Human peripheral mononuclear cells do not show proinflammatory patterns of cytokine transcription in early trauma: a preliminary report.

Injury has been hypothesized to cause inflammation through systemic release of lipopolysaccharide and pro-inflammatory cytokines, but this has proved difficult to demonstrate in humans. We looked for evidence of an inflammatory pattern of cytokine gene expression by peripheral blood mononuclear cells (PBM) in six polytraumatized patients (ISS = 25 +/- 8) upon ER admission, and in six matched healthy controls. PBM tumor necrosis factor (TNF)-alpha, interleukin (IL)-1 beta, IL-4, IL-6, IL-10, and interferon (IFN)-gamma message was assessed by semi-quantitative reverse-transcription polymerase chain reaction. No increase in expression of any of the pro-inflammatory cytokines (tumor necrosis factor-alpha, IL-1 beta, or IL-6) was found after trauma, and IFN-gamma tended to decrease. Of the immunosuppressive cytokines, IL-10 expression increased 5-fold (p < .05) but no change in IL-4 was discerned. This pattern is fundamentally different from the cytokine expression patterns expected with sepsis or exposure to lipopolysaccharide. These findings are inconsistent with the occurrence of systemic endotoxemia and subsequent global immunocyte activation early after trauma.

Mechanical factors in abdominal wound closure: the prevention of fascial dehiscence.

The incidence of fascial disruption after major abdominal operations is 1% to 3%, and dehiscence is associated with a mortality rate of 15% to 20%. Although several systemic factors (e.g., malnutrition, increased age, male sex, and chronic treatment with steroids) have been associated with an increased risk of wound disruption, their clinical importance has been overstated. Local, mechanical factors such as wound infections, abdominal distention, and pulmonary complications appear to be more important and should be prevented or treated aggressively should they occur. Paramedian wounds are less secure than are midline wounds, but the latter, when closed properly, are probably equivalent to transverse wounds. The peritoneum need not be closed, but the fascia should be sutured securely. Monofilament suture materials are preferred, and the continuous suturing technique has theoretic and practical advantages. Retention sutures are unnecessary if the fascia is closed properly, and the wound itself should not be violated by a drain or stoma. Although fascial dehiscence may not be eliminated, its incidence can certainly be reduced with proper attention to the mechanics of fascial closure.

Trauma is a recurrent disease.

BACKGROUND: Many victims of trauma have a history of repetitive accidental or violent injuries, which implies that trauma is not necessarily a random event. Recurrent trauma is thought to be a problem of urban areas, associated with criminal activities, but there are few data from rural areas that include the victims of nonintentional injuries. METHODS: The prior trauma experience of 200 consecutive patients admitted for trauma was compared with that of 100 consecutive emergency nontrauma surgical admissions and 100 elective surgical admissions to a university hospital and level I trauma center. RESULTS: Trauma patients were younger than emergency patients and elective surgery patients. They were more likely to be male than either emergency or elective surgery patients and, along with emergency nontrauma patients, were more likely to be from a racial minority than were elective admissions. Trauma patients were more likely to have had a previous hospitalization for an injury than either emergency patients or elective surgery patients, and a greater proportion of their prior trauma admissions had been within the past 5 years than in the other two groups. There was no difference in the probability of a prior trauma admission between patients admitted with an intentional injury or an accidental injury, but patients whose current admission was for an intentional injury were three times more likely to have had a prior hospitalization as a result of an intentional injury than were patients admitted because of an accidental injury. CONCLUSIONS: Trauma is a disease with a high risk of recurrence. This may be related to chronic high-risk behaviors such as alcohol or drug abuse, preexisting psychopathology, and cultural acceptance of violent resolution of personal conflicts, all of which adversely affect patients' lives. The role of intensive preventive measures after an initial injury, and directed toward specific high-risk behavior, should be evaluated.

Oxyphil cell adenoma and hyperparathyroidism.

