Latent mammary tuberculosis: a case report.

Tuberculosis of the breast was diagnosed in this 63-year-old woman 14 years after she was treated for tuberculous pericarditis. Case history and a review of the literature are presented.

Cervical vascular injuries: a trauma center experience.

BACKGROUND: We analyzed 76 patients with cervical vascular injuries from penetrating neck trauma (n = 528) between 1977 and 1990 at a level I trauma center to evaluate the role of angiography in diagnosis and management and to assess the course and outcome of these patients. METHODS: Patients who were hemodynamically unstable underwent immediate surgical exploration. Stable patients were subjected to diagnostic investigation. Angiography was routinely performed to diagnose vascular injury in zones I and III and zone II if the trajectory was in the vicinity of major vessels. Therapeutic embolization was performed when possible at angiography; all other vascular injuries were treated surgically. RESULTS: Thirteen patients (2.5%) died of penetrating neck trauma, in 12 of whom hemorrhage was the contributing factor (12/76; 15.8% of patients with vascular injury). In nine patients who were hemodynamically stable vascular injury was diagnosed by angiography: 5 (6.8%) of 73 in zone I and 3 (5.4%) of 56 in zone III, four of whom underwent therapeutic embolic occlusion of the injured vessel. Injuries to vertebral and subclavian arteries and subclavian and innominate veins were often multiple, causing exsanguination and death (6.8% in zone I). In three patients with no preoperative neurologic deficit, the internal carotid artery was ligated without complication; in all other patients injury to the common carotid or internal carotid artery was repaired, in six of them with polytetrafluoroethylene grafts. CONCLUSIONS: Selective management of penetrating neck trauma should include routine angiography in zones I and III. Injuries to the common and internal carotid arteries should be repaired. The internal carotid artery may be ligated in the absence of preoperative neurologic deficit. Arterial injuries in the neck can be repaired with polytetrafluoroethylene grafts.

Meticulously restored lumina of injured veins remain patent.

We report our experience with 38 major venous injury repairs in 37 patients between January 1981 and December 1989. The injuries were caused by gunshot (n = 27), shotgun (n = 3), knife (n = 5), blunt trauma (n = 1), and dog bite (n = 1). These involved 27 femoral, 10 popliteal, and one brachial veins. Thirty patients had associated major arterial injuries and seven had major long bone fractures. Retrospective analysis yielded two groups. Group I consisted of 17 patients who underwent meticulous restoration of venous lumina ensured by intraoperative postreconstruction venography (IPV) in all patients. Two of these required revision on the basis of IPV findings. Late patency of venous repair was confirmed by postoperative venography (n = 10) or duplex scans (n = 7). All 17 venous repairs were patent (100%). In group II none of the 20 patients (21 veins) underwent IPV. Fifteen of the 20 patients underwent venography and five patients (six veins) underwent duplex scanning after surgery. Eight veins were occluded and 13 (62%) were patent. The difference in patency rates of venous repair between groups I and II was significant (p = 0.02). Three (37.5%) of eight patients with occluded venous repair required delayed fasciotomy, but only 1 (3.4%) of 29 limbs (30 veins) with patent lumina required fasciotomy (p = 0.03). We conclude that meticulous restoration to normal-caliber venous lumina, confirmed by IPV, can achieve high patency and low morbidity rates.

Blood transfusion increases the risk of infection after trauma.

To determine whether blood transfusion influences infection after trauma, we analyzed data on 5366 consecutive patients hospitalized for more than 2 days at eight hospitals over a 2-year period. The incidence of infection was significantly related to the mechanism of injury: penetrating injuries, 8.9%; blunt injuries, 12.9%; and low falls, 21.4%. Stepwise logistic regression analyses of infection using the variables age, sex, respiration rate in the emergency department, Glasgow Coma Scale in the emergency department, Injury Severity Score, shock (systolic blood pressure < 90 mm Hg on admission to the emergency department), and log of total amount of blood transfused during hospitalization showed that amount of blood received and Injury Severity Score were the only two variables that were significant predictors of infection across groups. Even when patients were stratified by Injury Severity Score, the infection rate increased significantly with increases in numbers of units of blood. Blood transfusion in the injured patients is an important independent statistical predictor of infection. Its contribution cannot be attributed to age, sex, or the underlying mechanism of severity of injury.

