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H L Pachter

Publications and source records attributed to H L Pachter.

At least 19 recordsLinked to original sources
PubMed1992

Significant trends in the treatment of hepatic trauma. Experience with 411 injuries.

Several significant advances in the treatment of hepatic injuries have evolved over the past decade. These trends have been incorporated into the overall treatment strategy of hepatic injuries and are reflected in experiences with 411 consecutive patients. Two hundred fifty-eight patients (63%) with minor injuries (grades I to II) were treated by simple suture or hemostatic agents with a mortality rate of 6%. One hundred twenty-eight patients (31%) sustained complex hepatic injuries (grades III to V). One hundred seven patients (83.5%) with grades III or IV injury underwent portal triad occlusion and finger fracture of hepatic parenchyma alone. Seventy-three surviving patients (73%) required portal triad occlusion, with ischemia times varying from 10 to 75 minutes (mean, 30 minutes). The mortality rate in this group was 6.5% (seven patients) and was accompanied by a morbidity rate of 15%. Fourteen patients (11%) with grade V injury (retrohepatic cava or hepatic veins) were managed by prolonged protal triad occlusion (mean cross-clamp time, 46 minutes) and extensive finger fracture to the site of injury. In four of these patients an atrial caval shunt was additionally used. Two of these patients survived, whereas six of the 10 patients managed without a shunt survived, for an overall mortality rate of 43%. Over the past 4 years, six patients (4.7%) with ongoing coagulopathies were managed by packing and planned re-exploration, with four patients (67%) surviving and one (25%) developing an intra-abdominal abscess. One additional patient (0.8%) was managed by resectional debridement alone and survived. During the past 5 years, 25 hemodynamically stable and alert adult patients (6%) sustaining blunt trauma were evaluated by computed tomography scan and found to have grade I to III injuries. All were managed nonoperatively with uniform success. The combination of portal triad occlusion (up to 75 minutes), finger fracture technique, and the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries (grade III to IV). Juxtahepatic venous injuries continue to carry a prohibitive mortality rate, but nonshunting approaches seem to result in the lowest cumulative mortality rate. Packing and planned reexploration has a definitive life-saving role when used adjunctively in the presence of a coagulopathy. Nonoperative management of select hemodynamically stable adult patients, identified by serial computed tomography scans after sustaining blunt trauma is highly successful (95-97%).

Adult↗
PubMed1992

Blunt colonic injury--a multicenter review.

During the past decade there has been a shift in the management of injuries of the colon to primary repair without a protective diverting colostomy. Unfortunately, reports concerning this practice contain relatively few patients with blunt trauma and it is unclear whether the principles established for penetrating injury should be applied in the setting of blunt colon injury. A retrospective review of 54,361 major blunt trauma patients admitted to nine regional trauma centers from January 1, 1986, through December 31, 1990, was conducted. Statistical analysis of the data collected regarding 286 (0.5%) of these patients who suffered colonic injury revealed: (1) injury to the colon is found in more than 10% of patients undergoing laparotomy following blunt trauma; (2) available diagnostic modalities are unreliable in detecting isolated colonic pathology; (3) primary repair of full-thickness injuries or resection and anastomosis may be safely performed without diversion; (4) gross fecal contamination is the strongest contraindication to primary repair. Further, delay of surgery, shock, and the timing of antibiotic administration were not associated with significantly increased morbidity.

Abbreviated Injury Scale↗
PubMed1992

The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries.

The evaluation and management of patients with minor head injury (MHI: history of loss of consciousness or posttraumatic amnesia and a GCS score greater than 12) remain controversial. Recommendations vary from routine admission without computed tomographic (CT) scanning to mandatory CT scanning and admission to CT scanning without admission for selected patients. Previous reports examining this issue have included patients with associated non-CNS injuries who confound the interpretation of the data and affect outcome. We hypothesized that patients with MHI and no other reason for admission with normal neurologic examinations and normal CT scans would have a negligible risk of neurologic deterioration requiring surgical intervention. To validate this hypothesis we studied 2766 patients with an isolated MHI admitted to seven trauma centers between January 1, 1988, and December 31, 1991. There were 1898 male patients and 868 female patients; injury was blunt in 99%. A neurologic examination and a CT scan were performed on 2166 patients; 933 patients had normal neurologic examinations and normal CT scans and none required craniotomy; 1170 patients had normal CT scans and none required craniotomy; 2112 patients had normal neurologic examinations and 59 required craniotomy. The sensitivity of the CT scan was 100%, with positive predictive value of 10%, negative predictive value of 100%, and specificity of 51%. The use of CT alone as a diagnostic modality would have saved 3924 hospital days, including 814 ICU days, and $1,509,012 in hospital charges. Based on these data, we believe that CT scanning is essential in the management of patients with MHI and that if the neurologic examination is normal and the scan is negative patients can be safely discharged from the emergency room.

