Isolated blunt traumatic rupture of gallbladder.
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Accidents, Traffic↗
Biomedical subjects
J F Fang
Publications and source records attributed to J F Fang.
Intra-abdominal pressure monitoring as a guideline in the nonoperative management of blunt hepatic trauma.
BACKGROUND: Nonoperative management has been validated as a standard of care for patients with blunt hepatic trauma. We herein study the correlation of intra-abdominal pressure (IAP) and other clinical parameters to predict the failure of nonoperative management, and attempt to use IAP to determine further therapeutic options. METHODS: During a 9-month period, 25 hemodynamically stable patients sustaining grades III to V blunt hepatic injuries were prospectively studied. They were admitted to the intensive care unit for clinical reevaluation, and hemodynamic and IAP monitoring. If the patient developed an IAP greater than 25 cm H(2)O, then an emergent laparotomy or laparoscopy was performed to achieve hemostasis and decompression of intra-abdominal hypertension (IAH). On the basis of an IAP of 25 cm H(2)O, the correlation between the IAP and an estimated amount of liver-related transfusion, the Pao(2)/Fio(2) ratio and peritoneal signs were analyzed. RESULTS: Of the 25 patients being studied, 20 (80%) had an IAP below 25 cm H(2)O, 1 of whom was found to have a pelvic abscess from an amputated segment of liver. On the other hand, five other patients with an IAP greater than 25 cm H(2)O received decompression and laparoscopic examinations, and one needed an open hepatorrhaphy. In general, though, 19 patients (76%) were successfully treated without operation. All recovered well after different therapeutic regimens; however, two developed liver abscesses, for a morbidity rate of 8% (2 of 25). This analysis revealed a strong association between the IAP value and the presence of peritoneal signs (Phi coefficient = 0.890, p < 0.001), but not in the estimated amount of liver-related transfusion and Pao(2)/Fio(2) ratio. CONCLUSION: This preliminary investigation suggests that IAH or abdominal compartment syndrome can develop while patients receive nonoperative management for grade III to V blunt hepatic injuries. There were no parameters that precisely reflected ongoing hepatic hemorrhage or predicted hemodynamic instability. Although the amount of hepatic hemorrhage was not accurately measured by the IAP, it could be reflected by an increased IAP. During nonoperative management, IAP monitoring may be a simple and objective guideline to suggest further intervention for patients with blunt hepatic trauma. Laparoscopic hepatic evaluation and abdominal decompression may be helpful in this situation.
Abdominal Injuries↗
Gallbladder torsion: case report and review of the literature.
Torsion of the gallbladder is a surgical emergency, occurring mainly in the elderly. Female is predominant to male with ratio 3 to 1. Despite its unknown etiology, the anatomical variations in the attachment of gallbladder which occur on the mobile mesentery to the inferior margin of the liver are usually found. When the gallbladder twists around the cystic duct and artery, torsion takes place with ensuing occlusion of the flow of bile and blood. Preoperative diagnosis is difficult to make; however, patients who receive prompt surgical treatment with cholecystectomy always get excellent outcomes. Mortality rate is low with 3% to 5%. Here, we report on elderly male patient with gallbladder torsion at our hospital and review the existing literature.
Aged↗
Acute appendicitis during pregnancy: a clinical assessment.
BACKGROUND: Acute appendicitis is the most common non-obstetric reason for laparotomy during pregnancy. The purpose of this study was to analyze the characteristics of the clinical presentations and postoperative outcomes of these patients and their fetuses. METHODS: Patients who underwent appendectomies during pregnancy from July 1991 to June 1997 were retrospectively identified. Their ages, clinical presentations, the severity of the inflammatory change in the appendices, and the postoperative complications of these patients and fetuses were recorded and analyzed. Long-term outcomes were confirmed by telephone contact, when possible. RESULTS: Forty-five pregnant women who underwent appendectomies for suspected acute appendicitis were retrospectively reviewed. The histopathological inflammatory change in the appendix was proven in 35 patients (78%). Sixty-three percent of the patients were multiparous, and 86% were in the first 2 trimesters. In the clinical settings, pain and tenderness in the right lower abdominal quadrant were the most common symptoms and signs in presentation. Perioperative administration of ritodrine had no obvious advantage in the prevention of fetal loss. Appendectomy was performed beyond 36 hours of onset of symptoms in 28% of the patients, among whom one-half had gangrenous or perforated appendices. Only one fetus was spontaneously lost in 32 patients with diseased appendices (3%), excluding 3 patients choosing artificial abortion. There was no maternal death in our series. CONCLUSION: The rate of fetal loss due to surgery for acute appendicitis during pregnancy was low. Delay of operation was pertinent to the more-inflammatory changes of the appendix and to the higher maternal complication rate. Early surgical intervention is essential.
