Superior mesenteric venous injuries: to ligate or to repair remains the question

BACKGROUND: Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL: Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS: There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS: SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.     

Early repair of injury to the ureter or bladder after hysterectomy

In the present study we investigated the effectiveness of early diagnosis, repair of injuries to the ureter and urinary bladder sustained during hysterectomy, as compared to the results of delayed intervention. There were 46 ureteral injuries and 20 vesicovaginal fistulas in 55 patients. In 14 cases of ureteral injury an endoscopic approach management was employed. There was complete healing in 18 vesicovaginal fistulas while there was a single case of a ureteral injury that required nephrectomy because of stenosis. This study shows that early repair of urological injuries after hysterectomy has considerable advantages and the results are equally comparable with those of delayed intervention. In most cases of ureteral injury an attempt of an endoscopic repair is warranted before proceeding to open surgery.     

To stent or not to stent bilioenteric anastomosis after iatrogenic injury: a dilemma not answered?

BACKGROUND: Bile duct injury is a complex and serious complication whose frequency has not diminished. A bilidigestive anastomosis (Roux-en-Y hepaticojejunostomy) is usually needed after complex injuries. Placement of an anastomotic stent is a matter of debate and to our knowledge there is no study that compares the results between stenting and not stenting the anastomosis. DESIGN: A retrospective review of medical records of patients operated on for biliary reconstruction after iatrogenic injury. SETTING: Tertiary care academic university hospital. PATIENTS: A comparative study was performed of patients operated on between 1995 and 1999, who were referred to our hospital for acute or elective reconstruction of the biliary tract following iatrogenic injury. All patients underwent Roux-en-Y hepaticojejunostomy. The patients were divided into 2 groups: those who underwent Roux-en-Y hepaticojejunostomy with a transanastomotic stent and those who underwent Roux-en-Y hepaticojejunostomy without a transanastomotic stent. MAIN OUTCOME MEASURES: Operative mortality, anastomotic dysfunction, biliary fistula, reoperations, postoperative complications, postoperative liver function tests. RESULTS: Sixty-three patients with high and complex biliary injuries (Bismuth type III, IV; Strasberg D, E). Thirty-seven cases had reconstruction with the placement of a transanastomotic stent and 26 did not have a stent placed. No operative mortality was observed. The postoperative outcomes of both groups were compared and no differences found. Good results were observed in more than 80% of the patients. Reoperations were more frequent in the nonstented group (15% vs. 5%) and complications were more frequent in the stented group (16% vs. 7%). CONCLUSIONS: Good results are obtained with a Roux-en-Y hepaticojejunostomy after complex injuries. The use of transanastomotic stents has to be selective according to the individual characteristics of each patient and the experience of each surgeon. We recommend their use when unhealthy (ie, ischemic, scarred) and small ducts (<4 mm) are found.     

