Penetrating cardiac injuries

Our objective was to determine the influence of several clinical factors on the survival of patients with penetrating wounds to the heart. A retrospective review of 80 consecutive penetrating cardiac injuries treated in a Level II urban trauma center from 1980 through 1994 were examined. Thirty-six patients (45%) had gunshot wounds (including 1 shotgun wound), and 44 (55%) had stab wounds. Intervention consisted of emergency room (ER) or operating room thoracotomy. We measured the effect of several clinical factors on morbidity and patient survival. Survival rate was 17 of 36 (47%) in gunshot injuries and 35 of 44 (80%) in stab injuries, with an overall survival rate of 52 of 80 patients (65%). The average age was 24 years (range, 9-53), and there were 3 female patients. Twelve patients (15%) had multiple cardiac injuries, and 63 (79%) had other associated injuries. Fourteen patients (17%) presented with no blood pressure, and 55 (69%) were hypotensive on admission. ER thoracotomy was performed on 7 of 52 survivors (13%) and 24 of 28 nonsurvivors (86%). Survival after ER thoracotomy was 7 of 31 patients (22%). A selective approach is recommended, because ER thoracotomy has a limited role in penetrating cardiac injury. A high index of suspicion, prompt resuscitation, and immediate definitive surgical management resulted in a high survival rate for these frequently lethal injuries.

Laparoscopic approach to the management of incarcerated hernia of appendices epiploicae: report of two cases and review of the literature

Appendices epiploicae may be involved in several intraabdominal pathologic processes, including occasional incarceration in hernias. This diagnosis is most frequently made intraoperatively. In addition to repair of the hernia, management includes a thorough evaluation of the involved appendage in terms of its viability. Any appendage found to be nonviable or of doubtful viability needs to be excised. Such evaluation and excision has traditionally required an open approach. Laparoscopy offers the advantage of a comparable evaluation of viability, the ability to excise the affected appendage if necessary, and a significantly lower morbidity. The requirement of general anesthesia and the need to generate a pneumoperitoneum may be limiting factors in patient selection.

Saint's triade presenting as volvulus of the gallbladder

Saint's triade of hiatus hernia, colonic diverticula, and cholelithiasis presenting with volvulus of the gallbladder is a unique occurrence. Possible etiology of volvulus of the gallbladder involves kyphosis, viceroptosis, cholelithiasis, and in this case adhesive bands. Laparoscopic decompression of the gallbladder, division of the adhesive bands, detorsion of the volvulus, and finally laparoscopic cholecystectomy successfully resolved this uncommon clinical problem. We describe a case and review the literature.

The effect of complications on length of stay

OBJECTIVES

The authors determined the effect of complications on length of stay (LOS) in surgical patients.

SETTING

From 1987 to 1990, in the Professional General Surgical Unit of Royal Victoria Hospital, a retrospective survey was conducted on 5128 consecutively admitted patients with 396 different diagnosis; 228 different operations were examined.

MAIN OUTCOME MEASURES

Patient LOS during a 3-year period in a general surgical ward was analyzed from hospital activity analysis, case notes, ward audit notes, and sepsis audit notes. Readmission rates for complications in patients with a short LOS were examined. Comparison were made between LOS and age, type of surgery, and complication type.

RESULTS

Pressure on beds resulting from an increased demand on surgical care decreases patient's hospital LOS; increasing age increases LOS. In general, complications double the average LOS. The authors calculated that a surgical complication can be given a numerical ratio that directly reflects the severity of the complication and increases the patient's LOS. The ration of the infective complication corresponds with the clinical severity of the complication. However, a short LOS may lead to readmission of patients for further treatment. For patients readmitted with complications, 41% had been discharged earlier than the average LOS for their diagnosis.

CONCLUSION

Length of stay is increased by complications and can be used to implement discharge planning in general surgical patients. Furthermore, a complication of their treatment can be given a numerical ratio that corresponds to the clinical severity of the complication and the increased LOS in hospital.

Intraperitoneal rupture of ectopic varices--a rare complication of portal hypertension

A 50 year old man presented with sudden abdominal pain, abdominal distension and shock. At emergency laparotomy a large amount of blood was found in the peritoneal cavity. There was micronodular cirrhosis of the liver and the spleen was enlarged. The bleeding was traced to distended veins in the right paracolic gutter which were oversewn and the abdomen closed. A coagulopathy was diagnosed and treatment including high dose aprotinin commenced. However, he continued to bleed and at a second laparotomy the area of previous haemorrhage was packed. Further deterioration continued until death 12 hours later. Intraperitoneal haemorrhage from ectopic varices is a rare occurrence. There is a high mortality rate usually due to an advanced coagulopathy. This is the first report of aprotinin being used in an attempt to treat this. On the basis of this report aprotinin would not seem to be of benefit for this condition.

Evaluation of "gastric" emptying time in the J pouch compared with a standard esophagojejunal anastomosis

Gastric emptying times and symptoms were recorded in 18 patients after total gastrectomy and either a 15-cm J-pouch (n = 10) or a standard esophagojejunal anastomosis (n = 8). A solid test meal labeled with 99mTc was used to compare the emptying times. The postoperative symptoms and nutritional status were also assessed. The J-pouch resulted in a prolonged period of food retention in the upper jejunum (p < 0.02) compared to that with a standard esophagojejunal anastomosis. The patients with a J-pouch had fewer episodes of postprandial pain (p < 0.03) or vomiting (< 0.04). They also had fewer dietary restrictions (p < 0.04) and better nutritional status.

Subclinical injuries in lacerations to the forearm and hand

This report describes the incidence and severity of subclinical injuries to underlying structures in lacerations to the hand and forearm. One hundred consecutive hand and forearm lacerations that penetrated the full thickness of subcutaneous tissue were studied prospectively. Lacerations were explored under either biceps or forearm tourniquets. Injuries, treatment, tourniquet time, causative agent and complications were recorded. In all, 97 patients sustained 100 lacerations. A total of 49 deep injuries were discovered, none of which was detected clinically before exploration. Of these, 33 were tendon lacerations; 21 tendons, including three flexor tendons, were repaired. Nineteen patients required treatment in a volar slab for at least 3 weeks. Five patients of 49 returning for review developed wound infection. No patient developed significant problems related to the tourniquet, which was inflated for a mean time of 4.9 min. There is a high incidence of subclinical injury in full-thickness lacerations of the forearm and hand. These should be explored under tourniquet, which should minimize complications such as wound infection and delayed tendon rupture.