Acute Disease↗
Laparoscopic decompression of abdominal compartment syndrome after blunt hepatic trauma.
Abdominal compartment syndrome (ACS) can occur in a variety of surgical conditions, particularly those with major life-threatening hemorrhage, massive volume resuscitation, prolonged operation times, and coagulopathy. In severely traumatized patients, the incidence of ACS is reported to be as high as 14% to 15% after damage control laparotomies. Although favorable results have been achieved with nonsurgical management of adult blunt hepatic trauma, the failure rates still range from 0% to 19%. Exploratory laparotomy is considered the intervention of choice in patients with blunt hepatic trauma who fail nonsurgical treatment. Expedient abdominal decompression currently is the treatment of choice after ACS. Oliguria, tachypnea, and tachycardia developed in two blunt hepatic trauma patients with grade IV and V injuries while they were receiving nonsurgical treatment. The intra-abdominal pressures measured more than 35 and 25 cm H 2O, respectively. Two patients with grade II and III ACS received laparoscopic examination instead of laparotomy. Their ACS was decompressed effectively via laparoscopy without any adverse effects. Therefore, we suggest that laparoscopy can be used as a safe alternative for the decompression of ACS.
Abdominal Injuries↗
Combined endoscopic and surgical treatment for the polyposis of Peutz-Jeghers syndrome.
Repeated laparotomy with extensive small bowel resectioning and eventual short-bowel syndrome is a major problem in Peutz-Jeghers syndrome (PJS) patients. This problem is caused by gastrointestinal polyposis with intussusception. A combined surgical and endoscopic approach can assess the extent of the polyposis, and small polyps can be removed by snare polypectomy. This can avert multiple enterotomies and decrease bowel resection segments. We applied an intraoperative colonscope via the enterotomy route in an 20-year-old PJS woman, and successfully removed the other 10 polyps distributed in the whole small bowel. As part of an aggressive approach to the management of polyposis in PJS, complete polypectomy can provide a longer symptom-free interval and remove potentially premaligment polyps.
Adult↗
Blunt hepatic injury: minimal intervention is the policy of treatment.
BACKGROUND: Many publications recommend nonoperative treatment for stable blunt hepatic injury patients. Unstable hemodynamic status is the only indication for surgery. When operation is indicated, controversies exist regarding which operative procedure will be more beneficial to the patients. The purposes of this study are to compare the results of operative and nonoperative management of patients with blunt hepatic injuries and to identify the optimal surgical approach when surgery is indicated. METHODS: Different prospective protocols of treating adult blunt hepatic injuries were conducted. From 1992 to 1993 (group I), urgent surgery would be performed in the presence of hemoperitoneum. The policy shifted to aggressive nonoperative approach between 1996 and 1997 (group II). The patients from each period were divided into three subgroups. Group A included the patients who received nonoperative treatment in either period. Group B consisted of the patients who received surgery in the first period and nonoperative management in the second period. Group C included the patients who were operated on in either group. Comparisons were made between matched groups. RESULTS: Groups IA and IIA patients had minor injuries and could be successfully treated nonoperatively. The results of groups IB and IIB were similar concerning hospital stay, morbidity, and mortality. Transfusion requirements of group IIB patients were significantly higher (2.2 vs. 1.1 units,p = 0.01) than those of group IB. However, 25 (58%) celiotomies of group IB patients were nontherapeutic. When surgery was indicated, group IC patients had significantly higher liver-related mortality (14 of 49 vs. 3 of 55, p = 0.002). Anatomic resection was performed more frequently in that period. CONCLUSION: Nonoperative treatment significantly decreased the rate of nontherapeutic laparotomy but carried the risks of higher transfusion requirements and delaying operation. When surgery was indicated, the policy of minimal intervention positively affected the patients' outcomes. The goal of surgery should be hemorrhage control rather than resection of the injured liver tissues.