Although the oxyphil cells of the human parathyroid generally are not thought to be involved in the secretion of parathyroid hormone, there have been numerous reports in the literature describing functional oxyphil cell adenomas. We reviewed 453 consecutive parathyroid explorations in 446 patients over a 13-year period and identified 15 patients whose hyperparathyroidism had been caused by adenomas composed almost exclusively of oxyphil cells. All patients were relieved of their hypercalcemia postoperatively, and there have been no recurreness during a mean follow-up of 40 months (100% follow-up). Three patients have died, all without evidence of recurrent hyperparathyroidism at the time of death. Immunoperoxidase and ultrastructural studies confirm that oxyphil cells from these adenomas contain parathyroid hormone and suggest that they are capable of secretory activity. A review of the literature showed that functional oxyphil adenomas occur more frequently than is usually appreciated, although they are an uncommon cause of primary hyperparathyroidism.

Massive rectal bleeding from colonic fistula in pancreatitis.

Two cases of massive hematochezia from pancreatitis-associated colonic fistulae occurred. Diagnosis was made by arteriography; prompt surgical intervention ensued and both patients recovered. This rare complication of pancreatitis should be considered in every patient with rectal bleeding and a history consistent with pancreatitis, especially when an abdominal mass is present. Contrast enema examinations may help to make the diagnosis, but visceral arteriography is preferred because it defines the source of bleeding and guides the operative plan. The minimal surgical treatment consists of ligating bleeding vessels, debriding necrotic tissue, widely draining the peripancreatic space, and creating a totally diverting colostomy. All involved organs should be resected when technically feasible, since this eliminates abnormal tissue and minimizes the chances that hemorrhage will occur.

Ileal duplications in adults. Presentation and treatment.

Alimentary tract duplications are uncommon anomalies that usually present in childhood. They are most common in the ileum but can occur anywhere along the alimentary tract. In this report, we describe an adult with an ileal duplication and review 12 other reported cases of ileal duplication in adults. Abdominal pain, nausea and/or vomiting, weight loss, and hematochezia were the most common symptoms. No patient was correctly diagnosed before operation. Three patients had malignant neoplasm in the resected specimens. Resection of the duplication and adjacent bowel is recommended because of the common blood supply to both, the possibility of malignant degeneration, and the risk of gastrointestinal ulceration and hemorrhage from ectopic gastric mucosa.

A randomized trial of abdominal incision suture technique and wound strength in rats.

OBJECTIVE: To determine whether interrupted en bloc suture or continuous running mass suture technique for closure of abdominal incisions results in stronger wounds, and to determine the time required for each technique. DESIGN: Randomized trial. SETTING: Arthur C. Guyton Animal Facilities, University of Mississippi Medical Center, Jackson. SUBJECTS: Male Sprague-Dawley rats. INTERVENTION: A midline laparotomy was performed on 103 rats that were separated into two groups using computer-generated random numbers. In group 1, incisions were repaired using a continuous mass closure suture technique. In group 2, incisions were repaired using an en bloc interrupted suture technique. OUTCOME MEASURES: Wound bursting pressure was determined on postoperative day 7. The time required to repair each incision was recorded. RESULTS: Continuous mass closure suture technique resulted in significantly greater wound strength (P < .05) and required significantly less time (P < .000001). CONCLUSION: Continuous mass closure suture technique is superior to interrupted en bloc closure with respect to wound strength and closure time.

Tumor necrosis factor alpha gene expression in human peritoneal macrophages is suppressed by extra-abdominal trauma.

BACKGROUND: Trauma is believed to activate immunocytes but paradoxically also increases the risk of intraperitoneal infection. OBJECTIVE: To investigate these events by evaluating changes in the cytokine control networks of human peritoneal macrophages (PM phi) early after trauma. DESIGN: Case-control study comparing cytokine messenger RNA (mRNA) expression by PM phi from patients with extra-abdominal trauma with that of both peripheral blood mononuclear cells (PBM) and PM phi obtained from healthy individuals. SETTING: Level I trauma center and basic science laboratory in a university hospital center. PATIENTS: Six patients with polytrauma (Injury Severity Score, > or = 15) with clinically negative diagnostic peritoneal lavages performed on routine indications at admission to the emergency department and six healthy age- and sex-matched individuals undergoing inguinal herniorrhaphy under local anesthesia. INTERVENTIONS: Peritoneal macrophages were isolated from diagnostic peritoneal lavages in trauma patients. Identical lavages were performed through the hernia sac in the control group. MEASUREMENTS: Cellular RNA was assayed for tumor necrosis factor alpha (TNF-alpha), interleukin-1 beta, IL-6, and IL-10 message by semiquantitative reverse-transcription polymerase chain reaction. RESULTS: Normal PM phi expressed high levels of TNF-alpha mRNA relative to PBM, but expression of the other proinflammatory cytokines was equivalent to that of PBM. Peritoneal macrophage expression of TNF-alpha mRNA was markedly (64-fold) decreased after trauma (P < .001), when PBM expression of IL-10 mRNA was increased (P = .03). CONCLUSIONS: Human PM phi constitutively show high levels of TNF-alpha message expression, and this is down-regulated by polytrauma. This might constitute a functionally "primed" state. If so, TNF-alpha down-regulation might contribute to functional PM phi suppression after systemic injury.

