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J L Sosa

Publications and source records attributed to J L Sosa.

At least 19 recordsLinked to original sources
PubMed1997

The role of thoracoscopy in the management of retained thoracic collections after trauma.

BACKGROUND: Retained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays. METHODS: Twenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection. RESULTS: In 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation. CONCLUSIONS: Videothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

Adult↗
PubMed1997

Laparoscopic management of achalasia.

Eight patients with achalasia were treated using laparoscopic esophagomyotomy and anterior (Dor) fundoplication. The procedures were done on patients with clinical, radiological, and manometric diagnoses of achalasia. All procedures were completed laparoscopically. Seven (88%) of the patients were eating by the 3rd postoperative day. The average hospital stay was 4.1 days (2-11 days); analgesic use was minimal. All myotomies were complete, with no patient requiring reoperation or dilation. The only complication was a mucosal laceration in one patient; this was successfully repaired laparoscopically. Follow-up from 8 to 20 months shows that swallowing is excellent in 88 per cent and good in 12 per cent of patients, and no patient requires antireflux medication. These results support minimally invasive surgical myotomy as the treatment of choice for symptomatic achalasia.

Adult↗
PubMed1997

Pyloric exclusion in the management of duodenal trauma: is concomitant gastrojejunostomy necessary?

Pyloric exclusion with gastrojejunostomy (PE-GJ) has been recommended in patients with severe injuries to the pancreatoduodenal complex. Recently, the management philosophy for pancreatoduodenal injuries has been that less treatment is probably the best treatment. But whether gastrojejunostomy (GJ) should be used routinely with pyloric exclusion (PE) remains controversial. A retrospective review was conducted of patients who underwent PE at a Level I trauma center during a 36-month period. Forty-five patients had duodenal injuries and 12 of these (27%) underwent PE for management of complex duodenal injuries. Gunshot wounds were the cause of the injuries in 10 of the 12 patients (83%). Eight patients (67%) underwent PE-GJ and had a mean hospital stay of 25 days. Four patients (33%) underwent PE alone and had a mean hospital stay of 29 days. All 12 patients had spontaneous opening of the PE, regardless of the technique used. One patient (12.5%) in the PE-GJ group developed marginal ulceration and significant hemorrhage, and one patient died in the PE-GJ group. The reported incidence of marginal ulceration in the PE-GJ group, the spontaneous opening of the pylorus, and the need to limit the extent of surgical repair to focus on all other associated lesions present in these patients, suggest that GJ should not be used routinely in patients undergoing PE for the management of severe pancreatoduodenal injuries.

Adult↗
PubMed1996

Laparoscopic patching of crack cocaine-induced perforated ulcers.

Since the advent of "crack" cocaine use in the United States as an illicit drug, crack-related perforated ulcers have been reported in the surgical literature. An ischemic process has been postulated as a cause of these perforations. As such, an acid-reducing operative procedure is not recommended. Omental patching of these ulcers has been recommended as the procedure of choice. With the advent of laparoscopic techniques in general surgery, it is now possible to perform this procedure laparoscopically. Laparoscopy may afford the advantages of reduced morbidity, decreased hospital stay, and results potentially equal to the open technique. We present three patients with crack-related perforated ulcers that have been repaired with laparoscopic-assisted patching techniques.

Adult↗
PubMed1996

Blunt traumatic injuries to the colon and rectum.

BACKGROUND: Experience in the treatment of patients with blunt colonic injuries is based on isolated case reports, and it is unclear whether the principles that guide the management of penetrating colonic injuries should be applied to these patients. Reviews of patients with these injuries suggest that such injuries present unique problems for diagnosis and treatment and are accompanied by excessive morbidity and mortality. STUDY DESIGN: A 42-month retrospective case series was analyzed. RESULTS: Data from 27 patients were analyzed, accounting for 8.5 percent of all colon and rectal injuries and for 0.5 percent of total blunt trauma admissions. Automobile crashes were the cause of injuries in 20 patients (74 percent). The mean Injury Severity Score was 28. All but 2 patients were operated on within 3 hours after admission. No significant difference was found in the morbidity and mortality rates based on the operation performed to manage the colonic injury. Indications for early exploration included a positive diagnostic peritoneal lavage in 23 patients, abnormal radiologic findings in 2, and positive clinical abdominal findings in the remaining 2 patients. CONCLUSIONS: Blunt colonic and rectal injuries are uncommon and pose problems for diagnosis and treatment. Associated injuries are common, and steering wheel compression of the upper abdomen as well as lap belts seem to predispose to colonic injuries. Initial diagnosis is made at the time of operation, and a thorough exploration of the abdominal cavity is important to diagnose associated injuries. Treatment must be individualized; however, based on our observations, the creation of ostomies is not mandatory for the treatment of these injuries.

Accidents, Traffic↗
PubMed1995

Acalculous cholecystitis: the use of diagnostic laparoscopy.