Adolescent↗
PubMed1992

Surgical diseases of the falciform ligament.

Surgical lesions of the falciform ligament are rare. Clinically, they present most often as a cystic abdominal mass, and less often as an abscess. Two cases of falciform ligament lesions are reported. The literature, histology, anatomy, clinical manifestations, and surgical management are detailed. Computerized axial tomography (CAT scan) is an essential tool in arriving at a correct preoperative diagnosis. Complete excision of the lesion is curative.

Abscess↗
PubMed1991

The role of microvascular free flaps in salvaging below-knee amputation stumps: a review of 22 cases.

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not bee utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46%), foot filet six (25%), latissimus dorsi four (17%), lateral thigh, tensor fascia lata, and groin one (4%). Free flaps were performed immediately after injury in five (21%) cases, within the first week in two (8%), between 1 and 3 months in 12 (50%), and after 3 months in five (21%). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25%) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21%), neuroma in three (13%), hematoma in two (8%), donor site complication in two (8%), thrombosis requiring reoperation in one (4%), and flap failure in one (4%). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury. Despite a protracted course in these severe injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps.

Activities of Daily Living↗
PubMed1990

Experience with selective operative and nonoperative treatment of splenic injuries in 193 patients.

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.

Adult↗
PubMed1990

The morbidity and financial impact of colostomy closure in trauma patients.

During a 10-year period, 87 patients who had undergone elective colostomy closure at Bellevue Hospital were retrospectively reviewed in order to evaluate the morbidity of colostomy closure after traumatic injury and its financial impact. Sixty-two per cent of the colostomies were in the left colon and 38% were right sided. The interval from the original injury to colostomy takedown varied from 20 to 465 days, with a mean of 144 days. The mean postoperative hospital stay for the entire group was 15.13 days at a cost of $13,995. There were no deaths and no anastomotic leaks in the entire series, but a morbidity rate of 25% ensued. Small bowel obstruction was the most frequent significant complication, occurring in ten patients (11.5%) and resulting in a prolongation of hospital stay by 7 days at an additional cost of $6,500 per patient. One additional patient developed a subphrenic abscess which required operative drainage, necessitating an additional 24 days in the hospital at an increased cost of $22,200. Other complications which did not prolong hospital stay included eight superficial wound infections, one transient respiratory failure, and two patients who returned at a later date with incisional hernias at the stoma site. The 25% morbidity encountered in this series suggests that colostomy closure is not a low-morbidity procedure and should be considered as an important factor favoring primary repair. Coupled with the significant financial impact of both colostomy formation and takedown, ample justification exists for greater efforts in avoiding colostomy formation whenever feasible.

Adolescent↗
PubMed1990

Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum.

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) has been charged to devise injury severity scores for individual organs to facilitate clinical research. Our first report (1) addressed O.I.S.'s for the Spleen, Liver, and Kidney; the following are proposed O.I.S.'s for Pancreas (Table I), Duodenum (Table II), Small Bowel (Table III), Colon (Table IV), and Rectum (Table V). The grading scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. We emphasize that these O.I.S.'s represent an initial classification system which must undergo continued refinement as clinical experience dictates.

Colon↗
PubMed1989

Hepatic trauma revisited.

As stated in the introduction to this monograph, much has changed in the management of major hepatic injuries during the past 5 to 10 years. The major changes are summarized as follows: 1. Computed tomographic scanning is now the mainstay of diagnosis for hepatic injuries after blunt trauma and allows for nonoperative therapy in many patients with lacerations, intrahepatic hematomas, or subcapsular hematomas; 2. Realization that the time limit for application of the Pringle maneuver can be extended. 3. Recognition that fibrin glue appears to be a useful topical agent in preliminary clinical studies; 4. Use of hepatotomy with selective vascular ligation instead of mattress sutures for deep lacerations or to control hemorrhage from tracts of penetrating wounds; 5. Use of resectional débridement of devitalized tissue and selective vascular ligation instead of formal anatomical resection; 6. Use of an "omental pack" as a filler of deep cracks or hepatotomy sites instead of closure with mattress sutures; 7. Use of perihepatic packing in selected patients instead of resection when a coagulopathy or major subcapsular hematoma is present; 8. Discontinued use of perihepatic drains for minor or moderate hepatic injuries as long as discrete methods of selective vascular and biliary ligation have been used.

Humans↗
PubMed1989

Organ injury scaling: spleen, liver, and kidney.

