Robert J. Freeark

A critical review of management of 392 colonic and rectal injuries.

SummaryThree hundred ninety-two patients underwent surgical treatment for injuries of the large intestine and rectum. The types of surgical intervention employed in these patients varied with severity of the trauma and location of injury. The highest incidence of wound infections and intra-abdominal abscesses occurred in the primary-repair group. Decompression technic significantly reduced the length of hospitalization, as seen in those patients with rectal injuries. This investigation does not support the contention that transfer patients are subject to a significant delay before surgery.An important surgical teaching principle is re-emphasized, namely, that trauma surgery involves a contaminated field and unnecessary surgery, such as incidental appendectomies, should be prohibited. The extent of contamination of tissue destruction, and not location of injury to the large bowel, predisposes the patient to increased morbidity.

Trauma to the Neck Region

Any neck trauma may potentially injure an essential component of the vascular, neurologic, respiratory, digestive, or skeletal system. Because the magnitude of the underlying injury is often obscured by an innocent appearing neck wound, surgical exploration is imperative. Special attention is given to the detection and management of these potentially dangerous underlying injuries, in order to prevent tragic consequences such as delayed hemorrhage, airway obstruction, deep infection, or cerebral infarction.

Arteriography of splenic trauma.

The most frequently injured organ in cases of blunt abdominal trauma is the spleen (10). Numerous reports have dealt with attempted roentgen diagnosis of splenic trauma on routine abdominal films (4, 8, 11, 13). More recently arteriography has been utilized in an effort to effect a greater accuracy in diagnosing this condition. Of historical interest is Burke and Madigans 1933 report (3) of the diagnosis of a ruptured spleen with Thorotrast. The first case in which arteriography via a retrograde femoral route was used was diagnosed by Norell (6). Various other methods, such as selective celiac or splenic arteriography and intravenous aortography, have added only 5 other cases to the English literature (2, 5, 7, 9). At a large trauma center we have had the opportunity to evaluate a number of suspect splenic injury patients and have made the correct preoperative diagnosis with arteriography in 17 instances of splenic rupture. Our purpose is to present the arteriographie findings in these cases and discuss ...

Penetrating Injuries of the Inferior Vena Cava

Despite the growing literature on the treatment of arterial injuries, comparable information on the care of great venous injuries has been slow to accumulate. Prior to 1961, there was only one report of the successful treatment of more than a single case of injury to the inferior vena cava.5 Since that time, large series of vena caval injuries have been reported from Houston3 and from Chicago.6 The purpose of the present report is to re-emphasize certain clinical features of inferior vena caval perforations, and to outline steps for the effective treatment of this potentially lethal injury. The 12 cases used for illustration of various problems have been previously tabulated6 and Cases 1–4 and 8 have been previously described in detail.5, 6

Common Bile Duct Obstruction by Free Floating Tumor

Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrsasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. Conclusion: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.

Institutionally shared trauma rotations are viable solutions to deficiencies in trauma training

Numerous national trauma leaders have expressed concern about the lack of uniformity of trauma training in this country. In 1984 we instituted a trauma rotation between the University of Louisville (U.L.), with a large trauma volume, and Loyola University (L.U.) in the planning stages of trauma center development. Third year L.U. residents rotated at U.L. in 3-month blocks with an increased level of responsibility monthly, culminating in major decision-making roles and operative treatment under the chief residents direction. The L.U. residents functioned as full members of the team and not as passive observers. Fifteen L.U. residents and 12 U.L. residents rotated during this period. Yearly major trauma visits, helicopter flights, and trauma service admissions average 1,908, 700, and 1,520, respectively. U.L. chief residents averaged 136 major operative trauma cases and 115 nonoperative trauma cases each were managed during this time period (RRC records greater than 85th percentile for all U.L. residents). L.U. residents performed an average of 30 major operative cases, nine as teaching assistant, in 3 months. Each managed more than 75 nonoperative cases. Several elements are critical in such a multi-institutional rotation: 1) active communication among the program directors, 2) commitment to one sharing arrangement only, 3) financing and malpractice for off-site residents, 4) housing, and 5) the ability to assimilate off-site residents as true trauma team members. The resident-to-resident interplay is crucial and has succeeded because both residency staffs have had excellent early training.(ABSTRACT TRUNCATED AT 250 WORDS)

The Value of Continuous 72-Hour Peritoneal Lavage for Peritonitis

Studies were performed in 120 rabbits to determine whether 72-hour peritoneal lavage is beneficial or harmful in the treatment of peritonitis. Results showed that against a high concentration fecal inoculum (90 percent mortality), peritoneal lavage containing gentamicin and clindamycin reduced mortality to 10 to 20 percent (p less than 0.05). Parenteral antibiotics alone and lavage not containing antibiotics did not decrease mortality. By contrast, against a low fecal inoculum (30 percent mortality), peritoneal lavage containing gentamicin and clindamycin did not alter mortality. However, lavage not containing antibiotics increased mortality to 70 to 80 percent (p less than 0.05). These data demonstrate that continuous peritoneal lavage may be helpful in the treatment of peritonitis provided the lavage solution contains antibiotics and may be harmful if it does not contain antibiotics.

Diverticulum of the Hepatic Duct: A Rare Anomaly

A diverticulum of the hepatic duct was found in a 25-year-old woman. Cholangiography revealed that the diverticulum was cystic in nature and contained several stones. Since the intrahepatic ducts are never seen at surgery, the authors stress the importance of preoperative and operative cholangiography in locating such anomalies.

Blunt Torso Trauma

Most blunt forces pose a simultaneous hazard to the regions of the chest and abdomen. Complications following such injuries to the torso are usually the result of delays in diagnosis or inadequate operative treatment. Successful operative treatment requires accurate hemostasis, detection of all injuries, and the application of generally accepted principles of repair.