A critical reappraisal of indications for fasciotomy after extremity vascular trauma.

OBJECTIVE: To critically reevaluate the indications for fasciotomy in vascular trauma of the extremities. DESIGN: Case-control study. SETTING: Level I trauma center. MATERIALS AND METHODS: One hundred sixty-three vascular injuries to the extremeties were analyzed. Fasciotomy as an adjunct to vascular repair was performed in 45 limbs (28%), based either on the nature of injury or measured compartment pressure of greater than 35 mm Hg. MAIN OUTCOME MEASURES: Need for fasciotomy or limb amputation. RESULTS: Fasciotomy was performed for 29.5% of isolated arterial injuries, 15.2% of isolated venous injuries, and 31.6% of combined arterial and venous injuries, and was not related to venous repair or ligation. Seven delayed fasciotomies were performed either for vascular repair failure (5 patients) or compartment syndrome (2 patients). The highest incidence was for popliteal vessel injury (arterial 57%, combined 61%). Of the 33 lower-extremity fasciotomies, 58% were for popliteal vessel injury. In 51 combined injuries of the lower extremity, only 7 (19%) of 38 patients with injury above the knee required fasciotomy, as compared with 8 (62%) of 13 with injury to the popliteal vessels (P<.001), with or without venous repair. There were 3 amputations, all resulting from vascular repair failure. CONCLUSIONS: The presence of a combined vascular injury or the need for venous ligation does not necessitate routine fasciotomy. The need for fasciotomy may be maximal for injuries to popliteal vessels.

Monitor-guided responses. Operability with safety is increased in patients with peripheral vascular diseases.

Poor cardiopulmonary reserve was demonstrated in a group of 75 elderly patients undergoing elective vascular reconstruction when cardiovascular hemodynamics were analyzed with the automated physiologic profile (APP) preoperatively. Only 25 patients (33.3%) had normal left ventricular function (LVF) and did not need any corrective therapy before surgery. Increment in preload was necessary in 20 patients (26.7%) to improve myocardial function; 30 patients (40%) revealed abnormal LVF and hence required pharmacologic modulation and preload adjustment, inotropic support, and afterload reduction to enhance the ventricular performance. Conventional methods of clinical evaluation did not reveal the degree of compromised ventricular function and potential high risk of surgical morbidity and mortality in many of these patients. The APP disclosed subtle and important physiologic aberrations indicating modification of anesthetic and operative procedures and precise modulation of physiologic factors. Optimization was achieved in all except two patients, and only one was denied the benefits of vascular reconstruction.

Depressed myocardial function after transurethral resection of prostate.

Cardiovascular physiologic monitoring was undertaken in 12 patients undergoing transurethral resection of the prostate with the aid of flow-directed Swan-Ganz catheter and the Automated Physiologic Profile. Cardiac and pulmonary pressures and physiologic parameters were derived pre- and postoperatively. Resecting time, body temperature, intravenous fluid administered, serum hemoglobin, and sodium also were recorded. Of the 12 patients studied, 66 per cent experienced a drop in their cardiac index as well as their left ventricular function after surgery. Myocardial function curves revealed that 7 patients (58 per cent) had decreased cardiac function, 2 had no change, and 3 had increased function. Four patients with preoperative pulmonary wedge pressures (PAW) over 9 mm. Hg experienced depressed cardiac function. Three patients were resected for over sixty minutes, and all experienced depressed cardiac function. Vital signs, serum hemoglobin, or serum sodium did not reflect this change. We believe that relative hypervolemia, undetected elevation of pulmonary wedge pressure. We believe that relative hypervolemia, undetected elevation of pulmonary wedge pressure, and prolonged resection are factors that depress cardiac function and increase the risk of cardiovascular complication in transurethral surgery.

A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH.

BACKGROUND: Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. STUDY DESIGN: Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits. RESULTS: Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death. CONCLUSIONS: Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.

Compartment syndrome in combined arterial and venous injuries of the lower extremity.

