Laparoscopic splenectomy after arterial embolisation

Laparoscopic splenectomy remains a challenging procedure, as haemorrhage causes the most complications. In order to reduce this risk, preoperative selective embolisation of the splicing artery has been performed in a series of six successful laparoscopic splenectomies in one male and five female patients with a mean age of 34.6 years (range 17-53 yrs). Indications for surgery were immune thrombocytopenic purpura (ITP)(n = 3), non-Hodgkin lymphoma with secondary haemolytic anaemia (n = 1), autoimmune haemolytic anaemia (n = 1) and congenital spherocytosis (n = 1). The mean splenic length was 12.3 cm (range 9-16 cm) and no accessory spleens were identified. Mean operative time was 96.7 min (range 90-150 min). There were no deaths nor haemorrhagic or septic complications. Recovery after surgery was excellent with a mean hospital stay of 5.2 days (range 2-10 days). We conclude that selective embolisation of the splenic artery, just prior to laparoscopic splenectomy adds to the safety, and operating time may be shortened.     

Penetrating chest trauma

This article reviews the current concepts in penetrating chest trauma. The authors discuss mechanisms of injury, nursing assessment, and interventions for penetrating injuries resulting in cardiac rupture, cardiac tamponade, tension pneumothorax, hemothorax, great vessel injury, and sucking chest wounds.     

Penetrating thoracoabdominal trauma

Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.     

Penetrating neck trauma

Penetrating neck trauma can pose significant diagnostic and therapeutic challenges for emergency physicians. Factors contributing to these problems are complex anatomy, proximity of vital structures, and potential for rapid deterioration of airway, vascular, or neurologic injuries. Other contributing factors are the lack of consensus in the literature regarding appropriate evaluation and management of penetrating neck injuries, and insufficient resources or experienced personnel at some institutions. This review focuses on the key components of the history and physical examinations that allow for an assessment of the severity and type of structures involved. In addition, current methods of airway management, as well as ways to manage penetrating neck trauma efficiently and cost effectively, are discussed.     

Penetrating thoraco-abdominal war injuries

BACKGROUND: From April 1991 till December 1995, Split University Hospital played a major role as a third échelon war hospital during the war in Croatia and Bosnia and Herzegovina. Among 2856 treated battle casualties in general, 70 patients with penetrating thoraco-abdominal war injuries were treated at the Department of Surgery. Explosive wounds were present in 38 (54%), gunshot wounds in 32 (45%) and puncture wounds in four (5.70%) patients. METHODS: The medical data from the evacuation unit, transportation, emergency department, surgical management and follow-up were obtained and analyzed. The principle of treatment of such patients is described, with particular reference to thoracophrenolaparotomy as the most efficient diagnostic-therapeutic surgical approach. RESULTS: There were considerably more explosive wounds than gunshot and puncture wounds (ratio 38/32/4). Resource utilization analysis showed a great amount of blood products (average 1.250 ml per patient), rehydrant solutions (average 3.750 ml per patient) and seven days antimicrobial chemoprophylaxis (penicillin, gentamycin, metronidazole) used. Mean time elapsed between injury and definitive surgical repair was seven hours (range, 1 to 48 hours). Recovery on discharge was recorded in 61 (80%) and lethal outcome in nine (13%) patients. CONCLUSIONS: The treatment of respiratory insufficiency and hemorrhagic shock, and prevention of infection are the basis of the management of these injuries. Treatment success depends on emergency first-aid, quick transportation, early diagnosis, resuscitation, surgical therapy and intensive care.     

Penetrating wounds of the thorax

From January 1989 to December 1993 at the Institute of Clinical Surgery of the University of Perugia, 5 patients were under observation for penetrating chest injuries. Two of them had show-wounds, one a slash, one a stabbing and slash and one a cutting blow. One of the patients with shot-wounds died on the operating table from a haemorrhage while the other was saved by surgery. One patient successfully underwent surgery for loss of tissue in the thorax walls. Another had a mini-thoracotomy plus lung suture which were successful. Finally, in the patient with a slash in the front region of the thorax and a slight pneumothorax, we inserted a chest thorax tube and so obtained a complete re-expansion of the lung. Total mortality was 20%. Surgical exploration of the thorax we believe is necessary wherever there is a risk of haemorrhage or possible lung damage requiring only surgery. According to many authors, video-thoracoscopy has the advantage of a reliable diagnosis and above all, enable us to repair lung wounds without opening the thorax. In one of our patients we could have avoided the mini-thoracotomy and used thoracoscopy to repair the lung damage.     

