reflux procedures. The selected sample of South African surgeons canvassed appears to have adopted endoscopic surgical techniques with enthusiasm and with complication rates that compare favourably with those reported elsewhere.

Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest.

The role of thoracoscopy in assessing the status of the diaphragm in penetrating knife wounds of the left lower chest was studied prospectively in 55 patients. Those with positive thoracoscopic findings (n = 22) proceeded to exploratory laparotomy and those with an uninvolved diaphragm (n = 32) were observed. Thoracoscopy was inconclusive in one patient and two were lost to follow-up. With operative findings or 30-month follow-up data as evaluation endpoints, thoracoscopy in 52 patients was 100 per cent sensitive, 90 per cent specific and 94 per cent accurate. A projected negative laparotomy rate of 63 per cent would have occurred with a policy of mandatory laparotomy; using thoracoscopy the actual rate was 6 per cent. Thoracoscopy is a safe and reliable method of evaluating the diaphragm in patients with left lower thoracic stab wounds.

Elective cholecystectomy via a 5 cm subcostal incision.

This report describes a technique whereby elective cholecystectomy is performed through a 5 cm abdominal incision. Initial results in 18 patients compared with 112 historical control patients undergoing conventional cholecystectomy suggest an encouraging reduction in postoperative hospitalisation time, analgesic requirements and period of recuperation. The procedure takes no longer to perform than conventional cholecystectomy and obesity is not a limiting factor, as originally thought. This technique deserves a place alongside laparoscopic and conventional cholecystectomy in future studies seeking the optimal method of managing symptomatic cholelithiasis.