The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds

Background

To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW).

Methods

Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes).

Results

Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%).

Conclusions

We find no role for DL in the evaluation of ASW patients solely to determine PV.     

Laparoscopic management of Meckel's diverticulum in children

Background

Rectal bleeding, recurrent abdominal pain, nausea, and vomiting in children could present a diagnostic as well as therapeutic challenge. Meckel's diverticulum (MD) is one of the causes. The objective of the current study was to evaluate the feasibility and outcome of laparoscopic management of MD.

Methods

The clinical data of 33 children admitted with rectal bleeding and/or recurrent abdominal pain with no identifiable cause were reviewed over a period of 8 years. There were 23 boys and 10 girls with a mean age of 5.12 ± 2 years (range, 3-12 years). In 21 cases, MD was an incidental finding on laparoscopic appendectomy and symptomatic in 12 cases. Patients with rectal bleeding were subjected to upper gastrointestinal endoscopy; colonoscopy, and technetium Tc 99m-labeled pertechnetate scan (MS). All patients were subjected to routine laboratory investigations and diagnostic laparoscopy.

Results

Of the 1200 appendectomies, incidental MD was found in 21 (1.9%) patients and symptomatic in 12 cases. Upper gastrointestinal endoscopy and colonoscopy did not show a bleeding source in 7 patients presented with bleeding per rectum. Four cases showed a positive MS uptake. Of these, 3 were found on laparoscopy to have an MD. Three cases showed a negative scan. Of these, 2 had an MD. In 5 cases with recurrent abdominal pain nausea, vomiting, and abdominal distention, diagnostic laparoscopy revealed Meckel's diverticulitis in 3 cases and intussusception secondary to MD in 1 case. Laparoscopic Meckel's diverticulectomy and laparoscopic-assisted Meckel's diverticulectomy was done for 18 and 12 cases, respectively. Ectopic gastric mucosa was present in 13 cases (44%).

Conclusions

Laparoscopy is safe, cost-effective, and efficient for the diagnosis and definitive treatment of MD. Compared with conventional laparotomy, it has the advantage of precise operative diagnosis, less traumatic access, fewer intraoperative and postoperative complications, and shorter recovery period.     

Laparoscopic diagnosis and treatment of postoperative complications

Background

There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications.

Methods

We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period.

Results

Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 ± 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.

Conclusions

Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.     

Role of Laparoscopy in Penetrating Abdominal Trauma: A Systematic Review

Background

Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma

Methods

The PUBMED database was searched with the keywords “Laparoscopy AND Trauma”. Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist

Results

In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7–100 %, specificity from 33.3–100 % and accuracy from 50–100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28.

Conclusions

In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.     

Drug and alcohol use among adolescent blunt trauma patients: dying to get high?

Purpose

We compared injury severity, hospital course, and outcomes between adolescent blunt trauma patients with and without positive toxicology screens.

Methods

Trauma registry data were used to identify adolescent blunt trauma victims between 2000 and 2005. Demographics, injury severity, hospital course, and outcomes were evaluated. Patients with and without positive toxicology results were compared.

Results

There were 9.3% that had positive toxicology results. The mean age of toxicology-positive patients was 17.2 years. The most commonly detected drugs were cannabinoids (40%), alcohol (30%), and polysubstances (23%). Toxicology-positive patients had significantly lower Glasgow Coma Scale (11.8 ± 4.6 vs 13.7 ± 3.3; P < .001), higher Injury Severity Score (16.7 ± 11.2 vs 10.4 ± 9.1; P < .001), and required more emergent operations (20.7% vs 12.8%; P < .001). Length of stay was longer (7.3 ± 8.1 vs 4.8 ± 7.2 days; P < .001). Functional Independence Measure scores were lower (10.5 ± 2.2 vs 11.2 ± 1.7; P < .001); mortality was higher (6.4% vs 2.6%; P < .001).

Conclusions

A significant number of adolescents had positive toxicology screens. Our data suggest that toxicology-positive patients were more severely injured, required more hospital care, and had worse outcomes than other adolescent blunt trauma victims.     

Laparoscopic vs open surgical approach for intussusception requiring operative intervention

Purpose

Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned.

Methods

This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure.

Results

Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different (P = .698) between the laparoscopic (49.56 ± 26.40 minutes) and open groups (45.00 ± 24.74). Length of stay, however, was significantly reduced (P = .005) in the laparoscopic group (3.00 ± 1.31 days) compared to the open group (4.52 ± 1.98). Total hospital charges were lower in the laparoscopic group ($8171 ± 2595) compared to the open group ($11,672 ± 5466); this difference was not significant (P = .088). There were no significant differences in intra- or postoperative complication rates (P = .637) between the 2 approaches.