Penetrating keratoplasty for bullous keratopathy

A retrospective review for bullous keratopathy in our hospital from 1985 to 1992 was studies. Among the cases with bullous keratopathy, 14 were performed with antiglaucoma operation and cataract extraction, 12 that experienced a contusion or penetrating trauma history underwent cataract operation. IOL implantation seen in 3 patients, 4 cases were associated with vitreous contact to cornea after cataract extraction, the other 4 cases had advanced glaucoma. Besides, there were 1 case of Fuch's endothelium dystrophy, ICE syndrome and severe herpes simplex keratitis, respectively. The preoperation visual acuity of them was all less than finger count. The follow-up was 3 months to 5 years. The results showed the grafts of 28 cases (70%) were clear, 7 cases (17.5%) semi-clear, 5 cases (12.5%) opaque. Postoperatively, all of the patients escaped from the pain and 22 cases achieved a visual acuity of 0.02-0.7. Some good advice in treatment of bullous keratopathy were proposed.     

Experimental missile wounding of the brain

If a missile penetrates a cerebral hemisphere and does not severely disrupt the brain or transit a vital brain structure, it is hypothesized that the indirect effect of ordinary pressure waves set up by the interaction of missile and tissue and that impinge on brain stem respiratory nuclei determines life or death. The likelihood of fatal apnea is a direct function of missile energy of deposit within the brain. With brain wounding, a reduction in CO may also occur, but missile energy required to produce a significant CO decrease is in excess of that required to produce respiratory problems. Unless the individual managed to survive a period of apnea or respiratory resuscitation occurred, the effects of apnea would overshadow any CO decreases. Although transmitted ordinary pressure waves might interfere with the reticular activating system within the brain stem and produce persistent coma, specific long-lasting neurologic defects from a missile wound usually result from direct missile damage to the cerebral cortex or cortical projections. In designing treatments for missile wounds of the brain, two distinct entities must be kept in mind: the brain stem and the cerebral cortex. To decrease the immediate mortality from brain wounding, prompt treatment has to be devised to aid dysfunctional respiratory nuclei and possibly cardiac control nuclei. To decrease long-term neurologic morbidity, drug therapy has to be instituted to help injured cerebral cortical neurons for days to weeks after wounding. Totally different strategies and drugs may be needed to treat the brain stem as opposed to the cerebral cortex.     

Solitary ileocolic arteriovenous malformation: spongostan and silk therapeutic embolisation

A debilitated patient with liver cirrhosis and poor haemostasis had a severe lower gastrointestinal haemorrhage. A superior mesenteric arteriogram revealed an early persistent and promiment draining vein in the ileocolic artery. Two fragments of Spongostan and silk were used to embolise the bleeding artery and the haemorhage ceased immediately. No infarction of the embolised area was observed and the bleeding was controlled.     

Penetrating injuries involving the intrathoracic great vessels

Approximately 50% of the forearm vasodilatation to intra-arterial infusions of acetylcholine is mediated by endothelium-derived nitric oxide. These conclusions have been derived from venous occlusion plethysmographic measurements of total forearm blood flow during co-infusions of acetylcholine and NG-monomethyl-L-arginine (L-NMMA), an inhibitor of nitric oxide synthase. Since venous occlusion plethysmography measures total limb blood flow, the relative proportion of the measurement from skin cannot be determined precisely. To determine the effects of acetylcholine on skin specifically, we have used laser Doppler flowmetry to measure vascular responses to local iontophoresis of acetylcholine in the forearm of normal male volunteers. To elucidate the possible mechanisms of cutaneous vasodilatation to acetylcholine, vascular responses were measured before and after systemic inhibition of prostanoid production and nitric oxide synthesis by oral aspirin (600 mg daily for 3 days) and intravenous L-NMMA (3 mg/kg for 60 min), respectively. After aspirin administration, dose-dependent vascular responses to acetylcholine were reduced significantly by approximately 53% (p < 0.005, ANOVA). In contrast, intravenous L-NMMA appeared to have no significant effect on cutaneous vascular responses to acetylcholine. While the role of nitric oxide is uncertain, vasodilatation to acetylcholine in the forearm skin is mediated largely by a prostanoid-dependent mechanism. Assessment of cutaneous vascular responses to iontophoresis of acetylcholine may, therefore, be useful in diseases where abnormal endothelium-dependent prostanoid function has been implicated.     

Penetrating head injury caused by weed--case report

A case of penetrating head injury caused by weed was reported. A 69-year-old man fell from a bicycle and was stuck by the hard stalk of weed through the right nasal cavity. On admission the patient was fully alert and with no neurological deficits. The weed was pulled out at an out-patient department and then he became semicomatose and hemiplegic on the left side together with an occurrence of nasal bleeding. Subsequent computed tomographic (CT) scan showed an intracerebral hematoma in the right frontal lobe. The hematoma was immediately evacuated and the dural defect, lateral to the cribriform plate, was closed. It is stressed that neuroradiological evaluation with CT scan and/or magnetic resonance imaging (MRI) is mandatory because an information about an anatomical location of penetrating objects and intracranial complications are essential to a decision-making of surgical strategy. The objects should be urgently removed in a surgical exposure of the intracranial lesion and the contused brain should be debrided with a repair of the lacerated dura mater.     