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) was appointed by President Trunkey at the 1987 Annual Meeting. The principal charge was to devise injury severity scores for individual organs to facilitate clinical research. The resultant classification scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. A number of similar scales have been developed in the past, but none has been uniformly adopted. In fact, this concept was introduced at the A.A.S.T. in 1979 as the Abdominal Trauma Index (A.T.I.) and has proved useful in several areas of clinical research. The enclosed O.I.S.'s for spleen, liver, and kidney represent an amalgamation of previous scales applied for these organs, and a consensus of the O.I.S. Committee as well as the A.A.S.T. Board of Managers. The O.I.S. differs from the Abbreviated Injury Score (A.I.S.), which is also based on an anatomic scale but designed to reflect the impact of a specific organ injury on ultimate patient outcome. The individual A.I.S.'s are, of course, the basic elements used to calculate the Injury Severity Score (I.S.S.) as well as T.R.I.S.S. methodology. To ensure that the O.I.S. interdiffuses with the A.I.S. and I.C.D.-9 codes, these are listed alongside the respective O.I.S. Both the currently used A.I.S. 85 and proposed A.I.S. 90 are provided because of the obligatory transition period. Indeed, A.I.S. 90 contains the identical descriptive text as the current O.I.S.'s. The Abdominal Trauma Index and other similar indices using organ injury scoring can be easily modified by replacing older scores with the O.I.S.'s.(ABSTRACT TRUNCATED AT 250 WORDS)

Abbreviated Injury Scale↗
PubMed1986

The management of juxtahepatic venous injuries without an atriocaval shunt: preliminary clinical observations.

Juxtahepatic venous injuries are usually fatal. The optimal method of dealing with these injuries remains controversial, but most experience has been with the insertion of an atriocaval shunt. However, the mortality rate with atriocaval shunting remains prohibitively high (60% to 100%). The experience at the Bellevue Hospital Trauma and Shock Unit during a 9-year period revealed a 50% mortality rate in four consecutive patients who underwent atriocaval shunting. As such, a different approach was used in the following five patients, all of whom survived. One additional patient died in the operating room before any definitive repair could be undertaken. Four steps are considered essential to the successful management of these patients: (1) compression of the injury site until adequate resuscitation has been achieved; (2) early recognition that a juxtahepatic venous injury exists, as indicated by failure of the Pringle maneuver to adequately arrest hemorrhage; (3) prolonged portal triad occlusion with hepatocyte protection by means of large doses of steroids and topical hypothermia (portal triad occlusion time in the nonshunted group ranged from 20 to 64 minutes with a mean occlusion time of 46 minutes; although a transient rise in liver function test results seemed to correlate with the length of ischemia time, neither hepatic dysfunction nor hepatic necrosis occurred; and (4) extensive finger fracture of the liver to the site of vascular injury for primary repair or ligation; the extent of the finger fracture varied from 15 to 30 cm in length and from 5 to 15 cm in depth. The successful results achieved in five consecutive patients who sustained juxtahepatic venous injuries treated without a shunt serve as a basis for recommending this operative approach.

Blood Transfusion↗
PubMed1986

The significance of small bowel intussusception in acquired immune deficiency syndrome.

The etiology, radiographic diagnosis, and surgical management of small bowel intussusception in adults have been well documented in the literature. It has been shown that unlike the intussusceptions seen in infants, the adult variety is in most cases associated with a focal pathological process and that surgical reductions and often segmental resections are indicated. We have recently examined a patient with acquired immune deficiency syndrome presenting with small bowel intussusception who at surgery showed no evidence of a leading pathological cause. The purpose herein is to underline the potential development of transitory intussusceptions in patients with acquired immune deficiency syndrome, based on the common association of diffuse enteritis. In these patients, a correct interpretation of the radiographic findings may prevent unnecessary surgical explorations.

Acquired Immunodeficiency Syndrome↗
PubMed1984

A prospective comparison of two regimens of prophylactic antibiotics in abdominal trauma: cefoxitin versus triple drug.

To determine the best antibiotic regimen to employ in patients undergoing laparotomy for trauma, a randomized prospective study was designed comparing cefoxitin alone with a triple-drug regime of an aminoglycoside, ampicillin, and clindamycin. One hundred nineteen consecutive patients sustaining abdominal trauma (97 penetrating; 22 blunt) were divided by date of admission to a 24-hour course of antibiotics. The overall infection rate was 16.0%, with 14.5% of the cefoxitin-treated patients, and 18.0% of the triple-drug-treated patients developing an infectious complication. Excluding remote site infections, the abdominal wound and intraperitoneal infection rates were 13.0% for cefoxitin-treated patients, and 12.0% for triple-drug-treated patients. There was one instance of oliguric renal failure questionably related to an aminoglycoside. It is concluded that a 24-hour course of cefoxitin is a safe and effective prophylactic antibiotic regime in patients undergoing laparotomy for trauma.