Surgical implications in malignant cardiac disease.

Despite the rarity of primary malignant tumors of the heart (0.0017 to 0.03% of large postmortem series) and the infrequency of clinical signs and symptoms (0 to 50%) of the more common metastatic cardiac tumors, many cardiothoracic surgeons at some time will encounter a patient with one of these two conditions. A review of the medical literature yielded 28 cases of primary cardiac tumors, 10 of secondary tumors, and 12 of carcinoid heart disease treated surgically and followed sufficiently for retrospective evaluation. We summarized those cases and made the following conclusions. Primary malignant tumors of the heart are occasionally resectable, although cure is unlikely; survival may be enhanced by postoperative irradiation but probably not by postoperative chemotherapy. For patients with secondary malignant tumors of the heart, surgical intervention is rarely of benefit except for establishing a tissue diagnosis, effecting artificial cardiac pacing, decompressing symptomatic pericardial effusions, or reducing an obstructive tumor mass. Patients with carcinoid heart disease affecting the valves may derive benefit from valve replacement or repair. Thus, in selected patients with malignant cardiac disease, surgical intervention may be feasible and should always be among the therapeutic options considered.

Effects of hypertonic saline versus lactated Ringer's solution on cerebral oxygen transport during resuscitation from hemorrhagic shock.

Hypertonic saline successfully restores systemic hemodynamics in dogs and humans with severe hemorrhagic shock and, in contrast to lactated Ringer's solution, does not increase intracranial pressure (ICP). This study compares cerebral oxygen delivery in 12 dogs subjected to hemorrhagic shock by the rapid removal of blood (mean arterial pressure of 40 mm Hg maintained for 30 minutes), and then resuscitated with lactated Ringer's solution (six dogs) or 7.5% saline solution (six dogs) to restore systolic arterial pressure. Both solutions effectively restored systemic hemodynamic stability, increasing cardiac output and systolic blood pressure while decreasing mean and diastolic arterial pressure and systemic vascular resistance. The ICP was significantly lower after resuscitation in the hypertonic saline group (p less than 0.05), but cerebral blood flow, which had decreased during shock, was not restored by either fluid, and cerebral oxygen transport fell further secondary to a hemodilutional reduction of hemoglobin. Although hypertonic saline may improve systemic hemodynamics and maintain a low ICP during resuscitation, it fails, as does Ringer's solution, to restore cerebral oxygen transport to prehemorrhagic shock levels.

Laparoscopic surgery during pregnancy.

BACKGROUND: Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans. PATIENTS AND METHODS: We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these women's charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time. RESULTS: Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up. CONCLUSIONS: Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

Laparoscopy in trauma.

Laparoscopy is a nearly century-old technique that has experienced a resurgence of interest from surgeons since the development of technology that has broadened its applications. Although laparoscopy has been used to evaluate patients with possible abdominal trauma, its use for this purpose is limited by the availability of other diagnostic procedures that may be more suitable for particular circumstances and are more accurate for certain injuries. Laparoscopy is contraindicated in patients who are hypovolemic or hemodynamically unstable and should not be performed in patients with clear indications for celiotomy. It may not be appropriate for patients with cardiac dysfunction, nor for those with significant head injuries who are at risk for intracranial hypertension. Its best applications may be in stable patients with stab wounds or those with tangential gunshot wounds of the abdomen. The likelihood of missing hollow visceral injuries depends upon the indications for conversion to celiotomy. If peritoneal violation or the presence of a small amount of blood in the peritoneal cavity is used as an indication for celiotomy, then the missed injury rate will be low but the unnecessary celiotomy rate will be diminished only slightly compared with a policy of mandatory celiotomy. Excessive enthusiasm for laparoscopy in trauma might result in its use when other diagnostic measures or simple observation are more appropriate. The desire to perform a procedure can be compelling, especially in circumstances in which the general surgeon would not operate upon a patient but simply provide postoperative care after other surgeons have operated. The use of laparoscopy for these purposes can only be condemned, as it increases the costs and risks of care without improving the outcome. The role of laparoscopy in trauma is evolving, and further research into its diagnostic role and therapeutic applications is clearly needed.