Acalculous cholecystitis (AC) carries a high mortality in the critically ill patient. This is partly due to the delay in its diagnosis. Clinical diagnostic examinations are often misleading. The purpose of our study was to evaluate the use of laparoscopy as a diagnostic tool in the evaluation of the critically ill patient suspected of having AC. From May 1993 to January 1994, we evaluated 10 critically ill patients. Mean age was 56 years (range 17-90 years). Nine of the patients were trauma victims (8 blunt, 1 penetrating). The other patient was postcoronary bypass surgery. The laparoscopy was done after a mean of 15 days (range 6-54 days) after ICU admission. All patients were receiving ventilatory support, and all patients had elevated temperatures of greater than 38.5 degrees C. Five patients had abdominal tenderness, and 6 had elevated liver function tests (LFT). Six laparoscopies were done under local anesthesia and IV sedation at the bedside, and 4 were done in the operating room. All patients tolerated the procedure well with no complications. The laparoscopic findings were gangrenous cholecystitis in 2 patients. They both underwent laparoscopic cholecystectomies in the operating room. We elected to drain a very distended gallbladder in 1 patient, who eventually was found to have an empyema of the chest. The other 7 examinations were normal. Six of these patients recovered and were discharged. Our results suggest that laparoscopy can be used in the diagnosis of acalculous cholecystitis. Its positive and negative findings are valuable in the treatment of the critically ill. It can be done safely at the bedside.

Adolescent↗
PubMed1995

Laparoscopic repair of a gunshot wound to the diaphragm: a case report.

The application of laparoscopy to the surgery of trauma is rapidly expanding. We report a case of laparoscopic repair of a gunshot wound to the right diaphragm. We discuss a technique for repair, as well as a method to create and maintain pneumoperitoneum while avoiding tension pneumothorax.

Adult↗
PubMed1995

Open versus laparoscopic appendectomy. A prospective randomized comparison.

OBJECTIVE: The authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time. METHODS: Adult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire. RESULTS: There was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was $6077 and for an open appendectomy $7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique. CONCLUSION: Laparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.

Adult↗
PubMed1995

Negative laparotomy in abdominal gunshot wounds: potential impact of laparoscopy.

OBJECTIVE: To evaluate the morbidity and hospital stay resultant from negative exploratory laparotomy (NL) for abdominal gunshot wounds (ABGSWs) and the potential impact the use of diagnostic laparoscopy (DL) could have on these variables. DESIGN: A retrospective study was conducted. MATERIALS AND METHODS: The charts of all patients with ABGSWs over a 4-year period were reviewed. Data was collected on injuries, rate of NL, morbidity and hospital stay. This was compared to a subsequent group of patients with ABGSWs managed with a DL protocol. MEASUREMENTS AND MAIN RESULTS: Over a 4-year period, 817 patients had exploratory laparotomy (EL) for ABGSWs. The NL rate was 12.4% (101 of 817); 69 of these patients had no associated injury or other procedures. They had a 22% morbidity and an average hospital stay of 5.1 days. Subsequently, 85 patients with ABGSWs underwent DL. This group was similar to the EL group and would have undergone EL prior to the introduction of DL at our institution. In this group, 34 patients had no associated injury or other procedures. They had a 3% morbidity, and their average hospital stay was 1.4 days. The morbidity and hospital stay were statistically significantly reduced (p < 0.01) in patients with negative DL versus NL. CONCLUSIONS: These data demonstrate that NL is associated with a high morbidity and long hospital stay. The use of DL can reduce the rate of NL, and result in lower morbidity and shorter hospital stay in patients with ABGSWs.

Abdominal Injuries↗
PubMed1995

Laparoscopy in 121 consecutive patients with abdominal gunshot wounds.

OBJECTIVE: The purpose of this study was to evaluate the sensitivity, specificity, and predictive value of diagnostic laparoscopy (DL) in a large group of stable patients with abdominal gunshot wounds (ABGSWs). DESIGN: This study was a prospective case series developed by management protocol. MATERIALS AND METHODS: In a 2 1/2-year period, DL was performed in 121 consecutive patients who were hemodynamically stable with ABGSWs and met protocol criteria. This represented 18% of all patients with ABGSWs seen in this period at the Ryder Trauma Center. The evaluation was conducted to determine peritoneal violation, the presence of intra-abdominal blood, and the need for exploration. MEASUREMENTS AND MAIN RESULTS: There were 42 (35%) positive and 79 (65%) negative DLs. In patients with positive DL, 39 (92.8%) had exploratory laparotomy. In this group, 32 (82%) had therapeutic laparotomy, 6 (15.4%) had nontherapeutic laparotomy, and 1 (2.5%) had a negative laparotomy. In this patient, DL was felt to be inadequate by the attending surgeon, although no penetration or intraperitoneal blood were present, and a negative laparotomy was done. This represents a failure rate of 0.8%. There were 3 (7.2%) positive DLs, in whom laparotomy was not performed. These patients had isolated nonbleeding liver injuries, and nontherapeutic laparotomy was successfully avoided. The negative DL group was divided into 47 patients (60%) with isolated ABGSWs, and 32 patients (40%) with associated injuries, mostly orthopedic and thoracic. There were no false-negative DLs and no delayed laparotomies in these 121 patients. There was no mortality in this study group. The sensitivity for peritoneal penetration was 100%, and the specificity was 98.7%. The positive predictive value was 97.6%, and the negative predictive value was 100%. In deciding on need for laparotomy (i.e., injury requiring repair), DL had a positive predictive value of 82%; more importantly, the negative predictive value was 100%. CONCLUSIONS: In stable patients with ABGSWs and questionable intra-abdominal injury, DL can be safely used. It is highly sensitive and specific. It can effectively reduce the incidence of negative and nontherapeutic laparotomies, and the overall morbidity and hospital stay in this group of patients.

