Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel

OBJECTIVE: To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries. METHODS: The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed. RESULTS: No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula. CONCLUSIONS: Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.     

Management of penetrating joint injuries

A classification scheme for penetrating joint injuries is presented. Diagnostic techniques and treatment recommendations for managing penetrating joint injuries in small animals are described. Techniques used in human and equine patients are discussed for comparison.     

Intracranial penetrating injuries via the optic canal

Two cases of intracranial penetration of a plastic or wooden chopstick via the optic canal are described. CT scans showed the chopsticks as linear hypodense structures in the suprasellar cistern contiguous with the optic canal. In one case, MR imaging was performed, which clearly depicted the foreign body and adjacent brain structures. Although they are extremely rare, transorbital intracranial penetrating injuries via the optic canal require physicians' awareness.     

Selective surgical management in penetrating neck injuries

OBJECTIVE: To evaluate selective operative management in penetrating neck trauma. DESIGN: A chart review. SETTING: A university-affiliated hospital in Johannesburg, South Africa. PATIENTS: All adults admitted to the hospital between January 1988 and June 1993 with a penetrating neck wound. Excluded were patients in whom there was no suspicion of an occult injury that might need further investigation. There were 755 patients in the study. INTERVENTIONS: Immediate surgical exploration (group A, 613 patients) and observation with constant monitoring (group B, 142 patients). MAIN OUTCOME MEASURES: Unnecessary explorations in group A and missed significant injuries in group B. RESULTS: In group A there was a 3% incidence of unnecessary explorations, and 4.2% of the patients died. In group B there was a 9.1% incidence of missed injuries, and 2.8% of the patients died as a result of the delayed diagnosis. Overall the death rate was 4%. CONCLUSION: Selective operative intervention for penetrating neck trauma results in fewer negative explorations and a death rate comparable to those of series that support mandatory neck exploration.     

Re: Evaluation of minor penetrating duodenal injuries

Neisseria meningitidis is a rare cause of cellulitis. No cases of meningococcal sialadenitis have previously been reported. We recently successfully treated a patient who had meningococcal cellulitis and sialadenitis. We review previously reported cases of cellulitis due to N meningitidis and speculate on the role of underlying disease in the pathogenesis of this infection.     

Iatrogenic esophageal injuries and their treatment

In our Department 22 patients were treated due to esophagus perforations in the years 1990-1996. Most of them (16) occurred after endoscopic examinations: diagnostic-3, after strictures dilatation-10, endoscopic intubation-2, sclerotherapy-1, transesophageal cardioversion-1. There were 5 intraoperative perforations: 3-after cardiomyotomy, 2-after intubation. The following treatment was performed: oesophageal suture and drainage-5 patients, subtotal oesophagectomy with oesophagogastrostomy-3 patients, oesophagectomy with salivary fistula and oesophago-gastro or -colostomy in second operation--9 patients, perforation covered with gastric fundus--3, intubation--1 patient, conservative treatment--1 patient. Four (18%) patient died.     

Conservative management of penetrating and blunt Type III renal injuries

This study examines whether, while controlling for local economic conditions, job design and other organizational factors affect facility aide turnover rates in a sample of 250 nursing homes from 10 states. Facility characteristics were largely based on administrator and director of nursing interviews conducted in 1993 as part of the Health Care Financing Administration's evaluation of the Resident Assessment Instrument (RAI) implementation. Aide turnover was significantly reduced by involvement in interdisciplinary care plan meetings. Turnover rates were higher in for-profit homes. Aide involvement in assessments, aide training and workload, case mix severity, payor source mix, and facility size were not significantly related to aide turnover.     

Pancreatic injuries resulting from penetrating trauma: a multi-institution review

