Air gun injuries of the abdomen in children.

From July 18, 1978 to Sept 15, 1982, four boys were treated for air gun injuries of the abdomen at the North Carolina Baptist Hospital, Winston-Salem. Three patients had wounds of one or more of the hollow viscera, and one patient had an injury only of the liver. There was no morbidity or mortality following repair. Some present-day air (pneumatic) weapons have muzzle velocities that equal or exceed those of common civilian handguns, and they are frequently used by unsupervised children. These weapons are not restricted and regulated as are other firearms, and are believed to be incapable of serious injury other than to the eye. These cases and others in the literature dispute that belief.

Lithotripsy for bile duct stones.

Fragmentation of bile duct stones by mechanical, electrohydraulic, and laser intraluminal lithotripsy has greatly facilitated the ability to remove stones that are otherwise difficult to remove by standard manipulative techniques. Even these approaches fail when stones lack access or are impacted within the biliary tree. Extracorporeal shock-wave lithotripsy (ESWL) was evaluated in the United States in a multicenter trial with 56 patients. Stone fragmentation occurred in 91 percent of patients and duct clearance in 79 percent. Adjunctive procedures were used in 54 percent. Two ESWL treatments were required for fragmentation in 28 percent. Complications were mild and relatively infrequent. Hemobilia (8 percent), gross hematuria (6 percent), and biliary sepsis (4 percent) occurred less frequently than expected. There were no deaths during the 1 to 31 days of hospitalization (mean 9 days). We conclude that ESWL is a safe and effective adjunct to the treatment of difficult-to-remove bile duct stones under the conditions observed in this trial.

Diaphragmatic rupture from blunt trauma.

Records of 31 patients who sustained a ruptured diaphragm from blunt trauma form the basis for this report. There were 23 left-sided ruptures, one bilateral rupture, and seven right-sided ruptures. Viscus had herniated into the chest in 30 patients. Right-sided ruptures were associated with greater morbidity and mortality, mostly due to the more serious associated injuries. Chest roentgenograms were abnormal in all 31 patients; bowel could be seen in the chest in 11 patients. Pneumoperitoneum, upper gastrointestinal barium studies, and liver/spleen scans were all diagnostically helpful in selected patients. The correct diagnosis was made preoperatively in 25 of the 31 patients; one-third of all diagnoses were delayed. All exploratory laparotomies for blunt trauma should include careful inspection of the diaphragm, especially in the posterolateral region, and the area close to the esophageal hiatus to detect diaphragmatic rupture and prevent chronic herniations.

Results of local excision of benign and malignant rectal lesions.

Local excision of selected rectal cancers is an acceptable alternative to radical surgery. The results of local excision of various rectal lesions using either the transanal or trans-sacral approach were reviewed over a 10-year period at this institution. A total of 56 procedures were performed on 47 patients (50 transanal/six trans-sacral). The trans-sacral approach was used six times on five patients for lesions averaging a distance of 8 cm from the anal verge. The transanal approach was used 50 times on two patients for lesions occurring at an average distance of 5 cm from the anal verge. Twenty-six malignant lesions were excised (25 transanal/one trans-sacral) with pathologies ranging from poorly to well-differentiated adenocarcinoma. Staging included 12 T1 lesions (46%), 10 T2 lesions (38%), and four T3 lesions (16%). Eighteen malignancies were completely excised and recurrence occurred in four of 18 (22%) with an average follow-up of 2.3 years (range 0-10 years). Local recurrence occurred in two patients (T1 and T2 lesions) and recurrence was in the form of distant metastasis in two patients (two T3 lesions). Three of the recurrences occurred in patients with T3 lesions (three of four; 75%), two occurred in a patient with a T2 lesion (two of 10; 20%), and one occurred in a patient with a T1 lesion (one of 12; 8%). There were no cancer-related deaths during the study period. Twenty-six premalignant lesions (adenomatous polyps) and four benign lesions were excised (25 transanal/five trans-sacral). Local recurrence occurred 10 times with an average follow-up of 1.8 years. In conclusion local excision of certain rectal cancers is an acceptable alternative in the treatment of these malignancies.

Modified Thiersch operation for rectal prolapse. Technique and results.