Abdominal Injuries↗
PubMed1995

Reclosure of the open abdomen.

BACKGROUND: The open abdomen technique for the treatment of diffuse peritonitis has gained acceptance. Our approach has been to use the zipper technique with daily irrigations. Once the abdominal problem has resolved, the mesh and zipper are removed. Surgeons are reluctant to reoperate on patients with such prior treatment because of the anticipation of a hostile abdomen. Our study is a retrospective review of 12 patients who were treated with the open abdomen technique. At a later date, they underwent elective reoperation. STUDY DESIGN: The charts of 12 patients were reviewed. After initial injury, the patients were in the surgical intensive care unit. Reoperations were performed nine months (mean) after discharge from this facility. The reasons for reoperation were closure of enteric fistula (five patients) and closure of an ostomy (seven patients). The abdominal wall was reconstructed in nine patients. In the other three patients, the abdomen was entered through a lateral incision and the bowel was reanastomosed. RESULTS: All of the patients survived. There were five complications. Two patients had ischemic skin grafts successfully treated by hyperbaric oxygen therapy (HBO). Two patients had ischemic skin flaps that were covering mesh. They responded to HBO with minimal slough of superficial tissue. One patient had a low output fistula that closed after two weeks of total parenteral nutrition. CONCLUSIONS: A history of an open abdomen is not a contraindication to later operation. Bowel continuity can be restored and abdominal wall reconstruction can be performed safely. This can be done as early as three to four months after recovery from the original injury.

Abdomen, Acute↗
PubMed1994

Laparoscopic-assisted colostomy closure after Hartmann's procedure.

PURPOSE: The aim of the study was to review our experience with colostomy closure after Hartmann's procedure and the possible impact of laparoscopic colostomy closure. METHODS: A retrospective review of hospital stay after colostomy closure by laparotomy in the last four years was conducted. A chart review of patients undergoing laparoscopic colostomy closure after Hartmann's procedure since the introduction of operative laparoscopy at our institution was also done. RESULTS: One hundred twenty patients had colostomy closure carried out by the trauma service at the University of Miami/Jackson Memorial Hospital. In thirty-seven patients, colostomy closure was associated with other surgical procedures such as ventral herniorrhaphy, delayed closure of the open abdomen, ureteroneocytostomy, and so forth, or they underwent loop colostomy closure. These patients were excluded from further review. Sixty-five patients underwent reversal of Hartmann's procedure by laparotomy. They had an average hospital stay of 9.5 days (range, 6 to 34 days). This group of patients had colostomy closure prior to the introduction of operative laparoscopy in our institution. With increased laparoscopy experience, laparoscopically assisted Hartmann's reversal has been attempted in 18 patients and completed in 14 patients. The average hospital stay in the laparoscopically completed group was 6.3 days (range, 4 to 10 days). This group had a 0 percent mortality and a 14.3 percent morbidity. This compares favorably to recently reported series of colostomy closure by laparotomy. CONCLUSION: Laparoscopically assisted Hartmann's reversal results in comparable morbidity, but may be associated with shorter hospital stay when compared with laparotomy.

Adult↗
PubMed1994

Laparoscopic assisted colorectal surgery.

Forty-nine consecutive patients underwent laparoscopic assisted colorectal surgery for benign and malignant lesions of the colon. Thirty-eight of the 49 operations (78%) were completed successfully with laparoscopic assistance. A large tumor bulk or dense adhesions were the most common reasons for conversion to laparotomy. Twenty-eight of the 38 patients (74%) in the laparoscopically completed group were tolerating a diet by postoperative day 2, and 31 (82%) passed flatus or a bowel movement by the third postoperative day. The mean postoperative hospital stay for this group was 4.8 days, which compared very favorably to that reported in the literature for traditional open colorectal operations. Twelve patients developed complications, for a 24% morbidity in the series. However, only 3 (6%) of these complications were related to the laparoscopic part of the procedure. Inspection of the pathologic specimens revealed adequate margins and a lymph node harvest that averaged 11 nodes per specimen. We concluded that laparoscopic assisted colorectal surgery is a safe and feasible technique, which may be associated with a faster return of bowel activity and a shorter hospital stay. Although the extent of resection appears comparable to that of laparotomy, it is too early to assess long-term outcome when it is applied in the treatment of malignancy.

Adult↗