Pancreatic injury from penetrating trauma continues to be a source of significant morbidity and mortality, with questions remaining regarding optimal treatment of injuries. Our goal was to evaluate current trends in the operative management of these injuries. Our patient population comprised all patients admitted to one of three Level I trauma centers over an 8-year period that had sustained penetrating pancreatic trauma. The study was a retrospective chart review. Sixty-two patients were identified. All had associated abdominal injuries, with the liver and stomach being the most commonly injured organs. There were 14 deaths (mortality 22.6%), 10 within the first 48 hours due to associated vascular injury. In the 52 patients surviving beyond 48 hours, there were 19 patients with injuries to the main pancreatic duct and 33 with parenchymal injuries only. Pancreatic resection was carried out for all patients with ductal injury except for one, who later required distal pancreatectomy for pseudocyst and pancreatic fistula. Significant pancreatic fistulae developed in five patients, three in patients treated by drainage and two in patients treated by resection. The incidence of fistula formation was significantly higher for drainage versus resection in the patients with ductal injuries. The incidences of other complications were not affected by type of pancreatic injury, associated injuries, or method of management. We conclude that the majority of deaths in patients with penetrating pancreatic trauma are due to associated organ or vascular injuries. Appropriate management of the pancreatic injury can reduce the long-term complications. These results support treating patients with suspected ductal injuries by appropriate resection. Drainage should probably be sufficient for most nonductal pancreatic injuries.     

Alternatives in the management of penetrating injuries to the iliac vessels

BACKGROUND: The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy. METHODS: Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996. RESULTS: A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%. CONCLUSION: Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.     

The overlooked blunt component in penetrating neck injuries: three case reports

Three cases of penetrating neck injury associated with an unsuspected blunt carotid injury are reported. Attention is drawn to the possibility of this rare association, that can cause irreversible damage, if overlooked. Early angiogram and possibly duplex Doppler scanning are warranted to prevent neurologic sequelae.     

Heat-shock protein 72 expression in excitotoxic versus penetrating injuries of the rodent cerebral cortex

The induction of heat shock protein 72 (hsp72) has been described in various experimental models of brain injury. The present study examined hsp72 expression patterns within the rodent cerebral cortex in experimental paradigms designed to mimic two mechanisms of damage produced by penetration of the cerebral cortex: (1) tissue tearing from the missile track and (2) diffuse excitotoxicity during temporary cavitation and shock wave formation. Adult male Spaque-Dawley rats received controlled penetration (stab) or injection of the NMDA receptor excitotoxin, quinolinic acid (QA), into the frontal cortex and were killed 1-24 h later. Tissue from the lesioned, sham-operated, or contralateral uninjected cortex was processed for Western and immunocytochemical analyses of hsp72 protein expression. By 12 h, both controlled penetration and excitotoxic brain injuries produced significant increases in hsp72 immunoreactivity, which decreased toward control levels at 24 h. However, the severity and regional distribution of hsp72 expression varied between the two models. Specifically, the controlled penetration injury produced many hsp72-expressing cells near the needle track, while immunoreactive cells within the QA-injected cortex were found in the periphery of the lesion site. Morphological assessment of brain sections subjected to dual-labeling procedures demonstrated that cells expressing hsp72 were primarily neuronal in both models of injury. These results suggest that although controlled penetration and diffuse excitotoxicity may induce similar temporal and cellular patterns of hsp72 expression, the spatial location of hsp72-immunoreactive cells may differ between the two models.     

The effectiveness of diaphragmatic pedicled grafts in esophageal injuries and wall reconstruction

BACKGROUND: In the early 1990s cases of tuberculosis in people with HIV infection and AIDS were undernotified. A study to evaluate changes in notification rates in two inner London local authorities was undertaken for the period January 1993-June 1996 inclusive. METHODS: For residents of the two local authorities, tuberculosis notifications were identified using a local database, and cases of AIDS with a recorded diagnosis of tuberculosis were identified from AIDS case reports. RESULTS: During the study period, only 13 (32 per cent) of the 41 AIDS cases with a recorded diagnosis of tuberculosis were also notified as a case of tuberculosis. However, the proportion of notified cases rose from 0 per cent (0 of 11) in 1993 to 50 per cent (5 of 10) in 1995 and 63 per cent (5 of 8) in early 1996. CONCLUSION: The increase in the tuberculosis notification rate for people with AIDS is encouraging, but scope for improvement remains.     

The role of diagnostic laparoscopy in treatment of penetrating injuries of the lower thoracic wall and anterior abdominal wall

Penetrating injuries of the lower thoracic wall and anterior abdominal wall cause difficulties in the decision for laparotomy. For gunshot wounds laparotomy without further investigations is in most cases justified, but in other penetrating traumata one should use every diagnostic modality to prevent unacceptably high negative laparotomy rates. We performed diagnostic laparoscopy (DL) on 39 patients with penetrating injuries of the anterior abdominal wall and/or lower thoracic wall. Of these 39 patients, 25 had negative and 14 positive results. We had only one false-negative finding. No false-positive result occurred. We think that DL is a very reliable diagnostic tool which requires a relatively high technology.     

