Surgery for liver trauma

Hepatic injuries are found in 30 per cent of patients undergoing operation after penetrating abdominal wounds and in 15 to 20 per cent of patients undergoing operation after blunt trauma. Signs of blood loss, peritonitis, or peritoneal traverse by a missile prompt early operation in many patients. Stable patients who have suffered stab wounds in proximity to the liver may be safely evaluated by diagnostic peritoneal lavage, whereas CT evaluation is now used in stable patients suffering blunt trauma that may involve the liver. "Simple" techniques of repair such as suture hepatorrhaphy, application of topical agents, or application of fibrin glue suffice in 60 per cent (blunt trauma) to 90 per cent (penetrating trauma) of patients with hepatic injuries. The remainder require "advanced" techniques of repair such as extensive hepatorrhaphy, hepatotomy with selective vascular ligation, resectional debridement with selective vascular ligation, lobectomy or segmentectomy, selective hepatic artery ligation, or perihepatic packing. Using the techniques described, the mortality rate for all patients with hepatic injuries will be approximately 10 per cent, with 75 to 80 per cent of all deaths occurring in the perioperative period from shock or transfusion-related coagulopathies. The most common major complications in survivors are perihepatic abscesses and postoperative hemorrhage, both of which are frequently treated by the interventional radiologist.     

A pressão arterial está associada a indicadores de adiposidade corporal em crianças de quatro a sete anos

Introduction and Objective

Studies in adults have shown an association between increased adiposity and hypertension, but few studies have analyzed this association in childhood. The aim of this study was to investigate the association between blood pressure (BP) and body adiposity indicators in children, controlling for the variables of birth conditions, sociodemographics, lifestyle and diet.

Unexpected structural and functional consequences of the R33Q homozygous mutation in cardiac calsequestrin: a complex arrhythmogenic cascade in a knock in mouse model

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmogenic disorder characterized by life threatening arrhythmias elicited by physical and emotional stress in young individuals. The recessive form of CPVT is associated with mutation in the cardiac calsequestrin gene (CASQ2). We engineered and characterized a homozygous CASQ2(R33Q/R33Q) mouse model that closely mimics the clinical phenotype of CPVT patients. CASQ2(R33Q/R33Q) mice develop bidirectional VT on exposure to environmental stress whereas CASQ2(R33Q/R33Q) myocytes show reduction of the sarcoplasmic reticulum (SR) calcium content, adrenergically mediated delayed (DADs) and early (EADs) afterdepolarizations leading to triggered activity. Furthermore triadin, junctin, and CASQ2-R33Q proteins are significantly decreased in knock-in mice despite normal levels of mRNA, whereas the ryanodine receptor (RyR2), calreticulin, phospholamban, and SERCA2a-ATPase are not changed. Trypsin digestion studies show increased susceptibility to proteolysis of mutant CASQ2. Despite normal histology, CASQ2(R33Q/R33Q) hearts display ultrastructural changes such as disarray of junctional electron-dense material, referable to CASQ2 polymers, dilatation of junctional SR, yet normal total SR volume. Based on the foregoings, we propose that the phenotype of the CASQ2(R33Q/R33Q) CPVT mouse model is portrayed by an unexpected set of abnormalities including (1) reduced CASQ2 content, possibly attributable to increased degradation of CASQ2-R33Q, (2) reduction of SR calcium content, (3) dilatation of junctional SR, and (4) impaired clustering of mutant CASQ2.     

Acute posttraumatic renal failure: a multicenter perspective.

Acute renal failure (ARF) following trauma is rare. Historically, ARF has been associated with a high mortality rate. To investigate this entity we conducted a retrospective review of 72,757 admissions treated at nine regional trauma centers over a 5-year period. Seventy-eight patients (0.098%) developed acute renal failure requiring hemodialysis. Detailed demographic, clinical, and outcome data were collected. Patients with pre-existing medical conditions (group I) had a 70% increase in mortality over those without pre-existing conditions (p less than 0.004). Twenty-four patients (31%) developed ARF less than 6 days after injury (group II). The remainder (group III) developed late renal failure (mean time to first dialysis, 23 days). The predominant cause of death was multiple organ failure (82%). There were no differences in mortality because of multiple organ failure among the three groups of patients. Of the 33 survivors, six (18%) were discharged with renal insufficiency, three (9%) were discharged on dialysis, 23 (70%) were discharged home or to rehabilitation, and 27 (82%) had no significant evidence of renal insufficiency. Conclusion: Posttraumatic renal failure requiring hemodialysis is rare (incidence, 107 per 100,000 trauma center admissions), but the mortality rate remains high (57%). Two thirds of the cases of posttraumatic renal failure develop late and are secondary to multiple organ failure; one third of the cases of posttraumatic renal failure develop early and may result from inadequate resuscitation.     

A PIL for every ill? Patient information leaflets (PILs): a review of past, present and future use

This article reviews the usefulness and importance of written information, specifically leaflets, being given to patients. Evidence suggesting how both patient and doctor may benefit from the giving of written information is reviewed. Identification of good practice relating to the content and readability of leaflets is discussed. An argument is put forward that the giving of written information is an under-utilized resource in contributing to improving patient outcomes but that this may be changing with the increasing use of patient leaflet databases. The advantages and disadvantages of computer- generated patient leaflets are discussed and desirable further areas of research on computer-generated leaflets are proposed.      

The role of surgeon-performed ultrasound in patients with possible cardiac wounds.

OBJECTIVE: The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA: Ultrasound quickly is becoming part of the surgeon's diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS: Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS: Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.     

Severe hepatic trauma: a multi-center experience with 1,335 liver injuries

The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Extraanatomic bypass for peripheral arterial injuries

Over an 8-year period, extraanatomic bypass grafting was performed for peripheral arterial injuries or infections in 12 patients. The indications for use of the technique were as follows: (1) extensive loss of soft tissue over arterial injury or avulsion; (2) wound infection with rupture of a previous arterial repair; or (3) combined infections in soft tissue and the underlying artery due to illicit drug injection. The technique involved excision of the injured or infected artery beyond the margins of the debrided wound and insertion of an autogenous saphenous vein as an extraanatomic bypass graft in a medial or lateral position around the wound. Shotgun wounds were the mechanism of injury in six patients, whereas an extensive injury or infection in the brachial artery was present in eight patients. Successful wound coverage or closure was accomplished and distal arterial flow preserved in 11 patients, 5 of whom had residual neuromuscular or bony defects related to the magnitude of the original injury.