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.     

Femoropopliteal vein grafts for claudication. Analysis of 100 consecutive cases

One hundred consecutive femoropopliteal venous grafts in 85 patients with claudication were followed for five years. At this time, three limbs had been amputated, approximately one quarter of the patients had expired, and 70% of the grafts in surviving patients remained patent. It is concluded that this operation does not appear to increase the risk of amputation and in fact, may lessen it. Moreover, it is associated with minimal risk and generally provides long term relief of claudication, thus enhancing the quality of life in most patients.     

Penetrating craniocerebral injuries. Report of two unusual cases

Two unusual cases of craniocerebral injury caused by a fishing harpoon trident are reported. Both patients, in spite of the apparent seriousness of the lesions, recovered satisfactorily.     

Penetrating renal injuries.

A retrospective analysis of 81 penetrating renal injuries revealed a need for surgical exploration in only 39 per cent, and the following conclusions are made: (1) Criteria for classifying a traumatic renal injury as major and therefore requiring further evaluation (arteriography) or appropriate urgent surgery, include urographic nonfunction or extravasation, persistent or severe hematuria or retroperitoneal hemorrhage, and deteriorating clinical status. (2) Preoperative urologic assessment is mandatory to avoid needless renal exploration; 58 per cent of patients with minor injuries were in this series operated on. (3) It is doubtful that late sequelae of penetrating renal injury occur so frequently that immediate surgery to prevent them is advisable.     

腹腔镜脾切除术100例

目的 总结8年多来行腹腔镜脾切除术（LS）的临床经验，探讨LS的安全性和有效性。方法 从1996年4月至2004年11月连续进行了100例15，94例为原发性和继发性脾功能亢进，6例为其它脾疾病，其中34例为巨脾。结果 100例15全部完成，1例术后5h需作小切口开腹止血，2例术后需再次腹腔镜探查和清除脾窝积血。平均手术时间2．3h，平均失血160ml。平均术后住院6d。结论 15安全、有效、切实可行，适用于有脾切除指征的原发性和继发性脾功能亢进或其它脾疾病。     

Penetrating iliac vascular injuries: recent experience with 233 consecutive patients

During a recent 11-year period, 233 consecutive patients with 358 penetrating iliac vascular injuries were treated at our institution. Injuries of the common and external iliac arteries were most often repaired with lateral suture (31%) although several other techniques were also employed. Lateral suture and ligation were used with nearly equal frequency in the management of venous injuries. The hospital mortality rate for the series was 28%, and 56/66 deaths (85%) were due to exsanguination or shock. One patient, initially treated with an end-to-end anastomosis of the iliac artery, died a year after discharge from a ruptured false aneurysm. Two patients treated with lateral suture of venous injuries died of pulmonary embolism. Arterial complications occurred in 15% of patients with arterial injuries and three patients required amputation. No graft infections occurred in 16 patients treated with PTFE interpositions, including four with associated colorectal injuries. Venous complications occurred in 12% of patients with venous injuries, and most were noted in those treated with ligation. Four patients treated by venous ligation developed chronic venous insufficiency. The prevention of death from exsanguination is the greatest problem in the management of patients with iliac vascular injuries. Although some late deaths and many complications may be related to the technique of vascular repair, circumstances often prohibit alternative methods. Despite two deaths from pulmonary embolism, insufficient data exist to condemn lateral suture of venous injuries.     

Penetrating arterial trauma. Analysis of missed vascular injuries

From 1976 to 1981, 677 patients with potential vascular injuries from penetrating wounds to the upper and lower extremities and the neck were treated. Surgical exploration was used to evaluate 237 patients; 440 patients were evaluated by arteriography alone, with negative results. In the group that underwent surgery, there were 137 arterial injuries detected. Follow-up studies were performed to assess the rate of missed vascular injuries using each diagnostic modality. Short-term follow-up was obtained in 81% of all patients. Long-term follow-up, averaging 5.1 years, was obtained in 33% of the patients. Vascular injuries, which went undetected at the time of initial evaluation, were present in both the group evaluated by vascular exploration and the arteriography group. The combination of arteriography and exploration detected no missed injuries on follow-up.     

Penetrating duodenal trauma

Ten cases of penetrating injuries to the duodenum are presented. Six injuries were treated with primary repair, retrograde decompressing jejunostomy, and feeding jejunostomy. There was no postoperative duodenal leak in any patient treated with primary repair and retrograde decompressing jejunostomy. In a review of 563 cases of penetrating duodenal trauma, the superiority of primary repair of duodenal injuries with decompression of the suture line by a tube inserted in a remote site of the bowel (stomach or jejunum) was demonstrated. This technique afforded the lowest mortality and incidence of postoperative duodenal fistulae. When applicable, primary repair with retrograde decompressing jejunostomy and feeding jejunostomy is a rapid, simple, and safe method for the treatment of penetrating duodenal injuries.     