To screen or not to screen: the prostate cancer dilemma

The European Randomized Study of Screening for Prostate (ERSPC) has updated their previous seminal report on prostate cancer mortality comparing screened men to controls. Now with 13 years follow-up, the rate ratio of prostate cancer mortality was 0.79 favoring the screened population. The authors concluded that there was a “substantial reduction in prostate cancer mortality attributable to testing with prostate-specific antigen (PSA)” but they also stated that a “quantification of harms” needed to be addressed. The issue of harms was not addressed by the ERSPC (at least not in this report) and hence this additional statement most likely reflects the controversy currently surrounding the risks associated with over-diagnosis and treatment of indolent diseases inadvertently detected by a screening protocol.1 In addition, the positive results from this trial conflict with those of the prostate, lung, colorectal and ovarian (PLCO)2 study and require further elaboration.Part of the challenge with interpreting the ERSPC is a result of the study design. France entered the study late (2 years), the screening intervals varied from 2 to 4 years, the biopsy indication by PSA varied, and screening was discontinued at different time points in several of the countries. Despite these limitations, screening detected substantially more prostate cancers than in the control group, 10.2% of the population versus 6.8%. However, even though the intervention arm experienced a 21% decrease in prostate cancer mortality, the absolute decrease was only 0.6% (545 per 89 352) to 0.5% (355 per 72 891); and this came at a burden of potential overtreatment in the patients with low-risk disease. The majority of the prostate cancers detected in the PSA arm had low-risk features (59.9%), whereas many fewer men in the control group were diagnosed with similar disease (41.6%). Unnecessary surgery or radiation has become a significant problem in the management of these men. Many clinicians chose to offer low-risk patients active surveillance (AS) rather than definitive therapy. However, this also creates an additional burden, as transrectal ultrasound biopsies are often repeated yearly, and PSA testing frequency is increased. Thirty to fifty percents of the men on AS eventually have surgery or radiation, and many have advanced disease at the time of treatment.3,4 The problem created by screening is that too many patients are identified with low-risk disease. Approximately, 50% have disease that can be safely managed by AS, while the other half would be best managed by definitive or focal therapy. Unfortunately, the procedure used to make a diagnosis, the TRUS biopsy, cannot differentiate between these two groups.The ERSPC study is often compared to the updated PLCO trial.2 The latter trial, with similar 13 years follow-up offered PSA and digital rectal examination (DRE) screening to about half as many men. The major difference between the two was about 50% of the control arm previously had a PSA or DRE test, and this “contamination” may have influenced the overall results. The PLCO trial failed to find a difference in prostate cancer detection (11.1% vs 9.9%, screened vs not screened) and no improvement in cancer mortality. It is also worthwhile noting that prostate cancer deaths were not that dissimilar between the two studies with 0.41% versus 0.38% of the study population dying from the disease, respectively.Where does that leave the physician who is trying to decide whether to offer early detection with PSA/DRE testing and how can our patients make an informed decision given these data? First it is important to recognize the patient populations were different in the American and European trials. Men in the USA have been exposed to prostate cancer “screening” since 19895,6 and it is estimated that over 75% of the population have had PSA testing. Early diagnosis came later to the Europeans, and PSA testing is not universally done in all countries. It should, therefore, not be surprising that the studies were positive in Europe and negative in America. Where does that leave the Asian patients? PSA testing is not routinely performed in Japan, where penetration is estimated at 5%–10%.7 In addition, more cancers are diagnosed at higher stage, and the death rate from the disease continues to increase.8 The situation is probably not dissimilar in other Asian countries. These data would be an argument in favor of routine testing.Nonetheless, a strategy needs to be developed to manage the majority of patients who are diagnosed by TRUS biopsy with low-risk disease. The danger in ignoring this problem is men may refuse testing putting them at risk for increased morbidity and death. The ERSPC study briefly mentioned multiparametric (mp) magnetic resonance imaging (MRI) as a technology to decrease over-diagnosis. Centers in Europe and the USA are utilizing mpMRI combined with targeted biopsies to identify high-grade disease. Men with elevated PSA get scanned and only biopsied when suspicious regions suggest high-grade disease. mpMRI is more likely to identify lethal cancers (Gleason score 8 and above) than low-grade disease.9,10 The men with a nonsuspicious mpMRI study would then not be biopsied at all. The available evidence on this issue needs to be confirmed by large, preferably multicenter studies. Another strategy employs genetic and epigenetic assays of biopsy material whereby apparent low-risk disease is reassigned into a more aggressive category and only these patients are offered definitive therapy. Studies are underway to see if either of these two strategies can improve treatment decisions in the AS group.One additional strategy should be mentioned. Several investigators have turned to saturation or mapping biopsies using a transperineal approach. Fifty to seventy-five percents of men on an AS protocol are found with multifocal or higher grade disease after a transperineal mapping biopsy (TPMB).11,12,13 Crawford has investigated TPMB using a mapping software program whereby disease sites within the gland can be precisely localized affording a large number of patients a targeted focal therapy (TFT) option.14,15 As more data is collected with mpMRI, genetic testing and TPMB, better selection of candidates for AS, TFT and definitive therapy should increase our confidence that PSA testing is the right choice for our patients.     

Early repair of iatrogenic injury to the ureter or bladder after gynecological surgery

Contrary to the traditional doctrine of delayed intervention in post-hysterectomy injuries of the ureter or bladder, the policy at our department has been to operate as soon as possible after the diagnosis is made. Of 68 patients (25 with vesicovaginal fistulas and 43 with ureteral injuries) early intervention was possible in 40 (59%). Primary healing was obtained in all patients. These results suggest that there is no disadvantage in early repair.     

A tricky tracheotomy: airway management dilemma following unusual stab injury to the mouth

Traumatic wounding to the upper aerodigestive tract can cause acute airway compromise. In these circumstances establishment of a safe airway is vital. We present a case report illustrating the decision making pathway in such a difficult case.     