Conclusions

Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.     

Laparoscopy vs minilaparotomy and full laparotomy preserves circulatory but not peritoneal and pulmonary immune responses

Purpose

Laparoscopy has been associated with lower inflammatory responses. However, it has been postulated that minilaparotomy, in contrast to full laparotomy, is equally minimally invasive.

Objective

The aim of this study was to investigate local, systemic, and distant organ immune responses after different surgical approaches to the abdominal cavity, such as minilaparotomy, full laparotomy, and laparoscopy, in a small animal model.

Methods

Male Lewis rats received a permanent central venous catheter and were randomized to 4 groups (n = 6 per group). The animals were subjected to anesthesia alone (control), minilaparotomy (1 cm), full laparotomy (7 cm), or laparoscopy for 60 minutes. Blood was collected via the central venous catheter before as well as 1 hour and 6 hours after the start of intervention. Peritoneal and bronchoalveolar lavages, as well as heart puncture, were performed after 24 hours.

Results

All surgical interventions led to a significant migration of polymorphonucleocytes into the abdominal cavity. Full laparotomy resulted in a significant increase in nitric oxide production by peritoneal macrophages as compared with control. Macrophage nitric oxide production after laparoscopy and minilaparotomy was not significantly different. A shift in the expression of OX-6 and CD54 was only detected after full laparotomy. Systemically, O₂⁻ release by circulating mononuclear cells was significantly increased after minilaparotomy and full laparotomy, but not after laparoscopy. The systemic levels of IL6 were significantly accelerated only after full laparotomy, with a maximum after 6 hours. In the lungs, function of alveolar macrophages was not altered in any group.

Conclusions

Any approach to the peritoneal cavity causes local inflammatory responses. Full laparotomy alters peritoneal macrophage functions more pronouncedly than does minilaparotomy or laparoscopy. Systemic inflammatory responses, such as free oxygen radical release, are significantly increased by both minilaparotomy and full laparotomy, whereas laparoscopy preserves systemic immune function. Our results may lead to further preference for the laparoscopic approach over minilaparotomy and full laparotomy.     

Desmoplastic small round cell tumor in children: a new therapeutic approach

Purpose

Desmoplastic small round cell tumor (DSRCT) is a rare, highly aggressive malignancy with distinctive histologic and immunohistochemical features occurring in a young population with a male predominance. The tumor appears to arise as masses in the abdominal cavity without a clear visceral origin. Five patients with DSRCT were treated as usual with combined chemoradiation and surgery. In addition, in our center, patients underwent autologous bone marrow transplant (BMT), which is a novel approach to this disease.

Methods

Charts of 5 patients (4 males, mean age of 11 years) treated between 2000 and 2007 were reviewed. The diagnosis of DSRCT was made on the basis of clinical examination, computed tomographic scan, and explorative laparotomy with biopsy, and biochemical markers were negative. All patients were treated with aggressive chemoradiation and surgery. Three patients also had autologous BMT.

Results

Three patients (BMT recipients) responded to treatment. The responding patients had surgery with the intent of removing all disease. Two patients died of their cancer, neither of whom underwent BMT.

Conclusion

The patients DSRCT are sensitive to an aggressive combination of chemotherapy, surgical debulking, and radiation therapy, followed by autologous BMT. It appears that this new multifaceted treatment offers good palliation, which may prolong survival and a possible cure.     

Laparoscopy for nonpalpable testes

Purpose

Laparoscopy is now considered integral to the management of nonpalpable testes, although its benefits are not clearly documented. The authors prospectively determined the value of laparoscopy in patients with nonpalpable testes.

Methods

Between December 1997 and October 2001, 37 patients with 40 nonpalpable testes were scheduled for laparoscopy followed by definitive treatment. Laparoscopy was cancelled in 4 patients (5 testes) because their testes became palpable under anesthesia. In the remaining 33 patients (35 testes), it was determined at the time of surgery whether, as a consequence of laparoscopy: (1) retroperitoneal exploration was avoided (2) definitive treatment was facilitated.

Results

Laparoscopy did not alter the management of 27 testes (77%) that were treated through an inguinal incision with orchiopexy for 17 testes (6 intraabdominal and 9 at the deep ring) and removal of 10 atrophic nubbins. It was only useful in avoiding retroperitoneal dissection for 5 (14%) vanishing testes, and it may have been of benefit for 3 testes treated with a 2-stage Fowler-Stephens orchiopexy.