Penetrating injuries of the neck.

In view of the close arrangement of a large number of vital structures in the neck, penetrating wounds in this region should be considered as potentially lethal. Nineteen cases of injury to great vessels and food and air passages which required repair are analysed. There were 4 deaths, giving an overall mortality of 21 per cent. Two of these were injuries of the subclavian and innominate veins when prolonged delay for resuscitation was probably the main reason for the deaths. The third was in a patient with tracheal injury in whom a coexistent oesophageal lesion was missed and the fourth a case of spinal cord injury. When adequate exposure cannot be obtained by exploration of the neck, median sternotomy or anterior thoracotomy is advisable.     

Penetrating injuries of the neck.

A review of 271 patients with penetrating wounds of the neck is presented. A policy of selective conservative management appears totally justified in view of the low mortality and morbidity in this series. Particular attention has been paid to the presentation and surgical approach to the injured vertebral artery.     

Bipolar hemiarthroplasty in degenerative arthritis of the hip. 100 consecutive cases

This retrospective study represents the authors' experience with bipolar hemiarthroplasty in 100 consecutive patients with degenerative arthritis. Seventy of 100 patients were available for follow-up assessment. Mean follow-up interval was 4.3 years (range, two to 13.5 years). Mean modified Harris hip score was 78.8. Good-to-excellent results were obtained in 75.8% (excellent, 22.9%; good, 52.9%). Revision was required in six cases (8.6%). Subgroup analysis revealed comparable outcome in 50 patients with at least three years of follow-up assessment (mean, 5.1 years), indicating no deterioration of results. Anterior thigh pain, attributed to femoral component loosening, was the predominant patient complaint. Use of proportionately sized femoral components and use of cement when indicated should decrease the incidence of anterior thigh pain. This intermediate-term follow-up study suggests a role for bipolar hemiarthroplasty in the primary surgical treatment of osteoarthritis.     

Penetrating abdominal vena cava injuries.

OBJECTIVE: The surgical management and outcome of abdominal vena cava (AVC) injuries is presented. STUDY DESIGN, PATIENTS AND METHODS: A retrospective record review of patients with AVC injuries treated in the Trauma Unit at Groote Schuur Hospital between January 1999 and December 2003 was undertaken. Demographic data, mechanism of injury, surgical management, associated injuries, duration of hospital stay, complications and mortality were extracted from patient records. Patients with acute peritonitis and/or shock underwent emergency laparotomy. RESULTS: Forty-eight patients with AVC injuries were identified. Gunshot wounds accounted for 45 (94%) injuries. The mean weighted revised trauma score, injury severity score (ISS) and penetrating abdominal trauma index (PATI) were 6.3, 24 and 42, respectively. The AVC injury was infrarenal and suprarenal in 41 and seven patients, respectively. Thirty injuries were ligated. There were 15 deaths (31%). Significant differences between survivors and non-survivors included ISS, preoperative hypotension and blood transfusion requirements, whereas site of injury, PATI, and surgical management did not. CONCLUSION: Abdominal vena cava injuries are associated with a high mortality. Ligation of the AVC in critically ill patients is a feasible and life-saving option.     

Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases.

Between August 1982 and November 1985, 100 patients underwent ileal "J" pouch-anal anastomosis (IPAA) at the University of Utah. All operations were performed in a standard fashion by a single surgeon. Seventy-eight patients were operated on for chronic ulcerative colitis and 22 for familial polyposis coli. Sixty of the patients were male and 40 were female with a mean age of 33.2 years and a range of 11-63 years. Mean +/- SEM operating time was 5.9 +/- 0.4 hours, blood loss was 666 +/- 49 ml, and total hospitalization was 10.1 +/- 0.3 days. No operative deaths occurred. The overall operative morbidity was 13% after IPAA. Clinical "pouchitis" was observed in 18 patients, all of whom were operated on for chronic ulcerative colitis. No patients had frank incontinence. Twenty per cent of patients experienced frequent nocturnal leakage in the early postoperative period with a significant improvement over the ensuing 6 months. Stool frequency at 1, 3, 6, 12, and 24 months was 7.5 +/- 0.2, 6.5 +/- 0.1, 6.2 +/- 0.3, 5.4 +/- 0.1, and 5.4 +/- 0.2, respectively. Stool frequency at 12 months correlated inversely with ileal pouch capacity and the diagnosis of familial polyposis. It is concluded that ileal pouch-anal anastomosis is a safe and effective operation for patients with chronic ulcerative colitis and familial polyposis coli.