Hemodynamic sequelae of combined arteriovenous injury in an experimental canine hindlimb model: Venous ligation vs. repair

The hemodynamic effects of combined venoarterial injury and stasis were studied in the hindlimbs of 10 dogs. Femoral arterial blood flow and pressure, peripheral venous pressure, and peripheral resistance were measured after the restoration of blood flow following venoarterial injury and a 4-hour period of occlusion for up to 72 hours. In one limb of each animal both the artery and vein were repaired, whereas only the artery was repaired in the other limb and the vein was ligated. Arterial blood flow was similar in both groups but was significantly diminished from baseline for the first 30 minutes after restoration of blood flow, but then it became significantly reduced in the limbs with venous ligation when compared with values in those with venous repair. By 72 hours the flow on both sides returned to control values. Peripheral venous hypertension and edema occurred in all 10 limbs with venous ligation and persisted for the 72-hour experimental period. In the 10 limbs with venous repair, edema occurred in four and venous hypertension in none. The peripheral resistance was elevated on both sides; this elevation persisted for 75 minutes and then dropped to control values. None of the repaired arteries and only one repaired vein thrombosed during the experiment. Combined venous and arterial occlusion for 4 hours reduced both the amount of arterial flow and its subsequent rate of increase compared with changes seen after release of an actue venous occlusion. The rate of increase was enhanced by repair of the affected venous segment compared with simple venous ligation.Supported by the William Beaumont Hospital Research Institute and Department of Surgery, RI-91-41RM.Presented at the Sixteenth Annual Meeting of the Midwestern Vascular Surgical Society, Cleveland, Ohio, September 11–12, 1992.     

Ubiquitous use of prosthetic mesh in inguinal hernia repair: the dilemma

Summary The omnipresence of prosthetic materials (mesh) used in hernia repairs throughout the world deserves careful review. The propensity to develop operative techniques wherein prosthetic mesh is used routinely, regardless of type hernia, has reached an unacceptable level of practice. Being foreign bodies, postoperative complications occur which directly can be traced to the implanted meshes. Recent interest in mesh complications, i.e., infection, mesh shrinkage, migration and fistula formation, has escalated. Although mesh foreign body tumorigenesis has not been seen in humans following hernia repair, there is sufficient animal data to cause concern. Similarly, neural complications following use of mesh, particularly after the open anterior notension repair methods, are being reported at alarming rates. Many types of inguinal hernias do not need mesh repairs. It is our premise that these hernias must be identified preoperatively. Certainly, type I, II and III C inguinal hernias of our classification, should not receive a prosthetic mesh repair. If prosthetic mesh is to be used, it should be placed to buttress the inguinal wall posteriorly so that advantage of Pascal's law may be assured.     

Venous disease: investigation and treatment,fact or fiction?

This review looks at some clinical and experimental methods and treatments used in venous disease, and attempts to dispel some myths which have been associated with it. Over the last century numerous techniques have been introduced to aid the understanding of the physiology of normal legs and the pathophysiology of those with venous disease. Tourniquet testing along with clinical examination remains the only method of venous assessment in most hospitals. Venous ulceration in the past has been associated with deep vein incompetence, but the newer, non-invasive techniques of Doppler ultrasound and duplex examination are now identifying patients with leg ulceration who have superficial venous insufficiency and therefore a surgically correctable condition. Perforating veins and their possible role in the aetiology of venous ulceration along with invasive and non-invasive methods for their detection is reviewed. Some of the conservative compression treatments and dressings available for the treatment of venous ulceration are discussed. It is concluded that adherence to sound surgical principles remains the mainstay of the successful management of patients with venous disease.     

Complex blunt aortic injury or repair: beneficial effects of cardiopulmonary bypass use