Rectal prolapse is best treated by intra-abdominal or perineal procedures that either resect the redundant rectosigmoid colon or fix the rectum within the pelvis. We have found the Thiersch procedure to be adequate treatment in patients who are high risk or who have only mild to moderate prolapse of the rectum. Over the past 20 years, we have treated 15 patients with a modified Thiersch procedure, using a knitted Dacron vascular graft to encircle the anus. One patient required a second Thiersch procedure after failure of a Ripstein procedure that followed failure of a Thiersch procedure done with wire. A second Thiersch procedure was required in two patients after suture breakage, and in one patient after removal of an infected graft. Two other patients had graft infections necessitating removal of the Dacron graft; one patient had a perianal infection that was treated without removing the graft. Continence was achieved in six of nine patients previously incontinent, and maintained in the six patients who had been continent before operation. Prolapse was corrected in 13 of the 15 patients. Although the Thiersch procedure is not applicable to all patients with rectal prolapse, it can be used successfully when performed properly.

The management of snake and spider bites in the southeastern United States.

Of all snake bites reported in the United States of America each year, 75 per cent occur in the states that form the Southeastern Surgical Congress. Pit vipers, coral snakes, and exotic imported snakes are all found in that area. Deaths from those snake bites are rare, but morbidity is high and it is often due to overtreatment rather than undertreatment. Treatment in the field is rarely necessary for the victim who is less than 1 hour away from definitive care. The type and size of the snake and the age, size, and health of the patient are important guides to therapy. Envenomation may not occur. When envenomation occurs from pit viper bites, antivenom is not always necessary, and its inherent dangers (serum sickness and possible hypersensitivity) must be weighed against the severity of systemic and local manifestations. All coral snake bites resulting in envenomation must be treated vigorously with coral snake antivenom. The Oklahoma City Poison Control Center can guide the treatment of bites from exotic snakes. The most frequently encountered toxic spider bites in the Southeast are those of the black widow and brown recluse spiders. The symptoms of black widow envenomation are best controlled with calcium gluconate or a muscle relaxant. Antivenom should be reserved for severe reactions. Brown recluse necrotic lesions are best controlled with dapsone.

Management of epiphrenic esophageal diverticula. A fifteen-year experience.

Epiphrenic esophageal diverticula represent an unusual cause of dysphagia, pain, and weight loss. Although commonly associated with motility disorders, distal esophageal diverticula also have been associated with reflux strictures or other lesions. To determine the most appropriate diagnostic evaluation and operative approach, we reviewed the recent 15-year experience with epiphrenic esophageal diverticula at our institution. Over the study period, 18 patients were diagnosed with pulsion epiphrenic diverticula. Nine patients (50%) with symptomatic diverticula were referred for surgical management. All referred patients were evaluated with preoperative manometry, endoscopy, and contrast esophagography. Diverticulectomy was performed via posterolateral thoracotomy in all patients, combined with myotomy in the 6 patients (67%) with abnormal manometric results and in 2 patients with normal manometric results. The third patient with normal manometric results underwent simple diverticulectomy. There was no operative mortality. One complication, a small esophageal leak, was managed successfully by early reoperation. All patients were free of dysphagia at discharge. Follow-up was obtained for 17 patients (94%) ranging from 3 months to 12 years. Good to excellent results (measured by relief of symptoms, weight gain, and absence of clinical recurrence) were seen in all 9 surgical patients; 6 of 9 nonsurgical patients remained or became symptomatic. This experience demonstrates the efficacy of surgical management of symptomatic epiphrenic esophageal diverticula. Diverticulectomy combined with selective myotomy permits excellent operative results and resolution of associated symptoms.

Prevalence of ischemic nephropathy in patients with renal insufficiency.

To estimate its clinically unsuspected prevalence among patients with renal insufficiency, renal duplex sonography (RDS) was used to estimate the presence of critical renal artery stenosis (RAS) in that population. Patients, aged 45 to 75 years, with a serum creatinine of greater than or equal to 2.0 mg% but without dialysis dependence, prior renal transplantation, or prior renal artery surgery were considered for RDS. Fifty-three patients who met criteria for study were randomly selected from the Section of Nephrology clinic files and each patient was contacted both by mail and by telephone. Twenty-five patients agreed to RDS, and renal artery anatomy was determined in 21 patients using standardized RDS techniques. These techniques have demonstrated an overall accuracy of 96 and 97 per cent when compared prospectively to conventional angiography during validity analyses in the authors' center. Results of RDS revealed significant findings in 5 of 21 patients (24%). Three patients demonstrated criteria for ischemic nephropathy (IN): one patient had RAS with contralateral renal artery occlusion confirmed by angiography, while 2 patients demonstrated unilateral RAS. An abdominal aortic aneurysm and unilateral hydronephrosis were discovered in the fourth and fifth patients. Evaluation of patient demographic data and functional parameters as predictors of IN revealed that the duration of renal insufficiency at the time of RDS and extra-renal organ-specific atherosclerotic damage were significantly different between the groups with and without IN. The authors preliminary findings suggest that unsuspected ischemic nephropathy may exist in a significant minority of patients with renal insufficiency.

