Retrograde hepatic venous flow: a sign of mesenteric infarction.
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Aortic Dissection↗
Biomedical subjects
G P Naude
Publications and source records attributed to G P Naude.
Gunshot injuries of the lower oesophagus.
We present seven cases of lower oesophageal gunshot injury cared for by one surgeon. Diagnosis was made clinically, with the help of chest X-rays and with oesophagography and oesophagoscopy. Five were treated with wide debridement and resection of the distal esophagus and oesophago-gastric anastomosis with a Nissen wrap to protect the anastomosis. Two lesser injuries were treated by primary repair. The five treated with resection and oesophago-gastric anastomosis did not leak and the patients were discharged after oesophagography 10 days postoperatively. Primary repairs in two patients were complicated by oesophageal leaks, one subclinical and one with an empyema. The oesophageal blood supply is segmental in areas and variable in the distal part. Injury due to a bullet wound may cause more damage than is evident at surgery. Additional mobilization can further devascularize the distal oesophagus and lead to anastomotic leaks. We advocate wide debridement of oesophageal gunshot injuries and resection of the distal oesophagus. Continuity is restored with a primary oesophago-gastric anastomosis (double layer) with a fundoplication to protect the anastomosis.
Adolescent↗
Laparoscopic cholecystectomy facilitated by hydrodissection.
Hydrodissection has been used in the past in open cholecystectomy to facilitate dissection in difficult cases. Injection of 50 mL of saline, with a laparoscopic cyst aspiration needle during laparoscopic cholecystectomy between the gallbladder and the liver, causes an edematous area 1-1.5 cm thick between the gallbladder and the liver. This allows dissection to be carried out prograde and retrograde with less bleeding and a much smaller chance of gallbladder perforation and the escape of stones. One hundred and thirty-three laparoscopic cholecystectomies (LC) utilizing hydrodissection were compared to 48 historical controls (HC), comparing blood loss, stone spillage, and dissection time. Blood loss was on average less than 5 mL in the LC group and 56 mL in the HC. One case of minor biliary spillage occurred in the LC group and 11 gallbladder perforations in the HC group. Time taken for the dissection was 6.4 minutes for LC and 16 minutes for HC. Laparoscopic hydrodissection was accompanied by less bleeding, fewer incidents of gallbladder damage and stone spilling, and a much faster dissection time. It can also be performed prograde, which is helpful in liver cirrhosis.
Blood Loss, Surgical↗
Base of skull internal carotid and internal jugular gunshot wounds treated conservatively: inadequate treatment, or was well enough left alone?
Zone three carotid injuries present problems of access in emergency situations. Not only are the methods time consuming, but they also put certain structures in the neck at risk. A patient was treated at this institution with a large calibre gunshot injury of the right internal carotid and internal jugular vein. He was neurologically intact and his bleeding had been completely controlled. A decision was made to treat him conservatively and he recovered uneventfully with no neurological deficit and no further bleeding. Emergency exposure of the distal carotid artery involves dislocating the mandible, putting the facial nerve and parotid gland at risk of injury. Base of skull carotid injuries are best treated expectantly if there is no active bleeding or progressive neurological impairment. Careful follow-up is required to diagnose and treat carotid-jugular fistulas, false aneurysms and stenoses early.
Adolescent↗
Femoral hernia: the dire consequences of a missed diagnosis.
Femoral hernia has always presented more difficulty in diagnosis than other external abdominal hernias. The incidence of incarceration and strangulation is higher in our series than the published literature would suggest. A retrospective study was performed at our institution from February 1990 to June 1995. In that period, 22 patients were operated on for femoral hernia. There were 16 women and 6 men, average ages 51 and 48 years, respectively. The men weighed on average 209 lb, and the women, 154 lb. Three of our patients had elective repair of their hernias (16%); 19 were performed urgently or emergently (86%). Of the emergency repairs, 3 had strangulated small bowel requiring resection (16%), 1 had a strangulated vermiform appendix with abscess formation (5%), 3 had strangulated omentum requiring excision (16%), giving a total of 7 patients with strangulation and necrosis of the hernial contents (36%). The remainder had viable contents in the hernia sac. The time from the onset of symptoms to presentation at the hospital varied from 1 day to 3 years. The time from strangulation to presentation was between a few hours and 4 days. Surgery was performed on the day of admission (within 24 hours) on all but 2 of our patients. Procedures performed were McVay repair, 13; Bassini, 4; laparoscopic with Marlex mesh, 1 patient; drainage of a groin abscess in 2 patients with later repair; and on 2 patients the type of repair was not specified. One of the patients died. Postoperative wound infection occurred in 2 heavily contaminated patients, and 3 had pneumonia. Patients with no regular physician and no routine physical examinations are at higher risk for developing strangulation of femoral hernias. Emergency physicians and general practitioners are in the best position to diagnose these hernias early, when treatment can be elective.
