Stanley R. Klein

Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection.

BACKGROUNDnOptimal treatment of necrotizing fasciitis (NF) requires rapid diagnosis. The purpose of the study was to identify objective admission measurements that help differentiate NF from nonnecrotizing (non-NF) infection and, among NF patients, to identify admission factors that predict mortality.nnnMETHODSnTwenty-one NF cases were paired with matched non-NF controls. Statistical comparison of admission vital signs, laboratory values, and radiographic studies was performed.nnnRESULTSnOn multivariate analysis, admission white blood cell count (WBC) >14 x 10(9)/L, serum sodium <135 mmol/L, and blood urea nitrogen (BUN) >15 mg/dL separated NF from non-NF patients. Mortality for NF patients was predicted by admission WBC >30 x 10(9)/L. Mortality was also significantly increased for patients transferred from an outside institution prior to definitive therapy.nnnCONCLUSIONSnObjective admission criteria (elevated WBC and BUN and decreased serum sodium) can assist in distinguishing NF from non-NF infections. The best objective predictor of mortality in NF patients is marked elevation of admission WBC.

Complications of therapeutic laparoscopy.

Laparoscopic surgery holds great promise as a technique for reducing hospital stay and convalescence. Although advantages in hospital cost cannot be shown for all such procedures, improvements in technique and operator experience will undoubtedly improve the situation. Analysis of the pertinent physiologic aspects and complication rates indicates that laparoscopy is not minimally invasive, but rather exposes the patient to many of the risks normally incurred by open procedures. Enthusiasm for the use of these techniques must be tempered by good judgment and scientific evidence supporting equivalent or better long-term results at equal or lower rates of morbidity and mortality.

Vascular injuries in the urban battleground: experience at a metropolitan trauma center

The increasing frequency and severity of urban violence and vehicular injuries have brought with them a rise in the number of complex vascular injuries. To examine the cause, incidence, management, and outcome of this problem, we created a vascular trauma registry which includes all such cases treated at a Level I metropolitan trauma center over the past nine years. This constitutes a summary report of that registry. During the period 1979-1988, 411 patients (355 men, 56 women) with 478 vascular injuries were treated. There were 18 deaths (4%). Primary diagnosis was grouped by anatomic region: (1) head and neck vessels, 62 (15%); (2) thoracic, 39 (10%); (3) abdominal and pelvic, 63 (15%); (4) upper extremity, 161 (39%); and (5) lower extremity, 86 (21%). Surgery was required in 241 cases (60%). Operative techniques consisted of ligation or resection in 26 (12%) and direct repair in 212 (88%). Associated procedures included: (1) laparotomy (n = 83); (2) craniotomy (n = 4); (3) thoracotomy (n = 49); (4) orthopedic procedures (n = 118); and (5) peripheral neurological repair (n = 70). Mechanisms of injury were: (1) gunshot wounds (32%); (2) stab wounds (45%); (3) motor vehicle accidents (18%); (4) fall (3%); and (5) other mechanisms (2%). We conclude: (1) vascular injuries were found frequently in the severely injured patient; (2) multiple vascular repairs were required in a significant proportion of these patients; and (3) outcome is dependent more upon associated trauma than on the vascular injuries themselves.

Laparoscopic occlusion of testicular veins for clinical varicocele

Surgery via the laparoscope is now a reliable and cost-effective alternative to some open surgical procedures. Advances in videoendoscopy, incorporating optical magnification combined with the development of instruments with which to dissect, ligate, and transect blood vessels provide the urologist the opportunity to surgically correct a varicocele. In the outpatient setting, 4 patients (14-26 years of age) underwent laparoscopic ligation of the left internal spermatic veins for painful left varicocele. Carbon dioxide pneumoperitoneum was obtained using a Veress needle. A 10-mm laparoscope was placed intraperitoneally through a cannula inserted in the infraumbilical border. Utilizing two additional endosurgical ports (5 mm and 10 mm) through which 5-mm dissecting instruments and vaso-occlusive endoclips were placed, three veins were individually isolated and ligated in each of the 4 patients. In all 4 patients, the left testicular artery was visualized and preserved. There was no blood loss or other intraoperative complication. In each patient the varicocele was successfully corrected. Analgesic medication was not required postoperatively. We conclude that laparoscopic ligation of the internal spermatic veins is a safe and effective way of treating a varicocele without immediate postoperative sequelae. Long-term follow-up is necessary to determine the place of the endoscopic approach.

The Problem of Vascular Shotgun Injuries: Diagnostic and Management Strategy

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.

Microporous flow surface variation and short term thrombogenicity in dogs

Abstract This study was designed to evaluate the effect of three luminal surface coatings on short-term thrombogenicity in 4 mm internal diameter vascular prostheses. Microporous replamineform grafts (20–30 μm pore size) composed of silicone rubber were coated with medical grade biomaterials: Biolite®, TEDMAC-heparin, and Biomer®.These grafts were compared to each other and to control grafts of silicone rubber and Biomer that did not have coatings. Following three hours of implantation in the canine femoral artery, the prostheses were removed, opened longitudinally and evaluated for quantity of thrombus, % thrombus free surface, and type of thrombus. Silicone rubber grafts coated with Biolite carbon had the least thrombogenic flow surface followed by the control Biomer grafts, Biomer-coated silicone rubber grafts, TEDMAC-heparin coated silicone rubber grafts, and the control silicone rubber grafts. Due to the small number of samples, no statistical analysis was performed. Hence, the conclusions drawn are tentative.

Endovascular Occlusive Intervention in the Management of Trauma

This report summarizes a 10-year experience (1978-1987) in a metropolitan hospital with 102 patients sustaining a variety of complex or inaccessible vascular injuries. Management included the application of occlusive interventional arteriographic techniques. Regional injuries included head and neck (56%), trunk (13%), and extremity (32%). Techniques of vascular occlusion were often performed in conjunction with the initial arteriographic evaluation and were comprised of particulate embolization (42%), placement of mechanical devices (36%), or tissue adhesives (1%), or a combination (21%). There were no deaths in this series and the only complications included four cases of dislodgement of the occlusive agent. We demonstrate that endovascular occlusion is a useful, safe and efficacious procedure in selected patients with complex, inaccessible or life-threatening vascular trauma.

Cadaveric Renal Transplantation: Surgical Results and Expectations in the cyclosporine Era

During a 36-month period 100 patients received 104 cadaveric renal transplants with cyclosporine-based immunosuppression. Of the patients 26 required 31 additional operations. Of the 19 secondary operations performed 1 month after transplantation 18 were emergency in nature, whereas beyond this period the majority of the procedures were elective. Both deaths in this series were related to the operation. Only 1 graft loss was directly attributed to a secondary operation. The patient undergoing cadaveric renal transplantation is at significant risk (25 per cent) of requiring at least 1 additional operation. However, despite this high probability of reoperation, graft loss and patient death after such procedures should be rare.