OBJECTIVE: To compare the outcomes and associated morbidity in patients with blunt aortic injury (BAI) repaired using cardiopulmonary bypass versus no bypass. Special consideration is given to the influence of bypass in the outcome of complex injuries or repair circumstances. SUMMARY BACKGROUND DATA: There are conflicting data concerning the utility of bypass techniques in the operative management of BAI, and controversy over the subject persists. During the last decade, surgeons at the authors' institution have undergone a change in philosophy concerning management of these injuries and began almost exclusively using cardiopulmonary bypass for the repair in 1996. This project explores the effects of this change in the management of BAI. METHODS: The records of all patients with BAI admitted to a level 1 trauma center over a period of 12 years were reviewed for demographics, injury characteristics, operative technique, and outcome. The bypass group was compared to the no bypass group with respect to morbidity and mortality. Those with a complex injury or repair (CI/R) were examined as a subgroup. CI/R was defined as the presence of an injury with extension proximal to the subclavian artery, involvement of branch vessels, or requirement of maneuvers interfering with anastomosis construction, such as cardiac massage. RESULTS: From January 1, 1990, to December 31, 2001, 91 patients were admitted to Wake Forest University Baptist Medical Center with BAI. Sixty-five of these underwent operative repair. Sixty (32 no bypass, 28 bypass) survived to the immediate postoperative period. Injury Severity Score was similar (33 no bypass, 31 bypass, P =.48), as was admission base deficit (-9.2 m Eq/L no bypass vs. -7.0 mEq/L B, P =.13). Paraplegia occurred in four (12%) of the no bypass group as opposed to 0 of the bypass group (P =.05). No patient in the bypass group experienced complications related to heparinization, and two (7%) experienced bypass-related complications (cerebral edema, femoral vein laceration). Mean clamp time for the entire group was 27 minutes. Examination of the 10 patients with CI/R who survived the operating room showed markedly longer clamp times (59 minutes vs. 22 minutes, P <.0001) and a higher rate of paraplegia/paresis (30% vs. 2%, P =.01) as compared to those without CI/R. Logistic regression demonstrated a significant relationship between increasing clamp time and the CI/R classification (P =.007). All three (100%) of the CI/R patients repaired via clamp-and-sew technique developed paraplegia, while none of the seven CI/R patients repaired on bypass developed neurologic changes (P =.008). CONCLUSIONS: With the use of cardiopulmonary bypass in the repair of BAI, the incidence of paraplegia/paresis has fallen. While patients with typical injuries and uncomplicated repair can expect good results with either technique, cardiopulmonary bypass provides significant advantages in the repair of those with CI/R. With the use of bypass, no CI/R patient developed paraplegia, while all CI/R patients experienced paraplegia before bypass use. Although others have reported the importance of clamp time, in this series clamp time appeared largely to be a surrogate variable for complexity of injury.     

四肢主要血管闭合或隐匿损伤的诊断与显微外科修复

目的探讨四肢主要血管闭合或隐匿损伤诊断与修复方法及其临床效果。方法对11例闭合创伤合并动脉损伤或微小伤口合并动脉损伤的患者行血管成像技术（CTA）检查,诊断明确后行手术探查及显微外科修复。结果11例患者经CTA检查均清晰显示血管损伤,行显微外科血管重建后肢体恢复血循环。结论对怀疑肢体有闭合或隐匿主要动脉损伤行CTA检查,有助于早期诊断,明确损伤部位;及时手术探查、采用显微外科修复损伤血管是保全肢体成活起关键。     

医原性输尿管损伤的一期修补

目的 探讨医原性输尿管损伤的一期修补与预防方法，提高手术成功率，减少合并症的发生。方法 医原性输尿管损伤患者33例，男2例，女31例。双侧损伤2例，单侧损伤31例。术中发现4例，术后1～3d发现4例，术后4～28d发现18例，术后〉28d发现7例。采取单纯松解粘连、剪除缝线、输尿管损伤段切除端端吻合、输尿管膀胱再植术、Boari瓣输尿管膀胱再植术、输尿管膀胱再植腰大肌固定术等方法治疗。26例早期发现者（术后≤28d）中24例一期修复输尿管损伤；2例有感染或一般情况差，因无明显梗阻，未行尿流改道，3个月后行一期修复手术成功。7例术后发现晚或来院时间晚患者，3～8个月手术，除1例行肾切除外，亦行一期修复手术。结果　33例中32例行一期修复输尿管损伤。23例随访6～24个月，肾积水均缓解。结论　医原性输尿管损伤的患者，只要条件许可，一期修补均能达到良好的治疗效果，同时，输尿管损伤可以早期发现和预防。     

Venous injury during lymphadenectomy: management without laparotomy

During robotically-assisted pelvic lymphadenectomy, four venous injuries occurred that did not resolve with pressure. After the application of tightly woven, oxidized regenerated cellulose and a fibrin sealant, all four venotomies were hemostatic. There were no sequelae.