Abscess↗
Blunt disruption of the abdominal aorta: report of a case and review of the literature.
A 71-year-old woman had an abdominal aortic disruption as a belted passenger in a motor vehicle accident. The diagnosis was unexpected, and the patient died during surgery. There have been 54 patients operated with this diagnosis since 1953; our patient was the fifty-fifth. This is an unusual injury, because the aorta is well protected in this position. Thoracic aortic injuries are much more common (20 times) than abdominal injuries. The causes are motor vehicle accidents, blows to the abdomen, explosions, and falls. Obstructing lesions such as thrombosis and intimal dissection are the more common presentation. False aneurysms occur occasionally. Free rupture has a very high and immediate mortality rate, and few patients arrive at the hospital alive. Diagnosis can be clinical, based on distal ischemia and neurologic abnormalities, or made with Doppler scanning, ultrasonography, computed tomography, or arteriography. Two thirds present acutely and one third subsequently months or even years after the original injury. Treatment consists of flap suture, thrombectomy, bypass grafting in more extensive injury, or extra-anatomic bypass in the face of severe contamination. Recently, endoluminal stenting has successfully been used, avoiding an abdominal operation completely.
Accidents, Traffic↗
Antegrade laparoscopic common bile duct stone removal using a balloon-tipped embolectomy catheter.
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Catheterization↗
Comparative stress hormone changes during helium versus carbon dioxide laparoscopic cholecystectomy.
Laparoscopic surgery has been termed minimally invasive surgery by advocates of this technology. It has been demonstrated previously that using carbon dioxide for insufflation produces a respiratory acidosis due to transperitoneal absorption of gas. Insufflation with helium does not create this acidosis. We questioned whether laparoscopic surgery would elicit a stress response and whether the absence of acidosis with helium might prevent or reduce the levels of stress hormones. Sixteen female patients undergoing laparoscopic cholecystectomy were randomly assigned to helium (n = 8) or CO2 (n = 8) insufflation. Serum cortisol, epinephrine, and norepinephrine were measured preoperatively, after induction of anesthesia but before insufflation, at 45 min of surgery, and after desufflation. There were increases in epinephrine, norepinephrine, plasma cortisol, and urine cortisol at 45 min and at the conclusion of the procedure over the preoperative value. With ANOVA, each variable showed significant increases from preoperative values, at 45 min, and at the end of the case. Except for the increased epinephrine when helium was used, there were no significant differences in the other variables between helium and CO2. Laparoscopic cholecystectomy produces significant increases in stress hormone levels. Prevention of acidosis with helium insufflation does not appear to protect against increases in stress hormones. Epinephrine levels with helium insufflation are higher than with CO2, and elevations in stress hormones suggest that laparoscopic cholecystectomy is not physiologically minimally invasive.
Acidosis, Respiratory↗
Umbilical entry as an alternative in laparoscopy.
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Abdomen↗
Gunshot injuries of the sacrum.
Gunshots to the sacrum are unusual and present several management problems. Associated injuries and particularly sacral bleeding are troublesome. Conventional methods of hemostasis are not suitable in this setting as the spinal blood supply is very complex because it is largely derived from the longitudinal spinal arteries originating intracranially. Attempts at proximal control are difficult and could lead to neurological injury. We successfully managed brisk bleeding in three patients with sacral gunshots. After the major intra abdominal hemorrhage had been controlled, attention was turned to the sacral wounds that had been packed with sponges up to that time. The sacral defect was closed with bone wax to control bleeding definitively. Methyl cellulose was then put over the bone wax and the periosteum of the sacrum and posterior peritoneum (mobilized if necessary), sutured over the methyl cellulose. Post operatively the patients are carefully monitored for developing neurological deficit that would necessitate immediate sacral laminectomy and decompression. We advocate tamponading of the sacral wound with bone wax, covered by methyl cellulose and kept in place and held firm by the periosteum and posterior peritoneum sutured over it as a successful interim or definitive form of therapy.
