Claude H. Organ

Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience.

BACKGROUND Considerable skepticism still exists about the role of diagnostic laparoscopy in the evaluation of penetrating abdominal trauma. The reported experience with therapeutic laparoscopy has been limited. METHODS Retrospective analysis of a collective experience from three large urban trauma centers with 510 patients (316 stab wounds, 194 gunshot wounds) who were hemodynamically stable and had no urgent indications for celiotomy. RESULTS Laparotomy was avoided in 277 of the 510 patients (54.3%) either because of nonpenetration or insignificant findings on laparoscopy. All were discharged uneventfully after a mean hospital stay of 1.7 days. Twenty-six had successful therapeutic procedures on laparoscopy (diaphragmatic repair in 16 patients, cholecystectomy in 1 patient, hepatic repair in 6 patients, and closure of gastrotomy in 3 patients) with uneventful recovery. In the remaining 203 patients, laparotomy was therapeutic in 155. Fifty-two patients had nontherapeutic celiotomy for exclusion of bowel injuries or as mandatory laparotomy for penetrating gunshot wounds (19.7%). The overall incidence of nontherapeutic laparotomy was 10.2%. Complications from laparoscopy were minimal (10 of 510) and minor. CONCLUSIONS Laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma. In carefully selected patients, therapeutic laparoscopy is practical, feasible, and offers all the advantages of minimally invasive surgery.

Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.

Cardiac injuries : analysis of an unselected series of 251 cases

Retrospective analysis was performed on the medical records of 251 patients treated for cardiac injuries at Highland General Hospital trauma facility in Alameda County, California, to identify factors that contribute to patient survival and predict death. Thirty-six patients (14%) had blunt injuries, 153 patients (61%) had gunshot wounds (GSW), and 62 patients (25%) had stab wounds. The overall survival rate was 18.7%, GSW survival was 6.5%, stab wound survival was 37.1%, and blunt injury survival was 40%. Patients who arrived with some vital signs had 62.2% survival and patients who arrived with absent vital signs had < 1% survival. Stepwise multiple logistic regression analysis revealed that for patients with absent vital signs the only significant predictor of outcome was GSW as the mechanism of injury and for patients with vital signs the ISS and the presence of combined right and left heart injuries were significant independent predictors of outcome. We conclude that the routine and aggressive use of emergency room thoracotomy for patients with penetrating cardiac injury must be re-examined.

The interlocking of American surgery: An analysis of surgical leadership in the United States, 1945 through 1985☆

To analyze surgical leadership in the United States from 1945 to 1985, 15 positions of influence have been identified. Appointments to these positions have been reviewed by age at appointment, medical school of graduation, site of residency training, solo appointments, and geographic distribution. A weighting scheme was designed to quantify institutional and personal performance. The 460 surgeons involved in this study graduated from 72 medical schools and 68 residency programs. The top ranking medical schools were Harvard, Johns Hopkins, University of Pennsylvania, Washington University in St. Louis, and Northwestern, which together accumulated 48 percent and 47 percent of all points and appointments, respectively. The top ranking residency training programs were Harvard, Johns Hopkins, the Mayo Clinic, Washington University in St. Louis, and the University of Pennsylvania, with Cornell, University of Michigan, Columbia, University of Minnesota, and the University of California in San Francisco occupying the second tier. Personal performances revealed that 40 percent of the top 20 surgeons were located in Southern-based institutions. Since 1965, geographic and institutional diversity has begun to appear in the surgical leadership.