Conclusions

The majority of our patients with nonpalpable testes could have been treated through an inguinal incision with laparoscopy being reserved for situations in which the testis was not identified on inguinal exploration.     

Late-onset volvulus without malrotation in preterm infants

Purpose

The aim of the study was to report a new observation of late-onset volvulus without malrotation (VWM) in preterm infants.

Methods

The study used medical note review of infants with VWM identified at a single regional centre between 1996 and 2007.

Results

Ten patients were identified. Group 1 includes 4 patients (gestation, 28-38 weeks; median, 32) who presented within 4 days of age (range, 1-4; median, 3). Group 2 includes 6 patients (gestation, 25-33 weeks; median, 27), who presented later (range, 22-57 days; median, 45). Characteristics of group 2 patients included recurrent episodes of abdominal distension and bile vomiting (6/6), long-term continuous positive airway pressure requirement (5/6), and sudden, severe deterioration with acute abdominal signs (6/6). Small bowel volvulus was found at laparotomy requiring resection (30%-70% of total small bowel) and either primary anastomosis (4) or stoma formation (2). All babies survived.

Conclusions

There appear to be 2 clinical groups with VWM—one presenting within the first few days of life and the other presenting after the first month of life associated with a specific clinical history. This latter group has not been described before.     

Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma

Introduction

Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma.

Methods

This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes.

Results

One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst.

Conclusion

There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.     

Laparoscopy assists surgical decision making in infants with necrotizing enterocolitis

Background

Lack of specific indications for surgical intervention is not uncommon in critically ill infants with necrotizing enterocolitis (NEC). The authors hypothesized that knowledge of the extent of intestinal disease would assist in deciding the operative treatment of choice. The authors report that initial experience with laparoscopy in infants with NEC.

Methods

Prospective evaluation was done of 11 infants with a clinical diagnosis of NEC who were deteriorating despite maximal medical therapy. All underwent laparoscopy on the intensive care unit (ICU).

Results

Median gestational age at birth was 29 weeks (range, 24 to 34) and median weight at the time of laparoscopy was 1.2 kg (range, 0.6 to 2.9). Laparoscopy was tolerated well in all cases. NEC was excluded because of the normal intestinal appearance in 2 infants and confirmed in the remaining 9. Urgent laparotomy was avoided in 8 infants, in one of whom a laparoscopically guided ileostomy was performed. In 5 infants, a Penrose drain was inserted at laparoscopy; 3 of these did not require further surgery, and the remaining 2 underwent delayed laparotomy. Three infants, all with intestinal gangrene, died.

Conclusions

Laparoscopy performed in the ICU can provide information regarding intestinal viability which can guide further surgical management. It is feasible and tolerated well even in critically ill neonates less than 1,000 g.     

Sustainability of mechanically lengthened bowel in rats

Introduction

It has been shown that the length of an intestinal segment may be doubled by applying gradual mechanical stretching. This study evaluated whether the lengthened intestinal segment retained the structure and function after the stretching device was removed.

Methods

A 1.5-cm jejunal segment was separated from intestinal continuity in 20 rats. After advancing a screw into the isolated jejunal segment by 5 mm 3 times a week until it was stretched by 3 cm, the screw was removed. Three weeks later, the jejunal segments were retrieved for analyses. Comparisons were made between the lengthened jejunal segments.

Results

The jejunal segment doubled its length after gradual stretching and retained this length 3 weeks after the screw removal (3.1 ± 0.8 vs 3.2 ± 0.4 cm, P > .05). The villous height, the muscular thickness, and the total alkaline phosphatase and lactase activities of the stretched jejunal segments were also unchanged 3 weeks after the screw removal.

Conclusions

Mechanical force induced the sustained lengthening of isolated jejunal segments in rats. The histologic and enzymatic alterations also persisted 3 weeks after the mechanical force was removed. This phenomenon may provide a novel method for the treatment of short bowel syndrome.     

What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma?

Study objective

A recent Cochrane Review has demonstrated that emergency ultrasonography decreases the amount of computerised tomographic scans in blunt abdominal trauma.¹³ However, there is no systematic review that has evaluated the utility of the Focused Assessment with Sonography for Trauma (FAST) exam in penetrating torso trauma. We systematically reviewed the medical literature for the utility of the FAST exam to detect free intraperitoneal blood after penetrating torso trauma.