Penetrating trauma of the internal carotid artery

OBJECTIVE: To assess management of penetrating internal carotid artery (ICA) injuries. DESIGN: Retrospective review of institutional protocol. SETTING: Level 1 trauma center in a major urban area. PATIENTS: Sixty-one patients with penetrating ICA injuries. INTERVENTIONS: In the period 1975 to 1987 (group 1; n = 36), management was based on individual surgeons' preferences. Between 1988 and 1995 (group 2; n = 25), an algorithm was employed: (1) hemodynamically stable patients with suspected ICA injuries underwent a diagnostic angiography; (2) surgically accessible injuries were reconstructed regardless of neurologic status with 2 exceptions: (a) neurologically intact patients with ICA occlusion were treated by anticoagulation and mild pharmacological hypertension and (b) minimal nonocclusive injuries were managed nonoperatively and followed up by serial angiography or duplex ultrasonography; and (3) heparinization, shunting, and completion angiography were employed. MAIN OUTCOME MEASURES: Neurologic status at admission and discharge were compared by the Fisher exact test. RESULTS: In group 1, 24 patients (67%) presented neurologically intact, and 12 (33%) with a deficit. Sixteen injuries were managed nonoperatively, 14 were repaired, and 6 were ligated. At discharge 6 (17%) were improved, 24 (66%) were unchanged, 6 (17%) were worse. Four patients (11%) died of cerebrovascular causes. In group 2, 19 patients (76%) presented neurologically intact, and 6 (24%) with a deficit. Eleven injuries were managed nonoperatively, 12 were repaired, and 2 were ligated. A death occurred in a patient who arrested, was admitted to the hospital in a coma, and died before ICA repair. CONCLUSIONS: Neurologic outcome after ICA injury is enhanced by an algorithm predicated on the liberal use of angiography, a predefined surgical approach, and selective observation.     

Penetrating head injury caused by chopstick--case report

The effects of two different methods of cricoid pressure on laryngoscopic view were studied in 94 healthy women presenting for routine gynaecological surgery. Laryngoscopy was performed with either single-handed or bimanual cricoid pressure; after grading of the view obtained, the other method was used and second grading performed. Laryngoscopic view was better with the bimanual than with the single-handed technique (p = 0.016). In 21 cases, a better laryngoscopic view was obtained with the bimanual technique; in eight cases it was better with the single-handed technique; and in 65 cases, the method of cricoid pressure made no difference. Age, weight, Mallampatti score and thyromental distance did not differ between patients in these three groups. Bimanual cricoid pressure should be the initial technique of choice during rapid sequence induction but, in a minority of cases, switching to a single-handed technique may improve the laryngoscopic view. The technique of cricoid pressure which produces the best laryngoscopic view in an individual patient cannot be predicted from the physical features studied.     

Penetrating wounds of the neck in civilians

The management of penetrating neck wounds can be approached in a logical manner. The priorities in saving life are to ensure an airway and to maintain cardiocerebral perfusion. The initial evaluation and heroic life saving measure often rest upon the most inexperienced person, the house officer, who may be handicapped by the lack of experienced support personnel and sophisticated diagnostic and therapeutic equipment required for total management of these most challenging problems. It is hoped that this presentation provides the necessary guidelines for meeting this challenge. The pathophysiology, diagnostic approaches, and therapeutic measures are reviewed in the order in which they would be handled when the patient is brought to the emergency room, taken for special radiographic studies, and then subjected to surgical exploration. Special emphasis is placed upon diagnosis and management of traumatic arterial injuries, since these are the most challenging and most difficult to manage, as well as the most common causes of death following cervical penetrating wounds. Late vascular defects and associated injuries to the lymphatic, neural, airway, and foodway systems complete the discussion.     

Superselective arteriography and therapeutic embolisation for vascular malformations. (Angiodysplasias)

By virtue of superselective arteriography which makes possible the catheterisation of extremely fine arterial branches, the authors were able to embolise vascular malformations (angiodysplasias). Twenty seven cases were treated in this way with satisfactory results for twenty one of them. Seven patients must be operated on after the embolisation. The problem of the future of this technique is considered, and it will perhaps be possible to avoid revascularization by the use of new substances.     