Appendicitis. The diagnostic challenge continues.

The typical clinical manifestations of appendicitis are well described, but atypical presentations occur frequently. Uncertainty regarding the diagnosis may cause long delays before appropriate treatment is rendered. Several patients in whom the diagnosis was obscure are presented. Barium enema, ultrasonography, computerized tomography, and laparoscopy each may be helpful in diagnosis, but these studies should be used selectively and negative results can be misleading. It is wise to consider other causes of abdominal pain in patients suspected of having appendicitis, so that unnecessary operation can be avoided. It is more important to suspect appendicitis in patients who appear to have nonsurgical conditions of the abdomen, so that the incidence of perforation can be minimized.

Management of the difficult appendiceal stump: how I do it.

The appendix can usually be removed by the standard technique of stump ligation after transection, with or without inversion of the stump into the base of the cecum. When inflammation or necrosis extends into the cecum and the appendix cannot be ligated at its base, there are several options that can be employed. These include appendicocecostomy, partial cecal excision with a stapling instrument, and right colon resection. These techniques have been used 16 times in 249 patients operated upon for appendicitis. Although these techniques will be required infrequently, when they are necessary the risk of appendiceal stump breakdown with peritoneal soilage or cecal fistula can be minimized.

Resuscitation in uncontrolled hemorrhage.

Fluid resuscitation is considered to be an integral component of the management of hemorrhagic shock. Numerous experimental studies of hypovolemic shock have confirmed the value of volume infusions, but in these models the rate, volume, and duration of bleeding are carefully controlled. The results of such studies may not be applicable to clinical hemorrhage, in which bleeding continues unabated. Male Sprague-Dawley rats weighing 250 to 390 g were anesthetized, and a femoral artery and vein were cannulated for constant blood pressure monitoring and fluid infusion. Through a midline abdominal incision, the distal ileocolic artery and vein were transected and allowed to bleed freely into the peritoneal cavity. The abdomen was closed and the animals were randomized to one of five groups: no resuscitation; small volume lactated Ringer's solution; large volume lactated Ringer's; small volume hetastarch; or large volume hetastarch. After 3 hours or at spontaneous death, blood was withdrawn to measure hematocrit, platelet count, and fibrinogen. Blood in the peritoneal cavity was collected and measured. Animals that received either lactated Ringer's or hetastarch had more bleeding into the peritoneal cavity and a greater dilution of clotting factors than animals that received no resuscitation fluids (P < 0.05). In addition, survival was highest in unresuscitated animals, although only the small volume hetastarch group had a significantly lower survival when independently compared with no resuscitation (P < 0.05). These results suggest that in traumatic shock, fluid resuscitation should be minimized until mechanical control of bleeding can be achieved.

Thoracic outlet syndrome reconsidered.

During a four year period, 50 patients were evaluated for possible thoracic outlet syndrome (TOS). These 11 men and 39 women ranged in age from 27 to 60 years, with a mean age of 38.6 years. Their symptoms had been present from 3 months to 10 years (mean = 2.1 years). Twenty-seven had previously undergone 33 operations, including carpal tunnel release, shoulder arthroscopy, rotator cuff repair, cervical discectomy, and first rib resection, all without benefit. Patients were evaluated by history, physical examination, and radiographs of the cervical spine and chest. Additional studies such as electromyography/nerve conduction studies, computed tomography, magnetic resonance imaging, angiography, and myelography were obtained selectively. Only 12 patients were thought to have TOS, seven of whom underwent operation. Four had complete resolution of symptoms; three were improved but had residual symptoms for associated problems. Three patients who were not thought to have TOS underwent first rib resection in other hospitals; none was improved after surgery. The only study of positive value was evidence of unilateral subclavian artery compression with shoulder positioning on physical examination. All other studies were of value only if they demonstrated some other cause of the patient's symptoms. Of the 35 patients without TOS in whom long-term follow-up was obtained, four underwent appropriate operations with benefit, and 20 had good results from physical therapy and nonoperative management. Patients whose symptoms were work-related, and those who had engaged the services of a lawyer, were less likely to demonstrate improvement, regardless of the treatment employed. TOS is a relatively unusual cause of upper extremity pain and dysfunction. History and physical examination are the most important diagnostic studies, and radiographs of the chest and cervical spine and electromyography/nerve conduction studies are useful to identify other causes of pain and disability. Careful selection of patients for surgery can yield satisfactory results. A coordinated team of surgeons, neurologists, and physical therapists is important in the management of these patients.