Methods

We searched PUBMED and EMBASE databases for randomised controlled trials from 1965 through December 2009 using a search strategy derived from the following PICO formulation of our clinical question: Patients: patients (12+ years) sustaining penetrating trauma to the torso. Intervention: FAST exam during their initial trauma workup. Comparator: either local wound exploration (LWE), computerised tomography (CT), diagnostic peritoneal lavage (DPL), or laparotomy. Outcome: intraperitoneal and pericardial free fluid. The methodological quality of the studies was assessed. Qualitative methods were used to summarise the study results.

Analysis

Sensitivities and specificities were compared using a Forest Plot (95% CI) calculated by Revman 5 (Review Manager Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008) between the FAST exam and definitive diagnostic modalities such as LWE, CT, DPL, or laporotomy.

Results

We identified eight observational studies (n = 565 patients) that met our selection criteria. The prevalence of a positive FAST exam after penetrating trauma was fairly low ranging from 24.2% to 56.3%. The FAST exam for penetrating trauma is a highly specific (94.1-100.0%), but not very sensitive (28.1-100%) diagnostic modality.

Conclusion

From the review of the literature, a positive FAST exam has a high incidence of intraabdominal injury and should prompt an exploratory laparotomy. However, a negative initial FAST exam after penetrating trauma should prompt further diagnostic studies such as LWE, CT, DPL, or laparotomy.     

Positive peritoneal lavage cytology is a predictor of worse survival in locally advanced pancreatic cancer

Background

Peritoneal lavage cytology in the staging of pancreatic cancer is not widely used given improvements in computed tomography (CT). The aim of this study was to determine the utility of peritoneal lavage cytology in predicting survival in locally advanced pancreatic cancer.

Methods

Between 2000 and 2008, 202 patients with biopsy-proven pancreatic cancer who were determined by pancreas protocol CT to be locally advanced and not currently resectable underwent diagnostic laparoscopy and peritoneal lavage for cytology (DL-PLC).

Results

DL-PLC upstaged 58 of 202 patients (29%) to stage IV, who had a significantly worse median survival of 11 months versus 16 months (P = .03). Positive cytology was an independent predictor of worse survival (P = .02).

Discussion

Positive peritoneal cytology (stage IV disease) in locally advanced pancreatic cancer is common and predicts worse survival. This survival difference suggests that peritoneal cytology status might be useful in deciding treatment regimens in patients with locally advanced disease based on CT.     

Indirect versus direct laryngoscopy for routine nasotracheal intubation

Study Objective

To compare the effectiveness of the indirect laryngoscopes, Airtraq (A) and GlideScope (G), with the Macintosh (M) laryngoscope in routine nasotracheal intubation.

Design

Randomized, single-blinded study.

Setting

University-affiliated, tertiary-care hospital.

Patients

62 adult, ASA physical status 1 and 2 patients with normal airways requiring nasotracheal intubation for dental or maxillofacial surgery.

Intervention

Patients in Groups A and G underwent nasal intubation with the Airtraq and GlideScope, respectively, while laryngoscopy in Group M was performed with the Macintosh blade.

Measurements

Performance of the intubating tools was judged by the ease [Intubation Difficulty Scale (IDS) and numeric rating scale (NRS)] and time to intubation (laryngoscopy and endotracheal tube advancement). In addition, hemodynamic parameters, severity of postoperative sore throat, and posture of the intubator were recorded.

Main Results

IDS score was significantly lower with the Airtraq and GlideScope than with the Macintosh laryngoscope (mean ± SD: A 0.1 ± 0.3, G 0.3 ± 0.6, M 0.8 ± 1.0; P = 0.013). NRS reported by the intubators showed a similar preference for indirect over direct laryngoscopy (A 0.9 ± 0.7, G 1.1 ± 0.6, M 1.9 ± 1.1; P = 0.001). Duration of laryngoscopy and endotracheal tube insertion was similar in all groups. No significant intergroup differences in hemodynamic parameters were recorded. Postoperative sore throat was significantly reduced using the GlideScope compared with the other devices (P = 0.048).

Conclusion

The Airtraq and GlideScope facilitated nasotracheal intubation more so than the Macintosh laryngoscope in adults with apparently normal airways.     

Predictors of outcome in children and adolescents with rhabdomyosarcoma of the trunk--the St Jude Children's Research Hospital experience

Purpose

The aim of this study was to determine predictors of outcome in childhood truncal rhabdomyosarcoma.

Methods

Retrospective chart review evaluating the impact of demographic features, disease characteristics, and the extent and timing of surgical intervention on outcome was performed.

