Second hepatoma developing 13 years after resection of first tumor.

A patient underwent a left-sided hepatic lobectomy for primary hepatocellular carcinoma 13 years ago and remained symptom free. He then presented with spontaneous rupture of a large tumor in the right lobe of the liver. Although this tumor proved to be primary hepatocellular carcinoma, there were significant histological differences between the two lesions, suggesting that this was a second primary liver tumor. Bleeding from the tumor was controlled by selectively ligating the branches supplying the area of hemorrhage.

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.

Pyogenic splenic abscess in intravenous drug addiction.

Among the surgical complications of intravenous drug addiction, pyogenic splenic abscess is considered to be a rare entity. A review of the literature reveals only 24 cases of splenic abscess secondary to this particular etiology. The authors report five patients with intravenous drug addiction who underwent splenectomy for pyogenic splenic abscess within 1 year. Fever and abdominal pain were the only constant physical signs. Three patients had associated infective endocarditis, and the other two patients sustained blunt trauma to the left side of the trunk weeks earlier. Computed tomography (CT) and ultrasound were diagnostic in all five patients preoperatively, and they were complementary when combined. Four of the five patients had Staphylococcus aureus septicemia at the time of splenectomy. Three patients recovered from their operations, and the other two, both with endocarditis, died postoperatively from causes unrelated to splenic abscess and splenectomy. A high index of suspicion is warranted in this susceptible group of patients with vague abdominal signs and persistent sepsis to rule out splenic suppuration. The noninvasive imaging methods, CT scan and ultrasound, facilitate early diagnosis in these patients.

Penetrating right colon trauma. The ever diminishing role for colostomy.

Ninety consecutive patients with penetrating trauma to the right colon were analyzed. The severity of injury to the colon and other abdominal organs was quantified in each patient by the Colon Injury Score (CIS) and the Penetrating Abdominal Trauma Index (PATI). Sixty-five patients (72%) were managed definitively, i.e., by primary repair (46 patients) and by resection-ileocolic anastomosis (19 patients). There was no morbidity related to the colonic repair in these patients. Exteriorized repair was used selectively in eight patients and was successful in six (75%). Thirteen patients underwent loop colostomy and the mean CIS and PATI in this group were comparable to those in primary repair and exteriorized repair groups. Resection colostomy was performed in four patients with extensive colon and associated organ trauma (high CIS, PATI). The overall incidence of intra-abdominal abscess was 2.2 per cent (2 of 90 patients). The mortality was 4.4 per cent (4 of 90 patients) and none of the deaths was related to the management of the colon trauma. It is concluded that the majority of patients with penetrating right colon trauma can be treated effectively by primary repair or resection anastomosis. Exteriorized repair should be the preferred method whenever loop colostomy is considered. Colostomy should be used selectively in unstable patients who require colon resection.

Definitive treatment of colon injuries: a prospective study.

The results of a prospective protocol for penetrating injuries of the colon in 252 patients are presented. The protocol emphasized definitive management of the injury by repair, resection and anastomosis or exteriorized repair. Colostomy was reserved for left colon injuries requiring resection or for delayed treatment. Two hundred nineteen patients (86.9%) had definitive treatment by repair (N = 159), resection and anastomosis (N = 26), or exteriorized repair. This was successful in 205 patients (93.6%). Three patients had anastomotic leak after repair or ileocolostomy. Eight of the 34 patients with exteriorized repair had suture-line breakdown and 26 (76.5%) patients avoided a colostomy. Injury severity indices (anatomic: Abdominal Trauma Index and Flint grading of colon injury) were higher in the exteriorized repair than in the repair group. Postoperative abdominal abscesses occurred in 43 patients (17.1%). A multiple regression analysis identified the Abdominal Trauma Index (P < 0.0001) and the presence of colostomy (P < 0.0004) as significant independent factors in association with this complication. Mortality from sepsis was 2.4 per cent (6 patients) and in only one patient was the death directly related to colon injury management. We conclude that the majority of colon injuries can be managed by repair or resection with anastomosis. End colostomy is unavoidable in Flint 3 injuries of the left colon. In other situations, ileocolic or colocolic anastomoses appear to be safe in hemodynamically stable patients. Loop colostomy has a role in delayed treatment, but can be replaced by an exteriorized repair in Grade 2 colon injuries that do not require resection.

Craniocervical necrotizing fasciitis: critical factors in management.

Necrotizing fasciitis involving the head and neck is rare. The authors describe two such patients treated at their institution and analyse 39 cases reported in the literature. This entity may be divided into two groups based on the site of origin of the infection: group 1 (13 cases) infections, originating in the scalp and eyelids, mostly secondary to trauma, do not progress rapidly, respond well to medical and operative measures and result in minimal permanent disability. These infections usually are caused by hemolytic streptococci and Staphylococcus aureus. Group 2 (28 cases) infections, originating in the face or neck and mostly complications of dental and pharyngeal sepsis, progress rapidly to adjoining sites including the chest wall and mediastinum. These infections are caused by a wide variety of microorganisms including anaerobes; fatal complications are frequent and the death rate is high (32%). Early and very aggressive débridement and drainage are mandatory and should be repeated if warranted.