The anatomy of appendicitis.

Acute appendicitis is a common disorder and, ideally, should be diagnosed prior to the onset of gangrene or perforation. Nonetheless, the goal of early diagnosis remains elusive. In a prospective study, 100 appendectomies were performed for suspected acute appendicitis over 19 months. The location of the appendix was noted by the operating surgeon and was listed as anterior intraperitoneal, retrocecal, pericolic gutter, retroileal, pelvic, or retroperitoneal. The latter four positions were regarded as sites in which the appendix was hidden from the anterior parietal peritoneum. Fifteen patients did not have appendicitis. Of the 85 inflamed appendices, 25 were indurated, 19 were suppurative, and 41 were gangrenous or perforated. Patients with gangrene or perforation were more likely to have pain and tenderness at a site other than the right lower quadrant and had a higher mean heart rate on admission than patients with simple appendicitis, but there were no other differences in symptoms, signs, or laboratory findings among the groups. The appendix was in a hidden location in 15 per cent of patients with simple appendicitis or without appendicitis, compared with 68 per cent of patients with gangrenous or perforative appendicitis (P < 0.001). Complications were more frequent, and hospital stays were longer in patients with advanced appendicitis (P < 0.001). Patients and physicians were equally responsible for delays in treatment, but the high incidence of hidden appendices in those with advanced appendicitis resulted in less severe symptoms and signs than expected. Anatomic variations in the location of the appendix are often responsible for delays in the diagnosis of appendicitis.

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.

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism.

A retrospective review of patients treated for secondary hyperparathyroidism by total parathyroidectomy with parathyroid autotransplantation (tPTX) and subtotal parathyroidectomy (sPTX) is presented. Ten patients underwent tPTX, and 22 patients underwent sPTX between 1977 and 1982. Hypocalcemia and complications of its treatment were a problem in the tPTX patients. One patient in the tPTX group and no patients in the sPTX group have required reoperation for recurrence. Both procedures were highly successful in relieving symptoms of secondary hyperparathyroidism and in reversing renal osteodystrophy. The authors believe that sPTX is a proven, effective operation and the operative treatment of choice for secondary hyperparathyroidism.

Causes of the failed cervical exploration for primary hyperparathyroidism.

Over a period of 42 years, 581 patients with presumed hyperparathyroidism underwent an initial cervical exploration. Abnormal parathyroid glands were removed from 495 patients (85.2%). There was a greater probability of operative success in women, patients over 50 years of age, and patients with hypercalcemia, hypertension, or nonspecific abdominal pain. There was no association of operative outcome with some of the "classic" manifestations of hyperparathyroidism--peptic ulcer disease, neuropsychiatric symptoms, pancreatitis, bone disease, or urolithiasis. The probability of surgical success improved with time, increasing from 56 per cent in the 1950s to 97 per cent in the present decade. This improvement appears to be related to greater operative experience, since all four parathyroid glands were more likely to be found with increased experience, and there was a strong correlation between finding four parathyroids and achieving persistent normocalcemia. The most common causes of operative failure were inaccurate calcium assays (the patient was not truly hypercalcemic), an inappropriate diagnosis ("normocalcemic hyperparathyroidism"), and surgical inexperience. These three factors accounted for at least three fourths of all negative explorations. More accurate diagnostic studies, and careful exploration by an experienced surgeon should maximize the probability of a successful operation for primary hyperparathyroidism.