Adult↗
Factors determining operative mortality of grade V blunt hepatic trauma.
BACKGROUND: Despite recent advances in the management of severe hepatic injuries, the operative mortality rate of grade V hepatic injuries still ranges from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blunt trauma. The purpose of this study is to understand the risk factors determining operative mortality in grade V blunt hepatic trauma, and to try to improve the surgical management of these injuries. METHODS: A retrospective study was conducted at a medical center that offers services including primary, secondary, and tertiary care. Forty-four patients with grade V blunt hepatic injuries were treated during a 6-year period from January 1, 1991, to December 31, 1996. The operative mortality was compared by a multivariate analysis. RESULTS: Forty-four patients with grade V blunt hepatic injuries were identified. Seven patients had only parenchymal injuries, and the others had vascular and associated parenchymal injuries. Venorrhaphy was used in 37 patients; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt. The overall mortality rate was 68% (30 of 44), and liver-related mortality was 50% (22 of 44). Univariate analysis revealed that the significant variables affecting operative mortality were initial systolic blood pressure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward stepping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative blood loss of 5,000 mL or more (relative risk = 23.5) would, significantly, encounter a worsening prognosis. CONCLUSIONS: Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V blunt hepatic trauma. We suggest that prompt resuscitation and expeditious and appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepatic trauma.
Adolescent↗
Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma.
BACKGROUND: Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management. METHODS: During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material. RESULTS: The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable. CONCLUSION: With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.
Adolescent↗
Surgical treatment and outcome after delayed diagnosis of blunt duodenal injury.
OBJECTIVE: To review our experience of 18 patients with duodenal injuries after blunt trauma, the diagnosis of which had been delayed for more than 24 hours. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan, R.O.C. SUBJECTS: 18 patients who presented with duodenal injuries between January 1986 and December 1995. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The reasons for the delay were: injuries not found during the first operation (n = 6), patients had not sought medical help (n = 6), and injuries treated conservatively at local hospitals (n = 5). There was one delay in our department because the patient lost consciousness. 12 patients were treated by pyloric exclusion with no deaths and four complications (one duodenal fistula and 3 retroperitoneal abscesses). The other 6 had various operations including pancreaticoduodenectomy, jejunostomy, and gastrostomy, with six complications and one death, giving an overall mortality of 6% and morbidity of 50%. Three patients developed delayed extensive retroperitoneal abscesses and all three were treated successfully by laparostomy. 16 of the 18 patients required enteral feeding through a jejunostomy. CONCLUSIONS: Though the complication rate was high, the use of pyloric exclusion and a feeding jejunostomy kept the mortality low. Enteral nutrition should be started early. Laparostomy is a good way to manage retroperitoneal abscesses. To avoid delay, patients at risk of duodenal injuries should be evaluated early by experienced trauma surgeons and any central retroperitoneal haematoma should be explored during the initial laparotomy.
Abscess↗
Retroperitoneal laparostomy: an effective treatment of extensive intractable retroperitoneal abscess after blunt duodenal trauma.
BACKGROUND: Delay in surgical treatment and duodenal wound dehiscence are two major causes of extensive retroperitoneal abscess formation after blunt duodenal injury. This complication is traditionally treated with primary repair of the duodenal wound and drainage of the abscess through anterior laparotomy. Pyloric exclusion is sometimes added as an adjunctive procedure. The anterior approach, however, may result in inadequate drainage, and repeat surgery is sometimes needed. We reviewed our experiences and evaluated the effectiveness of retroperitoneal laparostomy for the treatment of retroperitoneal abscess with continuous soiling. METHODS: There were 52 blunt duodenal injuries during a 7-year period. Eleven patients developed extensive retroperitoneal abscesses. RESULTS: All 11 patients were treated with anterior laparotomy initially. Five patients recovered after this procedure. Six patients continued to have retroperitoneal abscesses and were under septic status. Two patients received another anterior drainage, and had recurrent abscesses later. Retroperitoneal laparostomy was performed for these six patients. After retroperitoneal laparostomy, daily wound care, and antibiotic treatment, all six patients recovered. Only two patients developed incisional hernia. CONCLUSION: Retroperitoneal laparostomy is effective in treating extensive intractable retroperitoneal abscess after blunt duodenal injury. Patients with the complications of duodenal leak and extensive retroperitoneal abscess should be treated with pyloric exclusion and drainage through anterior laparotomy first. If the duodenal wound does not heal after pyloric exclusion and retroperitoneal abscess persists, retroperitoneal laparostomy should be performed without further attempt to repair the wound.