Nonoperative management versus early operation for blunt splenic trauma in adults.

Forty-eight adult patients with isolated splenic trauma from blunt injury were analyzed during a six year period (1980 to 1986). Early laparotomy was performed upon 38 patients and splenic preservation was accomplished in 18. The remaining ten patients who were hemodynamically stable were managed nonoperatively with close monitoring. Splenic injuries were confirmed by one of the imaging methods, such as computed tomography, radionuclide scan or ultrasound. One patient with known hepatic cirrhosis underwent embolization of the splenic artery and recovered. Nonoperative treatment failed in seven of the remaining nine patients, mandating an exploratory laparotomy between the third and tenth day of admission. In six of the seven patients, splenic preservation was unsuccessful, necessitating a splenectomy. The length of hospital stay was longer for this latter group (a mean of 15.8 days) than for patients who had splenorrhaphy (a mean of 7.5 days), or splenectomy (a mean of 8.7 days, p less than 0.001). Patients managed nonoperatively required more units of blood compared with those undergoing splenorrhaphy (4.1 units versus 1.7 units, p less than 0.01). A review of the literature reveals that splenic preservation is possible in less than 25 per cent of the patients who fail to respond to nonoperative management. We conclude that splenic injuries after blunt trauma in adults are treated best by early laparotomy in order to achieve maximal splenic preservation.

Penetrating thoracic injuries: in-field stabilization vs. prompt transport.

One hundred patients who were in extremis and required Emergency Room Thoracotomy (ERT) after sustaining penetrating thoracic injuries were analyzed to compare the results of attempted stabilization in the field (n = 51) with those who had immediate transportation (n = 49). The clinical status of the patients in the field and in the E.R. was quantified by Trauma Score (TS) as well as Physiologic Index (PI), ranging in severity from 20 (clinically dead) to 5 (stable). The anatomic injury severity was expressed by Penetrating Trauma Index (PTI). Survival was analyzed according to the type of injuries: noncardiac and cardiac. The overall survival was 10%. There was only one survivor with noncardiac injuries. Sixty-nine patients had cardiac penetration, 33 in Group I (stabilization) and 36 in Group II (immediate transport). Despite attempts at stabilization, none of the patients in Group I showed an improvement in clinical status from the scene to the emergency room. There were a higher number of patients arriving at the E.R. with signs of life in Group II compared to Group I. In Group II patients, survival was significantly improved overall (p = 0.01), in patients with signs of life on arrival at the hospital (p = 0.02) and in patients with isolated right ventricular wounds (p = 0.01) compared with Group I. The anatomic injury severity (PTI) as well as the mode of injury in the two groups was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of peritoneal lavage and urological studies in major fractures of the pelvis--a reassessment.

Fifty patients with major fractures of the pelvis (Trunkey's classification types I and II) treated in an urban Level I Trauma Center were analysed to assess the role of peritoneal lavage and urological studies in the initial evaluation. The mechanisms of injury were automobile v. pedestrian (44 per cent), falls from heights (44 per cent), and motor vehicular accidents (12 per cent). Important hypotension was present in 46 per cent of patients on arrival. Peritoneal tap or lavage was selectively used in 11 patients (22 per cent). Four patients in refractory hypotension despite vigorous resuscitation had positive results. There were no false-positive results or missed intra-abdominal injuries in any of the 50 patients. Laparotomy was carried out in 10 of 50 patients. IVP or cystography was performed in 25 of 50 patients. However, injuries of the urinary tract requiring operative correction (eight injuries in six patients) were all associated with gross haematuria. Urological studies were negative in patients with 1 to 3+ microscopic haematuria. Peritoneal lavage is recommended on a selective basis in patients with pelvic fractures. Microscopic haematuria does not warrant contrast studies of the urinary tract.

Acid burns of the rectum and colon. Report of a case.

The case of a patient with acid burns of the large bowel from a self-administered enema of 95 percent sulfuric acid solution is reported. The authors were unable to find a similar case in the English medical literature. The patient presented in metabolic acidosis, and flexible sigmoidoscopy was of limited value. Peritoneal signs warranted early laparotomy, which revealed coagulation necrosis of the anus, rectum, and colon up to the hepatic flexure without any free perforation. The extent of damage was more severe than seen in the upper digestive tract from acid ingestion. Juxtaposed small bowel and the appendix sustained serosal burns. Subtotal proctocolectomy and perineal resection were done and the patient made an uneventful recovery. Early laparotomy is warranted, irrespective of endoscopic findings, for appropriate surgical correction.

Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury.

A method of quantifying the anatomic extent of injury to the heart, Penetrating Cardiac Trauma Index, (PCTI) and other thoracic organs has been proposed. The total extent of thoracic injury, Penetrating Thoracic Trauma Index (PTTI), was measured. When associated abdominal injury was present, it was assessed by the Penetrating Abdominal Trauma Index (PATI) of Moore et al. The severity of total injury sustained by the patient, represented by the Penetrating Trauma Index (PTI), was determined by the sum total of these scores. The extent of physiologic abnormality induced by cardiac penetration, (Physiologic Index or PI), was graded on a scale of increasing severity from 5-20 based on the vital signs of patients on admission. Analysis of 112 patients with penetrating cardiac injuries (1973-1983) revealed that the indices, PCTI and PI, showed an excellent correlation with survival (R2 = 0.827 and 0.928, respectively) as did the total extent of trauma (PTI). A composite prognostic score of the sum of PI and PTI demonstrated a significant separation of survivors from nonsurvivors (p less than 0.001). It is concluded that these anatomic (PCTI and PTI) and physiologic (PI) indices are valid and, with additional confirmation, may provide an objective method of evaluating penetrating cardiac injuries.

Penetrating colon injuries: exteriorized repair vs. loop colostomy.

Eighty-five patients with penetrating colon injuries, treated either by exteriorized repair (39) or loop colostomy (46), were analyzed. Missile wounds accounted for 75.3% of the injuries. The Penetrating Abdominal Trauma Index (PATI) was the scoring method employed to assess quantitatively the severity of injuries in each patient. Of 21 patients with right colon injuries, eight were treated by exteriorized repair and the remainder by loop colostomy. PATI and other variables were comparable in both groups. Suture line leaks occurred in two patients (25%) with exteriorized repair. The morbidity was similar in both groups. In left colon trauma, exteriorized repair was employed in 31 patients and 33 underwent loop colostomy. The injury severity indices, clinical status, and time lapse to laparotomy were similar in both groups. Colostomy was avoided in 67.7% (21 of 31) patients with exteriorized repair. The incidence of abscesses was significantly higher in the colostomy group compared to the group treated by exteriorized repair (24.2% and 6.4%, respectively; p less than 0.05). The length of hospital stay was shorter after exteriorized repair (17.2 days vs. 23.2 days; p less than 0.05). All three mortalities (3.5%) were related to associated injuries. We conclude that exteriorized repair is a safe and superior alternative to loop colostomy in penetrating colon trauma.

Aggressive definitive management of penetrating colon injuries: 136 cases with 3.7 per cent mortality.

One hundred thirty six patients with penetrating colon injuries (gunshot wounds, 95; stab wounds, 41) were retrospectively analyzed. A scoring system, the Penetrating Abdominal Trauma Index (P.A.T.I.), was employed to quantitatively assess the severity of injuries in each patient. Of 67 patients with right colon injuries, 48 (72%) were treated definitively by primary repair (32) and by resection and ileocolic anastomosis (16), with minimal morbidity. In 69 patients with left colon injuries, 47 (68%) were treated by colostomy (28) and by exteriorized repair (19). Overall, exteriorized repair was successful in 74% of patients. All five mortalities (3.7%) were related to associated injuries. It is concluded that the majority of the right colon injuries can be treated definitively. Exteriorized repair should be the preferred method whenever colostomy is considered, except in severe left colon injuries requiring resection.

Emergency room thoracotomy for penetrating cardiac injuries.

The results of emergency room thoracotomy (ERT) and cardiorrhaphy for 91 patients with penetrating cardiac injuries admitted in extremis to Lincoln Medical and Mental Health Center from 1963 to 1981 are reviewed to determine criteria for selection of patients for this procedure. Four groups were defined based on the severity of the effects of their injuries. The survival rates were 32.1 and 33.3%, respectively, for Group I ('fatal') and Group II ('agonal') patients. There were no survivors in Group IV ('D.O.A.') patients for whom ERT is a fruitless procedure. Survival in Group III ('profound shock') patients was only 40%, which might have been improved if ERT had been performed without delay. We conclude that ERT is essential for patients with 'fatal' and 'agonal' wounds and advise prompt ERT for patients in 'profound shock' who do not respond immediately to rapid volume infusion.

Penetrating injuries of the neck: criteria for exploration.

One hundred thirty-six patients with penetrating injuries of the neck over a 4-year period were studied prospectively. Seventy-two patients (52.9%) had no major physical signs on admission, 56 were observed without complications, and 16 had a negative exploration. Injuries below the level of the cricoid cartilage were associated with a very high mortality (12.12%). We recommend a policy of selective conservatism in the management of penetrating neck injuries.