Results

Thirty-three patients with a median age of 8 years were identified. Most had advanced Intergroup Rhabdomyosarcoma Study group III (n = 13) or group IV (n = 9) disease. Primary site included 20 (61%) chest wall, 6 (21%) paraspinal, 5 (15%) periscapular, and 1 (3%) abdominal wall. Most tumors were embryonal (n = 21), larger than 5 cm (n = 27), and locally invasive (n = 13); 7 had positive nodes.Tumor size, nodal status, and gross total tumor resection (upfront or delayed) were significant predictors of event-free and overall survival. Tumors 5 cm or smaller were amenable to upfront surgical resection (P = .007). In patients with tumors larger than 5 cm, resection at any time was associated with a 10-year overall survival 57% ± 13% compared with 8% ± 5% in those who had no surgery (P = .003). Tumor recurrence was local in 44% of cases, and survival after local recurrence was rare (1 of 8).

Conclusion

Tumor size, nodal status, and gross total resection at any time are significant predictors of outcome in truncal rhabdomyosarcoma. Gross tumor excision should be the goal of surgical intervention in this disease.     

Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers

Introduction

Trauma in pregnancy is the leading cause of non-obstetrical maternal death and remains a major cause of fetal demise. The objective of this study was to examine the outcomes of pregnant patients sustaining abdominal injury.

Patients and methods

This is a retrospective analysis of all pregnant trauma patients admitted to two level 1 trauma centers from February 1, 1996 to December 31, 2008. Patient data abstracted included mechanism of injury, physiologic parameters on admission, Injury Severity Score (ISS), abdominal Abbreviated Injury Scale (AIS), gestational age, diagnostic and surgical procedures performed, complications, and maternal and fetal mortality. Univariate analysis and logistic regression analysis were used.

Results

During the 155-month study period, 321 pregnant patients were included, of which 291 (91%) sustained a blunt injury, while 30 (9%) were victims of penetrating trauma. Of the penetrating injuries, 22 (73%) were gunshot wounds, 7 (23%) stab wounds, and 1 (4%) shotgun injury. The overall maternal and fetal mortality was 3% (n = 9) and 16% (n = 45), respectively. Mean age was 22 ± 6 year-old, and the mean ISS was 12 ± 16. The overall mean abdominal AIS was 2 ± 1.2. When adjusted for age, abdominal AIS, ISS, and diastolic blood pressure, the penetrating trauma group experienced higher maternal mortality [7% vs. 2% (adjusted OR: 7; 95% CI: 0.65-79), p = 0.090], significantly higher fetal mortality [73% vs. 10% (adjusted OR: 34; 95% CI: 11-124), p < 0.0001] and maternal morbidity [66% vs. 10% (adjusted OR: 25; 95% CI: 9-79) p < 0.0001].

Conclusions

Fetal mortality and overall maternal morbidity remains exceedingly high, at 73% and 66%, respectively, following penetrating abdominal injury. Penetrating injury mechanism, severity of abdominal injury and maternal hypotension on admission were independently associated with an increased risk for fetal demise following traumatic insult during pregnancy.     

Laparoscopic localization and microlaparotomy for focal isolated perforation in necrotizing enterocolitis: an alternative approach to a challenging problem

Background

Necrotizing enterocolitis has a wide clinical spectrum of manifestation. We report a novel method of managing focal isolated perforation in necrotizing enterocolitis by using diagnostic laparoscopy to localize the site of perforation and by making a microincision over the perforation to perform exteriorization or limited resection and primary anastomosis.

Methods

We included low-birth weight infants presenting with sudden clinical deterioration and pneumoperitoneum. Patients with gross abdominal wall signs were excluded on the probability that they had extensive disease. Diagnostic laparoscopy was performed using a 3.5-mm trocar and 1.9-mm telescope. A 1-cm incision was made over the site of perforation, and local surgical debridement was performed.

Results

There were 3 extremely low-birth weight patients (580, 700, and 780 g) and 1 larger infant (1.6 kg). In all cases, an isolated perforation was detected. None had widespread disease. The 3 smaller infants had exteriorization and enterostomies. The larger patient had resection and primary anastomosis. All patients recovered uneventfully.

Conclusion

Diagnostic laparoscopy can be safely performed in extremely low-birth weight infants. It allows precise identification of the site of perforation to perform a limited microlaparotomy at this site, significantly reducing the surgical trauma of extensive bowel handling. We report a novel method of managing this vexing problem.