Abdominal Abscess↗
Small bowel perforation: is urgent surgery necessary?
BACKGROUND: Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury. METHODS: One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation. RESULTS: Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation. CONCLUSION: Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.
Abdominal Injuries↗
Prognosis in presumptive hypoxic-ischemic coma in nonneurologic trauma.
BACKGROUND: The neurologic outcome of comatose patients has a wide variation from complete reawakening to death. Methods of predicting the outcome of coma caused by either head injury or cardiac arrest have been the subject of much discussion in the literature. However, prediction of neurologic prognosis in comatose trauma patients without head injury has rarely been discussed. We reviewed our experience in treating patients with presumptive hypoxic-ischemic coma after trauma and tried to identify factors relating to their neurologic outcomes. METHODS: Thirty-six patients with normal brain computed tomographic scans, who remained comatose 10 minutes after stabilization of their hemodynamic status, were studied. Serial motor response, verbal response, pupillary light reflex, presence of spontaneous breathing and seizure, and blood glucose level were recorded to evaluate their roles in predicting neurologic outcomes. RESULTS: There were five deaths (mortality rate, 14%) and 11 patients (31%) with neurologic deficits. An absence of spontaneous breathing, a blood glucose level greater than 300 mg/dL during resuscitation, and a presence of seizure signified a poor prognosis. Initial neurologic evaluation at 10 minutes after stabilization of hemodynamic status was not accurate in predicting outcome. A motor response worse than withdrawal from painful stimuli at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome, with a 100% accuracy rate. CONCLUSION: Hypoxic-ischemic coma in patients sustaining major trauma yielded a significantly better survival and neurologic outcome than that induced by cardiac arrest or head injury. Decision-making in the first 24 hours after injury should not be affected by the patient's neurologic status at that time. A motor response worse than withdrawal at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome.
Adolescent↗
Blunt trauma-induced internal thoracic artery injury: case report.
We report the case of a 54-year-old male motorcyclist with an apparent grade IV liver injury and life-threatening hemomediastinum and right hemothorax following blunt deceleration trauma. Massive hemothorax and an unstable hemodynamic status even under copious blood volume replacement made emergent surgical intervention mandatory. A midline laparotomy was performed at first to rule out abdominal bleeding accompanied by a diaphragmatic tear, but the procedure was soon converted to a thoracotomy after finding an intact diaphragm and persistent bleeding from the chest tube. An isolated internal thoracic artery (ITA) transection was identified. It was actively bleeding and causing a huge anterior mediastinal hematoma and had ruptured into the right pleural cavity. The bleeder was controlled with suture ligation and the hemodynamic status was soon stabilized. The patient recovered without significant sequelae. The rarity of this kind of presentation is discussed, including both the ITA injury mechanism and the problems posed in making an early and correct diagnosis.
Humans↗
Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury.
BACKGROUND: Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively. METHODS: During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed. RESULTS: Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy. CONCLUSION: The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.
Adolescent↗
Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma.
BACKGROUND: Most blunt hepatic trauma patients can be managed nonoperatively. The current failure rate in adult blunt hepatic trauma is reportedly 0 to 19%. We wished to evaluate the applicability of laparoscopy and fibrin glue as a minimally invasive alternative to laparotomy in these unsuccessfully nonoperative cases. METHODS: All adult patients with blunt hepatic trauma managed nonoperatively at Linkou, Chang Gung Memorial Hospital Medical Center, Taipei, Taiwan, over a 2-year period from July 1, 1994, to June 30, 1996, were eligible for the study. A laparoscopic examination was performed on those who failed conservative care before undertaking an exploratory laparotomy. Fibrin glue was sprayed over the wound surface if ongoing hemorrhage was evident from any liver laceration. The clinical data, operative and laparoscopic findings, operative methods, and outcomes of these patients were studied. RESULTS: Of the 61 patients, 55 patients were successfully treated without operation. Of the six failures (10%) all were liver related. After the introduction of laparoscopy, the nontherapeutic laparotomy rate would have decreased from 100% (6 of 6) to 50% (3 of 6), and with the adjunctive use of fibrin glue, the laparotomy rate went down to 0% (0 of 6). There were no deaths among the six patients receiving laparoscopy and fibrin glues; and only one developed a liver abscess, for a morbidity rate of 17% (1 of 6). CONCLUSIONS: The selective use of laparoscopy and fibrin glue can effectively reduce the nontherapeutic laparotomy rate among blunt hepatic trauma patients who fail nonoperative management.
