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S J Sclafani

Publications and source records attributed to S J Sclafani.

At least 19 recordsLinked to original sources
PubMed1999

Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison.

PURPOSE: To compare the efficacy of radiologic guided placement of percutaneous gastrojejunostomy (PGJ) and percutaneous endoscopic gastrostomy (PEG). MATERIALS AND METHODS: Patients were randomized to PGJ (n = 66) or PEG (n = 69). Indications for gastrostomy were need for prolonged enteral nutrition (97%) or gastrointestinal decompression (3%), with etiologies of neurologic impairment (81%), head and neck neoplasm (12%), bowel obstruction (3%), or other (4%). Mean follow-up was 202 days and 30-day follow-up was obtained for 85% of patients. RESULTS: PEG was successful in 63 of 69 (91%) patients, while PGJ established access in all of 66 attempts (100%) (P = .014). Average procedural time was 53 minutes for PGJ and 24 minutes for PEG (P = .001). At 30-day follow-up, there were 33 and 45 complications in the PGJ and PEG groups, respectively. This difference was due to the greater incidence of pneumonia in the PEG group (P = .013). Long-term tube-related complications occurred with 17 PGJs and four PEGs (P = .007). The PGJ cost more than PEG, but this advantage was offset by the cost of complications. CONCLUSION: PGJ had higher success rate and fewer complications, due to a lower incidence of pneumonia. PEG took less time to perform, cost less, and required less tube maintenance.

Adolescent↗
PubMed1998

Management of T tubes for common bile duct stones: a new technique.

BACKGROUND: The optimal treatment of common bile duct (CBD) stones is controversial, and depends on local expertise, the patient's medical condition and the time of diagnosis. Current practice entails a wide variation in the duration of leaving T tubes in place, anywhere from 7 to 30 days, and in the time to postoperative cholangiogram. Here we present a new technique for T-tube placement and management of secondary or retained CBD calculi that reduces T-tube duration to </= 5 days. MATERIALS AND METHODS: After CBD exploration and clearance, we place a 10- to 18-French T tube through a 22- to 34-French straight rubber catheter with side holes acting as a sheath. The two tubes are exteriorized together, with the sheath protruding 1-2 cm. We place a colostomy bag for collecting possible abdominal drainage over the site and run the T tube through the colostomy bag into a bile bag. RESULTS: Our method allows early removal of the T tube in patients with cleared ducts and early radiologic instrumentation of the CBD through the sheath to extract retained calculi. This obviates the need for postoperative endoscopic retrograde cholangiopancreaticography. CONCLUSION: This method reduces the length of hospital stay, the number of outpatient office visits and postoperative studies, and the duration of T-tube drainage, potentially decreasing the incidence of complications of T tubes, improving patient satisfaction.

Adult↗
PubMed1996

Internal carotid artery gunshot wounds.

OBJECTIVE: To review a series of patients who sustained internal carotid artery (ICA) gunshot wounds. DESIGN, MATERIALS, AND METHODS: We retrospectively studied the demographics and clinical presentation, angiographic findings, methods of treatment, and outcome of 38 consecutive patients who had ICA injury identified by angiography. RESULTS: Thirty-four of 38 patients were symptomatic with neck hematomas (32 patients), active hemorrhage (12 patients), and/or neurologic deficit (10 patients). Angiography showed active bleeding in 22 patients and occlusion in 16 patients. Twelve patients were treated operatively by ligation (seven patients), repair (four patients), or intracranial/extracranial bypass (one patient). Twenty-six patients were managed nonoperatively either by angioplasty (one patient), embolotherapy (17 patients), or observation alone (eight patients). Percutaneous balloon catheters were also used in three patients for vascular control of the ICA before operative repair or as a method of assessing intracranial collateral circulation. The mortality of 18.4% was largely related to strokes. CONCLUSIONS: Penetration of the ICA is a very severe injury with a high mortality. The major cause of death in this series was related to neurologic damage associated with carotid injury and shock. However, neurologic deficit among the survivors was uncommon and often resulted from emboli. Interventional radiology can play an important role in the management of these wounds and often obviates the need for operative exploration.

Adolescent↗
PubMed1996

Angiography and transcatheter arterial embolization of vascular injuries of the face and neck.

The condition of patients sustaining penetrating neck trauma often appears deceptively stable, even when major structures have been injured. The clinician must identify patients who require treatment and limit invasive procedures in those without significant injuries. Angiography is often used to search for vascular damage following penetration of the neck and face. The charts of 401 hemodynamically stable patients with penetrating cervicofacial wounds who were evaluated by angiography followed, when necessary by either transcatheter arterial embolization and observation or surgery were reviewed. One hundred twelve patients (27.9%) had 131 vascular injuries identified by angiography; 77 (68.8%) of these patients sustained injuries to zone III of the neck or the face. The most commonly injured vessels were the internal carotid artery (ICA), the vertebral artery, and the external carotid artery (ECA) system. Multiple vessel injuries were seen in 17 (15.2%) of 112 patients and were more likely in patients with wounds in zone III or above than in those wounded in zone II or below (20.8% vs. 2.9%, respectively; P < .025). Injuries to the internal maxillary artery (IMA) (60%), ECA (53.3%), and the ICA (30.8%) were also significantly more likely to be accompanied by additional vascular injuries (P < .005). No clinically significant venous injuries were missed. Complications were noted in only 4 patients, and no deaths occurred as a result of angiography. Angiography is a safe, effective modality in the head and neck trauma setting. Particular scrutiny should be given to patients with zone III or facial wounds, particularly those with documented ICA, IMA, and ECA injuries, since these patients have a higher incidence of multiple vascular injuries.