Acute penetrating tracheal trauma

Four hundred seventy blood access procedures performed on 170 dialysis patients during the period 1962-1975 have been analyzed according to survival of access with respect to age, sex and cause of failure. Subcutaneous forms of blood access have a significantly longer life and are more free of complications than external shunts. Although the mode of access can now be tailored to the individual patient, the arterio-venous fistula remains the least expensive and simplest surgical procedure. It should therefore remain as the first choice of access for most patients.     

Intraocular penetrating of amoxicillin

Experiments have been carried out on four adult ewes to determine the effects on duodenal motility of intravenous or intraduodenal infusion of glucose solution and intravenous injection of insulin. At blood glucose levels below 80 mg%, the mean frequency of duodenal contractions was 1.6/min, but following the establishment of hyperglycemia by either intraduodenal or intravenous glucose infusion, contraction frequency fell to 0.9/min. The strength of contraction was unaffected.     

Biomechanics of penetrating trauma

It is well known that injuries and deaths due to penetrating projectiles have become a national and an international epidemic in Western society. The application of biomedical engineering to solve day-to-day problems has produced considerable advances in safety and mitigation/prevention of trauma. The study of penetrating trauma has been largely in the military domain where war-time specific applications were advanced with the use of high-velocity weapons. With the velocity and weapon caliber in the civilian population at half or less compared with the military counterpart, wound ballistics is a largely different problem in today's trauma centers. The principal goal of the study of penetrating injuries in the civilian population is secondary prevention and optimized emergency care after occurrence. A thorough understanding of the dynamic biomechanics of penetrating injuries quantifies missile type, caliber, and velocity to hard and soft tissue damage. Such information leads to a comprehensive assessment of the acute and long-term treatment of patients with penetrating injuries. A review of the relevant military research applied to the civilian domain and presentation of new technology in the biomechanical study of these injuries offer foundation to this field. Relevant issues addressed in this review article include introduction of the military literature, the need for secondary prevention, environmental factors including projectile velocity and design, experimental studies with biological tissues and physical models, and mathematical simulations and analyses. Areas of advancement are identified that enables the pursuit of biomechanics research in order to arrive at better secondary prevention strategies.     

Management of penetrating war wounds

The management of most gunshot wounds and penetrating war injuries can be adequately performed by doctors without specialised training. A basic knowledge of wound ballistics and adherence to the principles outlined in this paper will allow these patients to be treated successfully in their own locality, thus negating the necessity for transfer to a major centre.     

Corneal neovascularization after penetrating keratoplasty

The purpose of this study was to delineate the patient and surgical factors that contribute to the development of corneal neovascularization (CNV) after penetrating keratoplasty (PK). Thirty-six eyes of 36 patients with no antecedent CNV were enrolled in the study. Grafts were sutured to the host with 16 10-0 nylon sutures with the knots buried alternately in either the host or donor corneal stroma. Multiple perioperative factors were recorded for each patient, and at each postoperative visit systematic corneal drawings were used to follow the development of neovascularization. The stroma adjacent to each suture of each graft was given a neovascularization score based on the extent of vessel growth toward the wound interface. Univariate and multivariate analyses were performed, including generalized estimating equations logistic regression where each eye is considered a cluster of observations. Thirty-four patients without preoperative CNV or inflammation were followed prospectively for 6-9 (mean, 7) months after PK. Fourteen eyes (41%) developed some degree of CNV. Indication for keratoplasty, age, gender, phakic status, and size of donor button were not risk factors for CNV development. The most significant risk factor identified for any degree of CNV was placement of the suture knot in the host stroma (p = 0.00007), with the overall relative risk of CNV associated with these knots over 2 (95% confidence interval, 1.1-4.2). Furthermore, the mean recipient size in eyes with postoperative CNV was larger than eyes that did not develop neovascularization (p = 0.015), and active blepharitis was associated with a fivefold increase in the risk of developing CNV to the wound edge (p = 0.008). Embedding suture knots in the host stroma, active blepharitis, and a large recipient bed are significantly associated with postkeratoplasty CNV.