Robert Zeppa

Management Of Lower Extremity Arterial Trauma

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Performance rating scale for peer and self assessment1

A performance rating scale was developed and tested on a class of junior medical students who rated themselves and four to ten of their peers. When 928 ratings were factor analysed, two strong factors, knowledge and relationship, emerged. Test-retest reliabilities were good. Validity was measured by correlation of ratings with grades, and though both sources of ratings correlated significantly with grades given by faculty, peer ratings were more highly related to grades than were self ratings. Students tended to rate themselves lower than they were rated by their peers. Grades are probably not the best estimate of performance, but are currently one of the most reliable. Use of the scale to judge performance of physicians in practice has not been tested. The question of how such evaluation of peer and self would relate to other measures of quality of care is raised.

The comparative survivals of alcoholics versus nonalcoholics after distal splenorenal shunt.

Survival after distal splenorenal shunt is appreciably better in nonalcoholic patients than in alcoholics. This increase in survival does not appear to be dependent upon the state of biochemical liver function or the severity of changes in liver histology since these latter were similar for both groups. We suggest that the poorer survival of alcoholics may be related to continuing alcohol toxicity, and that a possible reason for the failure to demonstrate this difference in survival after portacaval shunts may be due to the harmful effects of total portal diversion on the liver.

Balloon dilatation of biliary strictures through a choledochojejuno-cutaneous fistula

The problem of recurrent strictures following repair for bile duct injuries or in patients with sclerosing cholangitis is well recognized. For the most part, the recurrent problems have required repeated operations. The possibility of controlling the recurrent strictures by dilatation has been postulated, but repeated dilatations obviously require simple access to the entire biliary tree. We have found that stomatization of the afferent limb of a choledochojejunostomy or hepaticojejunostomy provides ready access to the biliary tree through which strictures can be readily traversed and dilated. Our early results with this procedure suggest that long-term patency can be expected following dilatation of these strictures.

Does surgery attract students who are more resistant to stress

This article examines perceptions of stress and career choice. One hundred sixty-nine junior students specified what they thought were the two most and two least stressful careers, as well as their own career preferences before and after a 12-week surgical clerkship. The class was divided for analysis into three groups: those who selected careers that they said were A) most stressful (42%), B) least stressful (10%), and C) neither most nor least stressful (48%). Surgery was cited as one of the two most stressful choices by 99% of the class before and 93% after the clerkship. The next most stressful career was internal medicine, cited by 43% before and 35% after the clerkship. The two least stressful careers were dermatology and radiology, cited by approximately 50% of the class before and after the clerkship. Those who chose careers that they said were most stressful had significantly higher self-esteem (p less than 0.05), experienced less unfavorable stress themselves as measured by a 31-item stress scale before and after the clerkship (p less than 0.01), and experienced more favorable (in their view) stress (p less than 0.05) than did the other two groups. Reanalysis of data comparing those who selected surgery with those who did not confirmed findings similar to that of the matched high-stress career group. The study suggests that some students may be able to tolerate stress better and in fact, tend to thrive in an environment that they perceive as stressful, and that such students are more likely to go into a surgical career, which they foresee as one of the most stressful that they can enter.

Hemodynamic contrasts between selective and total portal-systemic decompression.

Hemodynamic Contrasts Between Selective and Total Portal-Systemic Decompression Atef Salam;W. Warren;James LePage;Manuel Viamonte;Duane Hutson;Robert Zeppa; Annals of Surgery

The role of H.I.D.A./P.I.P.I.D.A. scanning in diagnosing cystic duct obstruction.

A newer approach to the early diagnosis of acute biliary tract disease is reviewed. Ninety-two patients were evaluated with a new hepatobiliary agent (H.I.D.A./P.I.P.I.D.A.) for the presence of cystic duct obstruction. Seven patients with suspected acute gall bladder disease were dropped from the study for the lack of pathologic confirmation of the diagnosis. Forty-four of the remaining 85 patients were subsequently operated on and found to have acute cholecystitis. Forty-three of the 44 had cystic duct obstruction demonstrated on H.I.D.A. Scan (one false negative). An additional 23 patients underwent cholecystectomy for chronic disease. In this group, the gallbladder scan was only 43% (10/23) accurate in correctly identifying disease. Eighteen patients with nonbiliary disease had normal scans. The accuracy of ultra-sonography and the scan are also compared in a smaller subgroup of 53 patients who had both studies.

Noncirrhotic portal hypertension in Felty's syndrome

SummaryA case of Feltys syndrome with nodular regenerative hyperplasia of the liver, presinusoidal portal hypertension, and bleeding esophageal varices is reported. Increased splenic blood flow may be a contributing factor to the development of the regenerative nodules. The portal hypertension is postulated to be a result of intrahepatic vascular compression.

Retrohepatic vein injuries: experience with 20 cases.

The mortality for injury of the retrohepatic veins is reported to vary from 50 to 100%. The use of hepatic bypass techniques, introduced in the 1960s, has not significantly decreased this mortality. We reviewed our experience with liver injuries over a 5-year period from 1982 to 1987 to determine our results with these particular injuries. Twenty patients had retrohepatic vein injuries. There were 11 patients with penetrating trauma and nine with blunt trauma. A total of 15 patients died, for a mortality rate of 75%. Fourteen patients died intraoperatively from exsanguination and one postoperatively from sepsis. A shunt was used in an attempt to bypass the injury in ten patients, with nine deaths. In the ten remaining patients who were not shunted, there were six deaths. Thus, in ten shunted patients the mortality was 90% and in ten non-shunted patients, 60%. Our review supports other studies reporting a lower mortality by direct exposure and repair of retrohepatic vein injuries. Although total vascular occlusion of the liver may not be well tolerated in hypotensive patients, rapid application of the above approach resulted in better patient survival than the use of shunts.

The effect of the distal splenorenal shunt on hypersplenism.

Twenty-four patients with leukopenia and/or thrombocytopenia improved these deficiencies after distal splenorenal shunts. The average white blood cell count for 23 neutropenic patients increased by an average 1000 cells/cu.mm p less than .01. The average platelet count for 13 thrombocytopenic patients increased by more than 40,000, p less than .02. Analysis of the data showed that patients older than 50 years, with a history of alcoholic liver disease and sinusoidal hypertension greater than 15mm Hg were most likely to correct leukocyte and platelet defects after distal splenorenal shunts.