Blood Vessels↗
PubMed1995

Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis.

OBJECTIVES: The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. METHODS: Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. RESULTS: Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). CONCLUSIONS: (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Adolescent↗
PubMed1994

Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes.

OBJECTIVES: To determine the hemodynamic responses to blunt trauma with a closed-head injury and to investigate the effect that volume resuscitation has on intracranial pressure. DESIGN: Prospective study with retrospective analysis of patient data and hemodynamic responses. SETTING: Surgical intensive care unit at an inner-city, Level I trauma center. PATIENTS: Consecutive patients (n = 30) who sustained multiple system injury, including a closed-head injury that was severe enough to require intracranial pressure monitoring but not a craniotomy. INTERVENTIONS: All patients underwent invasive hemodynamic monitoring with percutaneous arterial and pulmonary arterial catheters. Serum lactate concentrations and hemodynamic and oxygen transport variables were measured every 4 hrs. Intracranial pressures and vital signs were recorded each hour. Attempts were made to achieve a state of nonflow-dependent oxygen consumption and a normal serum lactate concentration. MEASUREMENTS AND MAIN RESULTS: Despite being normotensive and neither tachycardiac nor oliguric, 80% of patients had evidence of inadequate tissue perfusion. Only 50% of the remaining patients had an adequate response to volume. The other 50% received vasodilating inotropic agents. Despite volume loading and the administration of inotropic agents, intracranial pressure did not increase. This observation was found in patients who showed clinically important intracranial pathology on computed tomography scan, as well as in all other patients. Intracranial pressure did not correlate with the amount of fluid or blood infused or with hemodynamic performance, but intracranial pressures did correlate with serum lactate concentrations. CONCLUSIONS: Many patients with diffuse blunt trauma closed-head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodilating inotropic support improve oxygen transport without increasing intracranial pressure. The observed relationship between intracranial pressure and the serum lactate concentration requires further study.

Adolescent↗
PubMed1993

Nonoperative management of blunt abdominal trauma: the role of sequential diagnostic peritoneal lavage, computed tomography, and angiography.

STUDY OBJECTIVE: To determine the usefulness of sequential nonoperative diagnostic studies in the evaluation and treatment of stable patients after blunt abdominal trauma. DESIGN AND SETTING: Retrospective review of a prospective treatment plan in a large urban Level I trauma center. PARTICIPANTS: Fifty-two patients deemed stable after initial evaluation following blunt abdominal trauma. INTERVENTIONS: Patients with a positive diagnostic peritoneal lavage for red blood cells underwent abdominal computed tomography (CT) scanning. If CT demonstrated a visceral injury, it was followed by diagnostic angiography. Attempts were made to treat on-going bleeding by transcatheter embolization. RESULTS: Fifteen patients had negative CT scans and were successfully observed. In the other 37 patients, CT identified 17 liver, 16 splenic, and eight kidney injuries; eight extra-peritoneal bleeds; and one mesenteric hematoma. Six of these patients were observed. Thirty underwent diagnostic angiograms. Twelve had no active bleeding, and all were observed successfully. Seventeen underwent successful embolization of the bleeding site(s). One had injuries not controllable by embolization and required exploration. Six patients required laparotomy later in their course, but none had intra-abdominal bleeding or a missed intestinal injury. Despite being performed after diagnostic peritoneal lavage, CT missed only two injuries. There was one main complication, delayed recognition of a diaphragmatic injury. Three patients died, two from multiple organ failure and one from a pulmonary embolus; none was believed to be related to this technique. With our algorithm, 45 patients (86%) were spared laparotomy. CONCLUSION: Diagnostic peritoneal lavage and CT are complementary when evaluating blunt abdominal trauma. Diagnostic peritoneal lavage is an effective screening tool. CT may be reserved for stable patients with a positive diagnostic peritoneal lavage to specify the organs injured. Bleeding often may be treated by embolization, limiting the rate of surgery.

Abdominal Injuries↗
PubMed1993

Hemodynamic responses to penetrating spinal cord injuries.

