Carleton Mathewson

Exploratory laparotomy in patients with penetrating wounds of the abdomen

Abstract During a seven year period, 370 penetrating wounds of the abdomen were explored surgically. In retrospect, one hundred of these wounds (27 per cent) did not enter the peritoneal cavity. Eighteen per cent of these hundred patients manifested significant intraabdominal symptoms. All hundred patients were operated on with no mortality or serious morbidity. An additional hundred patients with penetration of the parietal peritoneum and serious or minor injury were evaluated with regard to their preoperative physical findings and stability of vital signs. Eighteen of these patients who had no abdominal findings were found to have significant injuries at laparotomy. Prompt operative evaluation of the patient with penetrating wounds of the abdomen is important in decreasing the morbidity and mortality secondary to perforation of vital structures, and we believe that this can be done with minimal risk.

Unusual manifestations of pancreatic pseudocysts and their surgical management.

Six cases representing selected complications of pancreatic pseudocyst are reported and their surgical management is discussed. Patients with mediastinal extension of a pseudocyst frequently present with symptoms in the chest rather than in the abdomen. Chronic recurrent pleural effusion, rich in protein and amylase, often accompanies mediastinal extension of a pancreatic pseudocyst. It is important to recognize that such an effusion almost certainly represents disruption of the pancreatic duct with formation of a pancreatic pseudocyst or a pancreaticopleural fistula. Internal drainage from below the diaphragm is the treatment of choice for pancreatic pseudocysts extending into the mediastinum. To be certain that obstructive jaundice is due to a pancreatic pseudocyst, there must be operative demonstration of compression of the common bile duct by the pseudocyst, relief of the obstruction by surgical drainage of the cyst, and subsequent disappearance of jaundice. Cysts that cause jaundice are located in the head of the pancreas, and cystoduodenostomy is the treatment of choice. Intraperitoneal rupture has been associated with a high mortality, but with adequate fluid replacement, prompt evacuation of the cyst contents from the peritoneal cavity, and adequate drainage, mortality can be lowered. Pancreatic ascites is much more common than is generally supposed and may result from a leaking pancreatic pseudocyst. In contrast to cirrhotic ascites, pancreatic ascites produces elevation of both the serum amylase level and protein concentration. Massive hemorrhage from pancreatic pseudocysts is usually due to the development of a false aneurysm in a branch of the celiac axis in the wall of the pseudocyst, with subsequent rupture of the aneurysm into the gut or peritoneal cavity. Any patient with a pancreatic pseudocyst who shows signs of bleeding should have prompt arteriography for determination of the bleeding site and appropriate surgical control. Pancreaticobronchial fistula is a rare complication. Treatment should be directed toward adequate drainage of the pseudocyst in the abdomen.

Clinical experiences with perforation of the esophagus.

Abstract Seventy-six patients with ruptures of the esophagus were studied. The first group (fiftyfour patients) was seen before 1957, and the second group (twenty-two patients) was seen since that date. Most of the esophageal ruptures were secondary to instrumentation (55 per cent of all patients in Group I and 80 per cent of all patients in Group II). The mortality was approximately the same in each group. The over-all mortality was 22 per cent. Mortality in patients with cervical ruptures was about half that of patients with ruptures of the thoracic esophagus. Conservative management was effective when begun early, before signs and symptoms of inflammation had developed, and when the pleura or peritoneum were not involved.

Traumatic rupture of the esophagus

Abstract 1. 1. Fifty-four cases of traumatic perforation of the esophagus have been studied. 2. 2. The most frequent location of the perforation was in the cervical esophagus. 3. 3. Instrumentation was the most frequent cause of perforation. 4. 4. Conservative management was undertaken in twenty-five patients, with five deaths. 5. 5. There were eleven deaths in the fifty-four cases studied.

Splenectomy incidental to iatrogenic trauma

Abstract 1. 1. Incidental splenectomy associated with iatrogenic trauma to the spleen is more common than is generally appreciated and occurred in 26 per cent of 925 splenectomies in this series. 2. 2. This indication for splenectomy has received little direct attention and scant recognition in the literature. 3. 3. Documentation of iatrogenic splenic injury as a significant complication should alert surgeons to this problem. 4. 4. A certain percentage of splenic injuries is unavoidable. 5. 5. Splenectomy remains the treatment of choice for any splenic injury. 6. 6. We believe that incidental splenectomy for iatrogenic trauma is, for the most part, a procedure without significant sequelae.