Abdominal Injuries↗
PubMed1984

Management of penetrating wounds of the back and flank.

The results of a retrospective and prospective study of patients with penetrating wounds of the back and flank showed that physical examination alone was accurate in 72 and 83 per cent, respectively. The inaccuracy was primarily due to false-negative examinations. The most commonly injured organs were the liver and kidney. The presence of gross hematuria and intravenous pyelography proved to have an accuracy rate of 95 per cent in patients studied prospectively. Peritoneal lavage, although similarly accurate (95 per cent), was associated with a 10 per cent false-negative result when the wound was located in the back. Guidelines for the management of these patients include hospital admission, careful physical examination, urinalysis by dipstick and cell count, intravenous pyelography and peritoneal lavage. Initial hypotension usually is associated with visceral injury and is an indication for exploratory laparotomy. Strict adherence to these guidelines was associated with a negative exploration rate of less than 10 per cent and a decrease in the number of patients observed with visceral injury from 50 to 6 per cent.

Abdominal Injuries↗
PubMed1983

Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries of the liver.

The most important concept emerging from the management of complex hepatic trauma is that direct suture ligation of severed blood vessels and bile ducts is the most effective treatment. Three essential maneuvers are necessary: (1) the use of the finger fracture technique to expose the laceration widely, so that individual ligation of severed blood vessels and bile ducts can be accomplished under direct vision; (2) occluding the portal triad for 20 to 60 minutes; (3) closure of the hepatic incision over a viable omental pedicle. Two hundred consecutive patients with hepatic injuries were treated at the Trauma and Shock Unit of Bellevue Hospital between July 1976 and January 1982. One hundred and twenty-five injuries (63%) could be managed by superficial suture and drainage alone; 75 (37%) more extensive injuries required additional therapy; 47 of the 75 injuries required inflow occlusion for periods of up to 60 minutes, with the mean occlusion time of 30 minutes. All patients were pretreated with 30 to 40 mg/kg of Solu-Medrol prior to cross-clamping the portal triad. In addition, the liver was cooled to 27-32 degrees C topically by pouring 1 liter of iced Ringer's lactate directly on the liver surface, monitoring the temperature with an intra-hepatic probe. Ischemia time exceeded 20 minutes in 70%, 30 minutes in 40% and 60 minutes in 7% of patients. This approach, with complex hepatic trauma, has been dramatically effective. There were only four deaths (5.3%). One (1.3%) patient required reoperation for bleeding; three patients (4%) developed perihepatic abscesses; and two patients (3%) developed biliary fistulae that spontaneously closed. An extended right hepatectomy was necessary in the one patient who required reoperation for bleeding. This represents the only case of a formal hepatic resection in this series. Hepatic artery ligation was not employed in any case. These experiences strongly endorse the direct approach to the treatment of major hepatic lacerations by opening a lacerated liver sufficiently to ligate lacerated blood vessels and bile ducts, followed by closure over an omental pedicle. The wide-spread adoption of this technique will probably lower the mortality from massive liver injuries to 5-10%.

Bile Ducts↗
PubMed1979

Recent concepts in the treatment of hepatic trauma: facts and fallacies.

Experience with 85 consecutive patients treated at Bellevue Hospital for hepatic trauma over the past two years has established the importance of several principles of management. Simple liver injuries can be treated by superficial suture and drainage. Using this approach in 57 patients there were no deaths and no postoperative abscesses. Among 28 other patients with complex liver injuries, the first six patients (Group 1) were treated by lobectomy alone (1 patient), lobectomy and intracaval shunt (3 patients), hepatic artery ligation (1 patient), and left lateral segmentectomy (1 patient). Only one of the six survived. In the next 22 consecutive patients managed by the Pringle maneuver combined with finger fracture technique of the hepatic parenchyma and a viable omental pack there was only one death (4.5%). An intracaval shunt was used successfully once in this group, in a patient with a lacerated middle hepatic vein. Only one patient developed a postoperative subphrenic abscess (4.5%), and no patients required reoperation for bleeding. Eighty-two per cent of these 22 patients safely tolerated inflow occlusion of greater than 20 minutes with steroid protection. Hepatic artery ligation is superfluous in the majority of liver injuries. In complex injuries involving lobar branches of the portal vein, the retrohepatic cava or hepatic veins hepatic artery ligation is probably ineffective. Hepatic resection is rarely required and carries a prohibitive mortality. The finger fracture technique provides a direct approach to the source of heniorrhage and is probably the procedure of choice.

Adult↗