Although the hemodynamic response to blunt spinal cord injury has been well described, much less is known about the responses to penetrating spinal cord injuries. In order to elucidate any differences, we reviewed the last 75 patients treated over the past 12 years with penetrating spinal cord injuries. There were 67 men and eight women; the mean age was 26.2 years (range, 15-59 years); 73 patients suffered 120 gunshot wounds; one patient was injured with an ice pick; one was stabbed twice. The offending missile causing spinal cord injury entered the neck in 24%, the thorax in 56%, and the abdomen in 20%. Nine patients (12%) were complete quadriplegics and 49 patients (65%) were complete paraplegics; 69 patients (92%) had no rectal tone; 17 patients (22%) had incomplete injuries. Despite the high proportion of complete spinal injury (78%), only 18 patients (24%) were hypotensive in the field. Five additional patients became hypotensive in the ED. Of the 23 patients with hypotension, 18 (74%) had significant blood loss to explain their low blood pressure. The mean HR was 100 beats/minute in the field (range, 50-130 beats/minute) and 90 beats/minute in the ED. Only five patients (7%) demonstrated the classic presentation of neurogenic shock (hypotension and bradycardia). This classic presentation of neurogenic shock is rare following penetrating spinal cord injury. Despite evidence of a complete spinal cord injury on initial physical examination, hypotension is usually secondary to blood loss in these patients. A careful search for sources of blood loss is mandatory before ascribing hypotension to spinal injury.

Adolescent↗
PubMed1991

The role of angiography in penetrating neck trauma.

Seventy-two consecutive patients who underwent neck arteriography were reviewed to assess recent suggestions that angiography is not indicated in asymptomatic patients with penetrating neck trauma. Proximity to major neck vessels without signs or symptoms of vascular trauma was the reason for angiography in ten of 26 patients with proven arterial injuries. Physical examination had a specificity of 80% and a sensitivity of 61% in this series. There was no correlation between mechanism or location of penetration and the likelihood of clinically significant injury. We conclude that recent recommendations suggesting that arteriography is unnecessary in asymptomatic patients with penetrating neck trauma are premature. Further investigations of larger patient samples are necessary to determine if "proximity" should be abandoned as an indication for arteriography. We advocate that, until additional data are accumulated, urgent arteriography and esophagography or operative exploration are indicated in stable asymptomatic patients with neck wounds which violate the platysma.

Adult↗
PubMed1991

The removal of intravascular bullets by interventional radiology: the prevention of central migration by balloon occlusion--case report.

A migratory intravascular bullet fragment located within the hypogastric vein was removed successfully with the aid of interventional radiologic techniques. The authors describe the use of the technique of balloon trapping as part of this procedure. A balloon should be inflated between the foreign body and the heart before retrieval is attempted in order to prevent migration back to the heart during the manipulation.

Adolescent↗
PubMed1991

Angiographically placed balloons for arterial control: a description of a technique.

Obtaining proximal and distal control is essential in the repair of arterial injuries. Occasionally, the location of the injury makes this difficult, risks excessive blood loss, or requires wide exposure to obtain control. Recently, we have used percutaneously placed balloons as an aid to vascular control in 11 patients who had arterial injuries identified angiographically. The balloon is placed under fluoroscopic guidance and is then deflated. The balloon is reinflated intraoperatively at the time vascular control is needed. Five balloons were placed for inflow control in patients with very proximal subclavian artery injuries. All were then able to undergo successful repair through a limited supraclavicular incision without sternotomy or thoracotomy. Two were placed in the internal carotid artery to obtain distal control in injuries located at the base of the skull. Both injuries were then repaired without problems. Two patients had balloons placed for external iliac artery injuries located at the inguinal ligament, one for proximal and one for distal control. Both injuries were then repaired through a limited incision. Two additional patients who had arterial injuries identified began to bleed massively while in the angiography suite. Balloons were placed proximally to control bleeding during transport and dissection. There were no complications from balloon placement. All balloons functioned well, greatly limited blood loss, and allowed for repair through a limited incision. We feel this is a technique that can be utilized in selected cases of angiographically identified arterial injuries in which operative exposure is likely to be difficult, cause significant blood loss, or require an extensive incision and dissection.

Adult↗
PubMed1991

Blunt splenic injuries: nonsurgical treatment with CT, arteriography, and transcatheter arterial embolization of the splenic artery.

The management and outcome of blunt splenic injury diagnosed with computed tomography (CT) were studied in 44 consecutive patients who were hemodynamically stable or whose condition stabilized rapidly with resuscitation. Celiac and splenic arteriography was used in the triage of patients for nonsurgical treatment or for hemostasis. Patients without arterial extravasation of contrast material at arteriography were treated with bed rest only (group 1, n = 19); patients who had such extravasation were treated with bed rest after percutaneous transcatheter coil occlusion of the proximal splenic artery (group 2, n = 17). Abdominal exploration without angiography or embolotherapy was begun if the patient or attending surgeon did not agree with the treatment protocol (group 3, n = 8). Treatment with bed rest alone was successful in 18 patients. Clinical control of hemorrhage was accomplished in all patients in group 2 and one patient in group 1. Thus, exploratory laparotomy was avoided in 34 of 36 patients (94%) in whom nonoperative management was attempted; splenic salvage was achieved in 35 of 36 patients (97%).

Adult↗