Microscopic hematuria after blunt trauma. Is pyelography necessary?

Hematuria after blunt abdominal trauma is common with multiple organ system injuries, and many trauma centers routinely perform intravenous pyelography (IVP) on all trauma patients having any degree of hematuria. However, it has been suggested that many IVPs could be avoided if more selective criteria were used. To help determine the need for an IVP, we reviewed the records of 102 consecutive patients undergoing IVP after blunt abdominal trauma over a 17-month period. Twenty-six (25%) patients had gross hematuria. Of these, seven (27%) had abnormal IVPs, and two (7.7%) of those required urologic surgery. Seventy-six (75%) patients had microscopic hematuria. Of these, one (1.3%) had an abnormal IVP but required no urologic surgery. Thus, if IVP had been performed only when gross hematuria was present, then all surgically significant urinary tract lesions would have been recognized, and 75 per cent of these 102 patients would have been spared IVPs. We agree with others that microscopic hematuria alone is not an indication for emergency IVP in these trauma patients. However, gross hematuria or other strong clinical evidence of renal injury still mandates IVP early during the assessment of patients who have suffered blunt abdominal trauma.

"Blind" placement of long-term central venous access devices: report of 589 consecutive procedures.

Placement of long-term central venous access devices, such as Hickman catheters and implanted subcutaneous ports, has traditionally been performed in the operating room with fluoroscopy. This study reports our experience with percutaneous placement of these devices in the outpatient clinic setting without the use of real-time imaging. Results were generated from a prospective database of all adult patients undergoing placement of central venous access in the outpatient clinic of the Wake Forest University Baptist Medical Center. This database revealed that during the years 1996 and 1997, long-term central venous catheter placement was attempted in 589 adult patients in the outpatient clinic. Technical success was achieved in 558 patients (92%). This included 278 tunneled catheters and 280 totally implanted devices. Repositioning of the catheter tip was required in 16 patients (2.9%). The incidence of pneumothorax was 1.9 per cent. Late complications, including infection and thrombosis, occurred in 9 per cent. The average procedure-related charge for placement of a single-lumen central venous port in the outpatient clinic was $1691 versus $4559 in the operating room and $3890 in the radiology department. We conclude that routine placement of long-term central venous access devices in the outpatient clinic, without the use of real-time imaging, yields acceptable success rates and may have economic advantages over procedures performed in the operating room or radiology department.

Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index.

A retrospective review of 676 tibial-fibular fractures and 985 femoral fractures treated over a 71-month period yielded associated major vascular trauma in 12 (1.7%) tibial-fibular fractures and in five (0.5%) femoral fractures. Vascular trauma combined with orthopedic trauma was also identified in four other cases--two disruptions of the pubic symphysis and two dislocations of the knee without fracture. Nine (43%) of the 21 involved limbs were eventually amputated. Limb survival was not related to the temporal relationship of vessel repair to skeletal stabilization; the presence or absence of shock on admission; the presence of associated but repaired venous injury; or the presence of unrelated injuries. Limb survival was related to the interval from injury to arrival in the operating room; the level of arterial injury; and the quantitative degree of muscle, bone, and skin injury. By combining these variables a limb salvage index was established that identified lower extremities likely to require amputation after combined orthopedic and vascular trauma (sensitivity 78%, specificity 100%). Use of this predictive salvage index may prevent the trauma surgeon from attempting to salvage a doomed or useless lower extremity and may thus permit early prosthetic rehabilitation to follow definitive primary amputation.

Supradiaphragmatic correction of esophageal reflux strictures.

Intragastric pressure measurements and cineradiographic contrast studies were done in monkeys in order to determine the pressure at which esophageal reflux occurred. Antireflux operative procedures were performed above and below the diaphragm, and the results compared. The Nissen fundoplication proved to be the most effective type of mechanical antireflux valve and worked equally well placed above and below the diaphragm. Of 200 consecutive adult patients undergoing operative correction of esophageal reflux, 19 had severe esophageal strictures. Through a transthoracic approach, two patients had subdiaphragmatic Nissen fundoplications, one with adenocarcinoma of the esophagus had an esophageal resection, and 16 had supradiaphragmatic Nissen fundoplications; those 16 patients form the basis of this report. No patients died; superficial, temporary esophageal ulcerations developed in two. Follow-up times have ranged from six months to eight years; the results in all cases have been good. Experimental and clinical evidence supports the belief that this less radical approach is the treatment of choice in the management of severe esophageal strictures secondary to reflux esophagitis.