Is duodenal ulcer perforation best treated with vagotomy and pyloroplasty

From 1967 to 1980, 65 patients underwent vagotomy and pyloroplasty for treatment of an acute perforated duodenal ulcer at the University of Oklahoma Health Sciences Center. Their age ranged from 15 to 82 years, with a mean age of 49.6 years. All vagotomies were truncal and pyloroplasties were of the Heineke-Mikulicz variety. The condition of each patient was classified as acute or chronic depending on the duration of symptoms before perforation. The postoperative complication rate and perioperative mortality were higher in the group of patients whose symptoms had been present less than 3 months before perforation. Patients who underwent vagotomy and pyloroplasty more than 24 hours after the onset of symptoms had a higher mortality compared with those who were operated on less than 24 hours from the onset of symptoms. We mainly attributed the perioperative death rate of 11 percent to advanced patient age and associated cardiopulmonary disease. There was no significant difference in the rate of postoperative complications in patients over 60 years of age compared with those under 40 years; hence, age alone does not preclude definitive treatment, such as vagotomy and pyloroplasty. The degree of contamination found at operation did not correlate with a poor postoperative course. There was no significant increase in the mortality in the group with gross contamination. Of the patients available for long-term follow-up, 85 percent remained free of symptoms. These results compare favorably with reports for the elective treatment of duodenal ulcer with vagotomy and pyloroplasty. We conclude that vagotomy and pyloroplasty is acceptable, safe, and ideal for patients with acute perforated duodenal ulcers, except when significant cardiopulmonary disease exists or when the duration of perforation is more than 24 hours.

Nutritional evaluation of a blenderized diet in five major burn patients

Five consecutively admitted major burn patients were successfully supported with a high calorie, high protein diet supplemented with a blenderized diet (formula) that was prepared in our hospital. The egg, rice, and milk base formula provided over 60 percent of the average daily caloric requirements essential to their recovery. It was effective in preventing significant weight loss and promoting wound healing and successful skin grafting. The formula is inexpensive, palatable, of high quality protein, and provides a complete feeding when administered daily in conjunction with vitamin and mineral supplements.

Abdominal Wall Lifting Devices as Alternatives to Pneumoperitoneum

Conventional laparoscopy requires pneumoperitoneum to elevate the abdominal wall for exposure. A continuous insufflation of a noncombustible gas in a sealed environment is esential. Undesirable physiological side effects have been observed with CO2 pneumoperitoneum. Furthermore, it has been necessary to retrain surgeons to use specialized instruments in order to operate on video images. Japanese and American investigators have recently used mechanical devices without pneumoperitoneum to elevate the abdominal wall for laparoscopic surgery. With their gasless technique, conventional instruments can be used, direct visualization of abdominal viscera is possible, and digital examination of abdominal contents can be performed without the fear of losing exposure. Since these procedures are being performed in an isobaric abdominal cavity, the risk of body fluid contamination to the operating team is diminished when compared to open or traditional laparoscopic surgery. With this technique, transition from open to laparoscopic surgery is minimal; it should be added to the training of future surgeons.

Long-term results with the combined operation for duodenal ulcer disease.

During the twenty year span from 1951 to 1970, the combined operation was selected as the procedure of choice 663 times in the surgical management of duodenal ulcer disease. A retrospective study of these cases represents a 70 per cent follow-up rate; thirty-two additional patients expired during this period of causes unrelated to peptic ulcer disease or the procedure, bringing the crude follow-up rate to 77 per cent. The known recurrence rate was 0.85 per cent and the mortality 0.6 per cent. None of the deaths were due to the operative procedure itself. Diarrhea (11 per cent) and dumping (24 per cent) were the principle postoperative sequelae, neither of which represented a significant problem after twelve to fourteen months. Their incidence after 1960 in this series was decreased due to improved technic, better overall total surgical care, and reduction of the extent of resection from 75 to 50 per cent. The results, as interpreted by surgeon, patients, and gastroenterologist, have been reviewed.

Investigators' responsibilities and rights

Based on recent reports, 1–9 there are increasing concerns about the control of the scientific data obtained from clinical trials sponsored by industry. Many of the problems encountered are the result of restrictions contained in the research contracts that participating investigators are asked to sign. A number of solutions have been suggested to ensure the integrity of clinical trials, including the establishment of appropriately constituted trial oversight committees, negotiating noninterference pledges from industry sponsors, and creating proactive support of investigators’ rights by organized medicine. 10

Surgical Publishing in the Twenty-First Century

The death of biomedical journals is perhaps premature. Electronic publication is currently being used increasingly in parallel to the traditional paper format [2]. The importance of the story of Rip Van Winkle was not that he slept for 20 years, but that he slept through a revolution. As surgeons, and particularly as editors, we must not sleep through this revolution and be more than marginally involved with these changes. Editors and journals must become more sensitive of and responsive to this rapidly evolving journalistic culture. In recent years our lexicon has become saturated with concepts such as the Inglefinger rule, the fair use doctrine and safe harbor guidelines. The electronic news media (ENM) have made us more acutely aware of the importance of issues surrounding intellectual property.