Adolescent↗
Cell count ratio: new criterion of diagnostic peritoneal lavage for detection of hollow organ perforation.
OBJECTIVES: Diagnostic peritoneal lavage (DPL) had been widely used in evaluating patients with suspected intraperitoneal injuries due to its high sensitivity. If the positive criteria are strictly followed, however, the incidence of nontherapeutic laparotomies will be unacceptably high. This realization has become more important recently with the popularization of nonoperative treatment for blunt solid organ injuries. For these patients, the early diagnosis of an associated hollow organ perforation is mandatory. METHODS: Three hundred and twenty patients undergoing DPL over an 18-month period were retrospectively reviewed to evaluate the usefulness of "cell count ratio" in diagnosing hollow organ perforation. The cell count ratio was defined as the ratio between white blood cell count and red blood cell count in the lavage fluid divided by the ratio of the same parameters in the peripheral blood. RESULTS: Two hundred twelve patients were diagnosed as having a positive DPL according to the classic criteria. Forty-four patients (21%) had a cell count ratio of greater than or equal to 1. The diagnosis at laparotomy was small bowel perforation in 31 patients, colon perforation in eight patients, diaphragmatic hernia in one patient, pancreatic transection in two patients, and liver laceration in two patients. None of the patients with a cell count ratio of less than I sustained hollow organ perforation. The average interval from injury to DPL was 5 hours, with the shortest being 1.5 hours. CONCLUSION: A cell count ratio of greater than or equal to 1 predicted hollow organ perforation with a specificity of 97% and a sensitivity of 100%. The selective use of the cell count ratio has improved the probability of early diagnosis of bowel perforation without increasing the cost of care. Nonoperative management can be applied more confidently to those patients sustaining a blunt solid viscus injury of the abdomen if the cell count ratio is low. We conclude that the cell count ratio of DPL effluent is a very sensitive and specific indicator of hollow organ perforation. In the treatment of blunt abdominal injuries, if the cell count ratio is positive, nonoperative treatment should be abandoned and a laparotomy undertaken.
Abdominal Injuries↗
Controlled reopen suture technique for pyloric exclusion.
BACKGROUND: Pyloric exclusion had been widely used in the management of complicated duodenal injuries. The original concept of pyloric exclusion was that this technique would temporarily exclude the pylorus during the healing phase, but would subsequently allow resumption of normal gastrointestinal tract transit through the duodenum. The best method for pyloric exclusion has not been well established. Controversies exist regarding the need for a gastrojejunostomy and vagotomy as part of the procedure. None of these combinations can fulfill the original concept of pyloric exclusion and avoid late complications. METHODS: We developed a controlled reopen suture technique for pyloric exclusion. This technique was applied to nine patients (group II) with a complicated blunt duodenal injury over the past 5 years. The clinical courses and outcomes of these patients were compared with an eight-patient comparison group treated by pyloric exclusion and gastrojejunostomy (group I) over the same time period. RESULTS: All 17 patients survived. There were one early (duodenal wound leakage) and two late complications (marginal ulcers) in the group I patients. No delayed complications were found in the group II patients. The average hospital stay was about the same in both groups. CONCLUSION: The controlled reopen suture technique is a quick and simple procedure. In the treatment of a complicated blunt duodenal injury, if repair of the duodenal wound will not compromise the lumen, gastrojejunostomy and vagotomy can be omitted when using this technique. This technique offers the best combination of limited surgery in the severely injured patient, effective exclusion of the duodenum until after the healing has occurred, and allowance for the resumption of normal gastrointestinal tract transit through the duodenum. The late complications of gastrojejunostomy can also be avoided.
Adolescent↗