In 9 of 45 patients treated for dual vascular injuries of the lower extremity, concomitant fasciotomies were performed at the time of initial surgery for associated soft tissue injury, fracture, or prolonged ischemia. Eight other patients developed compartment syndrome requiring delayed fasciotomy. In seven of them, vein was either ligated or the repaired vein became occluded. In the eighth patient, peripheral venous hypertension was caused by massive swelling of the thigh. In the laboratory, compartment pressure was monitored by wick catheter in 24 hind limbs of 12 dogs subjected to experimental conditions simulating vascular injuries and their management. There was a significant increase in compartment pressure in a group that simulated arterial and venous injuries managed by arterial repair and venous outflow obstruction. Based on our study, we suggest that obstruction to venous drainage and venous hypertension are major factors in the development of compartment syndrome in dual vascular injuries of the lower extremity.

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.

Penetrating pancreatic injuries. Analysis of 103 consecutive cases.

The optimal management of penetrating pancreatic injuries continues to be a matter of debate and controversy. The present study analyzes 103 consecutive patients with these wounds treated at a level I Trauma Center in a 14-year period (1975-1988). Twenty-seven patients died within 48 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 46.7). The majority of the remaining 76 patients were treated by debridement and drainage. Nineteen patients with grade III injuries had distal pancreatectomy. Six patients with extensive combined pancreatoduodenal injuries had pancreatoduodenectomy. Pancreatoenteric anastomoses or duodenal diversion procedures rarely were used. Pancreatic complications included major fistulas in four patients (5%) and pancreatic abscess in nine patients (11%). Only one of the fistulas required subsequent fistulojejunostomy. Intra-abdominal abscesses occurred in 18 patients (23.6%), mostly in patients with associated colon injury (P less than 0.001). It is concluded that a conservative approach to penetrating pancreatic injuries yields optimal results and that associated colon injury is an important predeterminant for abscess formation.

Open management of the posttraumatic septic abdomen.

Thirteen patients with abdominal trauma who developed abdominal sepsis resistant to conventional methods of reexploration and drainage were managed by an open method. Eleven of these patients had multiorgan failure. The extent of anatomic and physiologic injury was defined by Abdominal Trauma Index and Acute Physiology and Chronic Health Evaluation (APACHE) scores, respectively. Ten of the 13 patients (76.9%) survived, a significantly improved survival as compared with that predicted by APACHE (50%). Complications attributable to the open technique (enteric fistula and a subphrenic abscess) occurred in two of the ten survivors. It is concluded that the open method of management of abdominal sepsis is effective and feasible. It should be considered in patients with necrotizing wound infections, multiorgan failure, and ongoing abdominal sepsis uncontrolled by conventional methods. Larger, controlled series employing such systems as the APACHE are needed for a better definition of patient selection for the open method.

Penetrating cardiac injuries: twenty-year experience.

Analysis of 228 patients who sustained penetrating cardiac injuries (1963-1983) reveals that among patients who arrived with vital signs, survival was 73 per cent as opposed to 29 per cent of patients who arrived in extremis; and delay in thoracotomy contributed to an increased mortality among patients in profound shock who failed to respond promptly to volume expansion and agonal patients who were transported to the operating room for thoracotomy. An increasing incidence of gunshot wounds and a greater frequency of patients presenting in extremis was noted in the latter years of the study as compared with the earlier period. Our data indicate that there is an increasing need for emergency room thoracotomy in the management of cardiac injuries. Urban trauma centers should be equipped for major procedures in the emergency room and, ideally, should have operating rooms in this area.

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.

Management options in penetrating rectal injuries.

A retrospective analysis of 54 patients (1976-1989) with penetrating rectal injuries was carried out to evaluate the options in management. The diagnosis was made on proctosigmoidoscopy in 39 patients and at laparotomy in 15. Three patients died within 24 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 39.2). In the remaining 51 patients, rectal wound repair was performed in seven patients, four without proximal colostomy (mean ATI 16.5) and three with colostomy (mean ATI 24.8) without complications. Colostomy and presacral drainage with or without repair were employed in 43 patients. Twenty-one of these patients had rectal washout in addition. The other 22 patients did not have this procedure. The incidence of pelvic abscess in these two groups, who had comparable mean ATI, was identical (4.7% and 4.5%, respectively). One other patient with an extraperitoneal rectal injury had a colostomy alone without presacral drainage and subsequently developed pelvic abscess. The overall incidence of abscess was three of 51 patients or 5.8%. There were no late deaths from sepsis. It is concluded that colostomy (loop or end) and presacral drainage are the most important components of rectal injury management. Small and isolated rectal or rectosigmoid perforations may be repaired primarily without fecal diversion. The value of distal rectal irrigation remains to be proven, but it may be indicated in high-energy injuries of the rectum.