Adolescent↗
Gang warfare: the medical repercussions.
Gang related violence in Los Angeles County has increased, with homicides increasing from 205 in 1982 to 803 in 1992. This study examines the medical and financial consequences of such violence on a level I trauma center. Of 856 gunshot injuries over a 29-month period, 272 were gang related. There were 55 pediatric and 217 adult patients. Eighty-nine percent were male and 11% were female. Trauma Score averaged 14.7 +/- 3.1, Glasgow Coma Scale average score was 13.7 +/- 3.4, and the mean Injury Severity Score was 10.8 +/- 14. Twenty-two percent of the gunshots were to the head and neck, 20% to the chest, 20% to the abdomen, 6% had a peripheral vascular injury, and 33% sustained an extremity musculoskeletal injury. Emergency surgery was performed on 43%, including laparotomy 58 (49%), craniotomy 16 (13%), laparoscopy 14 (12%), vascular procedures 10 (8%), orthopedic procedures 6 (5%), head and neck endoscopies 4 (3%), thoracotomies 2 (2%), and 10 (8%) unspecified. There were 25 deaths (9%), primarily caused by head injuries and exsanguinating hemorrhage. Eighty-six percent entered the hospital during the hours of minimal staffing that preempted the use of facilities for other emergent patients. Charges totaled $4,828,828 (emergency room, surgical procedures, intensive care, and surgical ward stay) which equated to $5,550 per patient per day. Fifty-eight percent had no third party reimbursement, 22% had Medi-Cal, and 20% had medical insurance. Because of dismal reimbursement rates, the costs of gang violence are passed on to the tax payer. The cost of gang related violence cannot be derived from hospital charges only, because death, disability, and pain are not entered into the calculation. Education, increased social programs, and strict criminal justice laws and enforcement may decrease gang related violence and the drain it has on financial and medical resources.
Adolescent↗
From deadly weapon to toy and back again: the danger of air rifles.
More than 30,000 air gun injuries occur annually in the United States. While in the past these injuries were usually not serious unless an eye was injured, advances in technology have created air guns with the ability to maim and kill. A recent carotid injury with embolization of the BB is presented. Modern air rifles can produce a muzzle velocity of 1,200 feet per second, faster than many low-velocity handguns and rifles. Head, chest, and abdominal injuries have lead to permanent damage and death. Federal and state laws have not kept up and air rifles are only mentioned in the laws of 28 states, and then often only to exclude them from being termed firearms or weapons. The law should take cognizance of the fact that air guns have changed and should be governed by the same laws that apply to firearms.
Adolescent↗
Helium insufflation in laparoscopic surgery.
Carbon dioxide is the most commonly used gas for abdominal insufflation in laparoscopy today. Due to the solubility of carbon dioxide large volumes are absorbed into the circulation causing a high PCO2 and a low pH (respiratory acidosis). Carbon dioxide is also stored in several sites in the body and is released at the conclusion of the procedure prolonging the respiratory acidosis when the patient is least able to cope with this additional burden. Cardiac effects of CO2 consist of a lowering of the arrhythmia threshold, increased blood pressure, pulse and cardiac output. At a sustained high level this can lead to cardiac depression and death. These effects are particularly prone to occur in cardiac and respiratory cripples. Other gases that have been used include air, oxygen, nitrous oxide and nitrogen. Their use has been discontinued because of the danger of embolism. Air, oxygen and nitrous oxide are also not safe to use in the presence of electrosurgical instruments thereby limiting their usefulness even further. Helium has been proposed as a very promising alternative to CO2. In the laboratory and in a clinical trial, helium has not produced the respiratory acidosis associated with CO2 insufflation. This is further evidence that the acidosis is not primarily due to elevation of the diaphragm and consequent increased dead space, but to the large amount of CO2 that is absorbed directly from the peritoneal cavity. Helium would seem to be the gas of choice at this time as it comes close to fitting the criteria for an ideal insufflating gas. Helium is clear and colorless, allowing unimpeded vision to the operator. It is non toxic, not flammable or explosive and can be safely used with electrocautery and laser. Helium is easy to handle and not very soluble which decreases the amount absorbed from the peritoneal cavity and consequently the amount used. That which is absorbed is quickly cleared by the lungs. Helium is metabolically inactive (in contrast to CO2) and does not interfere with normal metabolic processes. In view of this promising initial work, further studies are indicated.
Abdomen↗