Traumatic pancreatitis with and without associated injuries

D URING the years rgq through 1950, 171 patients were admitted to the San Francisco HospitaI who, on the basis of serum amyIase studies, operation or autopsy, proved to be suffering from acute pancreatitis. During the same period pancreatitis due to injury was encountered in seventeen patients. Nine were due to blunt injuries to the abdomen and eight due to penetrating injuries (gunshot wounds and stab wounds). Many authors’+ have emphasized the fact that the pancreas because of its deep situation within the abdomen is we11 protected from injury. For this reason it is rare for a bIunt bIow upon the abdomen to cause injury to the pancreas alone. AIthough such injuries do occur, they are reported to be exceedingIy rare. abdomen with a semi-sharp instrument. One patient was struck with the headlight of an automobile, one with a poIiceman’s cIub, one with the handIebar of a motorcycle, one while pIaying volleyball and one was kicked in the region of an umbilica1 hernia. The remaining four patients in addition to injury to the pancreas had associated injuries to the spleen duodenum, stomach or liver. AI1 of the latter four were involved in accidents of severe violence; three were struck by automobiles and one patient fell from a fourth story window. These four patients presented not only evidence of intra-abdomina1 injury but also were suffering with injuries to the chest wall or extremities as weI1. The signrhcance of these associated injuries, remote from the abdomen, will be commented upon later.

Percutaneous Transhepatic Cholangiography

TTHERE ARE FEW problems more perplexing than the differential diagnosis of the jaundiced patient. Oral and intravenous cholangiography are not applicable in the presence of jaundice, and if jaundice has been present for any prolonged period, the usual chemical tests are of limited value in differentiating extrahepatic obstructive from hepatocellular jaundice. Percutaneous transhepatic cholangiography, however, will reveal the pathologic anatomy of the biliary tree in the presence of jaundice. In some cases it can distinguish obstructive from hepatocellular jaundice, and obviate laparotomy on a patient with hepatitis. In those patients with extrahepatic obstruction, the precise pathologic anatomy of the biliary tree is demonstrated preoperatively, and thus may save valuable operative time. The indications for percutaneous cholangiography are:: I. (A) To investigate jaundice of obscure etiology; this may differentiate hepatocellular from extrahepatic obstructive jaundice and/or; (B) Locate the level of extrahepatic obstruction, and distinguish carcinoma of the head of the pancreas

Treatment of injuries of the large bowel in civilian practice.

Abstract 1.1. Most small, grossly clean wounds of the large bowel may be sutured and returned to the abdomen without the establishment of proximal colostomy. 2.2. Large, grossly contaminated wounds are best treated by exteriorization when feasible. 3.3. Resection of the unprepared large bowel should be avoided whenever possible. 4.4. Retroperitoneal contaminated areas should be drained through the flank; however, drainage of the peritoneal cavity per se should be avoided. 5.5. All wounds of the extraperitoneal rectum should be drained posteriorly by opening the retrorectal space in the hollow of the sacrum through the rectococcygeal ligament. 6.6. Exploratory wounds of the abdomen in the face of gross fecal contamination should be closed with retention sutures and the skin left open for secondary closure.

Surgical management of extensive avulsions of skin

Abstract Seven patients with extensive avulsions of skin and subcutaneous tissue are reported with the details of treatment and comments on the final results. In our experience the method of treatment proposed by Dr. Farmer of Toronto, Canada, in 1939, has given the best results. His treatment involved the complete removal of all avulsed skin, careful debridement of the remaining denuded areas, removal of all subcutaneous fat from the skin and its replacement as a full thickness graft to the area from which it was removed. The importance of treating this type of injury as an acute surgical emergency is emphasized.

Intramural hematoma of the duodenum: A clinical entity

Abstract Uncomplicated intramural hematoma of the duodenum often produces a clinical picture so typical that it should be recognized as a clinical entity. The history of abdominal injury, particularly in children, followed after a lag period by abdominal pain and symptoms of high gastrointestinal obstruction should alert the astute clinician. The development of an upper abdominal mass is highly suggestive of the diagnosis. A flat plate of the abdomen demonstrating an air fluid level in the stomach and duodenum is typical. An upper gastrointestinal series is often diagnostic. Prompt laparotomy is indicated in most instances. Simple evacuation of the clot is the treatment of choice unless more extensive injury dictates otherwise.