A prospective reappraisal of primary repair of penetrating duodenal injuries.

Based on a retrospective analysis of 100 penetrating duodenal injuries, the role of primary repair or resection and anastomosis was assessed prospectively in 66 patients (1986-1992). Duodenal exclusion was reserved for extensive combined pancreato-duodenal injuries. Seven of the 66 patients died from extensive abdominal trauma (mean Abdominal Trauma Index, ATI 70) within 48 hours of admission. Fifty-six patients had primary repair, while pyloric exclusion was performed for three patients with extensive pancreatico-duodenal injuries. Three patients (5.1%) developed duodenal fistula, two being in the primary repair group (3.6%). All three patients had associated injury to the head of the pancreas. Four of the 59 patients died, one attributed to the duodenal repair, for a duodenal mortality of 1.7 per cent. Of the anatomic (ATI, duodenal, vascular, and pancreatic injury scores) and physiologic variables (shock, transfusions) analyzed, the ATI, the Duodenal Injury Score, and the Colon Injury Score were significantly higher in the fistula group. We conclude that the vast majority of penetrating duodenal injuries should be managed by primary repair or resection and anastomosis. Complex duodenal decompression or diverticulization rarely are necessary. Complex procedures should be considered for patients with ATI > 40, Duodenal Injury Score > 12, and the presence of injury to the head of the pancreas.

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.

A comparison of diagnostic related group length of stay outliers: motor vehicle crash versus penetrating injuries.

The incidence and degree to which patients injured by motor vehicle crashes (MVCs) and penetrating wounds remain in the hospital beyond the diagnostic related group (DRG) mean length of stay (LOS) are compared. During a 12-month period, records for consecutive patients admitted to eight hospitals (including three trauma centers) were studied. Patients aged 13 or younger, staying less than 48 hours, or with major burns or only distal fractures were excluded. In that time, 2,914 patients were eligible. Twenty percent of injuries were penetrating; 27% were MVC injuries; and, 53% were blunt injuries from other causes. Patients injured in MVCs and with penetrating injuries were compared with respect to mean LOS, incidence of DRG outliers, number of hospital days beyond the DRG mean LOS, and demographic variables. Patients injured in MVCs had a greater proportion of DRG LOS outliers and higher mean numbers of DRG excess days than did patients with penetrating wounds (p less than 0.01, for both). Injuries were distributed among relatively more DRGs for MVC patients. The DRG scheme may lack sufficient attention to factors more likely to affect MVC patients, such as multiplicity of injuries, incidence of CNS injuries, ICU requirements, and older age. In structuring more appropriate reimbursement for trauma care, special attention must be paid to patients injured in MVCs.

Causes of limb loss in civilian arterial injuries.

Progress in the management of complex vascular injuries of the extremities has not eliminated the necessity for amputation. An analysis of 100 consecutive patients treated at the Lincoln Medical and Mental Health Center during 1974-1980 disclosed that five amputations followed 24 instances of blunt trauma, but only one minor amputation of toes was required in 76 patients after repair of arterial injuries associated with penetrating wounds. Extensive skeletal, muscular and skin loss at the sites of blunt trauma precluded salvage of two limbs. Physicians' failure to suspect arterial injury on admission in three patients with blunt trauma caused delay in the diagnosis and management of occlusive arterial injury that ultimately led to three amputations. In contrast, limited soft tissue damage accompanying penetrating wounds and high index of suspicion resulted in expeditious repair, accounting for the minimal risk of limb loss. Amputation may be obligatory in the presence of extensive skeletal and soft tissue destruction. However, limb loss due to delay in diagnosis is preventable. In every instance of blunt trauma to extremities, we advocate the same suspicion of vascular injuries as in penetrating trauma, with early liberal use of angiography whenever pulses are not absolutely normal, and prompt revascularization of ischemic limbs.