Central nervous system infections after military missile head wounds

OBJECTIVES: To evaluate variables instrumental in central nervous system infections after military missile head wounds, using uni- and multivariate analysis in 964 patients during the 8-year Iran-Iraq War. METHODS: Factors considered in this retrospective study were: the types of projectile, mode of injury, paranasal sinus involvement, number of lobes involved, transventricular injuries, place of exploration (base hospital or Nemazee Hospital), cerebrospinal fluid (CSF) fistulas, Glasgow Coma Scale (GCS) score, retained bone, and retained shell fragments. RESULTS: During the study period, 105 patients (11%) developed central nervous system infections, including 20 abscesses, 1 case of cerebritis, 2 cases of fungus cerebri, and 82 cases of meningitis. gram-negative organisms, especially Klebsiella pneumoniae, were the most frequent offending organisms. Forty-one percent of the 133 deaths were due to infections, but the death rate from infection was only 4.4%. Univariate analysis showed mode of injury, number of lobes involved, ventricular penetration, paranasal sinus involvement, CSF fistulas, place of exploration, GCS score, and retained bone fragments to have significant bearing on the incidence of central nervous system infections. On the other hand, multivariate regression analysis disclosed the following factors each enhancing infection: CSF fistulas (chi2 = 46.526), transventricular injuries (chi2 = 13.4790), and paranasal petrous sinuses involvement (chi2 = 4.2221). When compared with primary exploration at the Nemazee Hospital, both exploration at a base hospital and no exploration at all were associated with increased chances of infection (chi2 = 4.7629 and 8.3220, respectively). Additionally, when tangential, crossed penetrating, and uncrossed penetrating injuries were compared with through-and-through injuries, the uncrossed penetrating mode was associated with less infection (chi2 = 0.1652, 2.6353, and 5.0817, respectively). Only two patients were readmitted for new evidence of infection 3 and 5 months after missile head wounds, one definitely due to and the other on suspicion of CSF fistulas. One hundred and thirty-seven of 587 patients with retained bone fragments were followed a mean of 42 months with no evidence of delayed infection. CONCLUSION: In this study, CSF fistulas and transventricular and paranasal sinus injuries all were associated with increased chances of central nervous system infections after military missile head wounds. Infection rate was lower in penetrating injuries not crossing into another dural compartment. Exploration at the Nemazee Hospital, despite delays in evacuation, had less incidence of infection than surgery at a base hospital within the first 24 hours of injury. Retained bone and metal fragments, a lower GCS score at the time of admission, secondary exploration at the Nemazee Hospital, and number of lobes involved were less important when evaluated in a multivariate regression model.     

Penetrating eye injuries associated with motor vehicle accidents

A 2 1/2-year review of penetrating eye injuries resulting from motor vehicle accidents and treated at the Princess Alexandra Hospital, Brisbane, is presented. The series dates from January 1, 1972, when legislation requiring the compulsory wearing of seat belts was introduced. The review shows a downward trend in injuries compared with the previous 6 1/2 years. Almost all the patients failed to wear a lap-and-sash seat belt or, if one was worn, it was not secured properly.     

Penetrating aortic ulcer: clinical and angiographic characteristics

BACKGROUND: "Penetrating aortic ulcer", an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows haematoma formation within the aortic wall, is rarely considered in the differential diagnosis of patients with sudden onset of severe chest or back pain. It has been suggested that it is a pathologic process that involves elderly hypertensive patients with severe atherosclerosis and rarely has been observed in the ascending aorta. METHODS: To determine the characteristics of this process, 11 clinical, 2 hemodynamic, 3 angiographic and 4 surgical variables were compared between 10 consecutive patients with penetrating aortic ulcers and 20 matched patients with classic acute aortic dissection. RESULTS: Clinical and hemodynamic variables were similar in both compared groups. In the group of patients with penetrating ulcer mean age was 58 +/- 6 years, previous hypertension was observed in 6 patients and the penetrating ulcer was located in the ascending aorta in 6 cases. In comparison to patients with aortic dissection, more angiographic projections were necessary to obtain the diagnosis in the group of patients with penetrating ulcer (2.4 +/- 0.8 vs 1.7 +/- 0.6; p < 0.05). In addition, the presence of angiographic aortic valve regurgitation was only observed in the group of patients with acute dissection (60% vs 0%; p < 0.001). Severe atherosclerosis was not present angiographically in any patient with penetrating ulcer. CONCLUSIONS: Penetrating aortic ulcer can also affect middle age patients without severe atherosclerosis and is frequently observed in the ascending aorta. Its form of presentation and clinical characteristics are similar to classic aortic dissection. The lack of angiographic confirmatory evidence of dissection with suggestive clinical history, should raise the possibility of penetrating aortic ulcer.