Yoram Ben-Menachem

Peritoneal lavage and angiography in the management of patients with pelvic fractures

One hundred consecutive patients with pelvic fractures who had undergone peritoneal lavage and abdominal and pelvic angiography were retrospectively analyzed. Sixty-four patients with negative lavages were treated successfully without laparotomy despite a 20 percent incidence of subcapsular or intraparenchymal hematomas of the liver or spleen. Thirty percent of the patients with positive peritoneal lavages were successfully managed without laparotomy when abdominal angiography failed to identify a source of active bleeding. Abdominal angiography was 92 percent accurate in predicting the presence or absence of hemorrhage in 25 patients who underwent laparotomy. There were no false-positive angiograms. The overall false-negative rate was 2.12 percent. These occurred in two patients with torn mesenteric vessels. Pelvic angiography identified arterial pelvic bleeding in 18 percent of the patients. Eighty-four percent of patients with major pelvic bleeding had successful embolization with prompt cessation of arterial bleeding. We conclude that abdominal and pelvic angiography can be a useful adjunct to peritoneal lavage in detecting intraperitoneal hemorrhage and can be of therapeutic value for arterial pelvic bleeding.

Arteriography of the Foot in Congenital Deformities

Angiography of the feet in four children with bilateral congenital club foot and in one child with congenital convex pes valgus revealed vascular abnormalities which may increase the risk of vascular insufficiency after corrective procedures for deformities of the feet. Preoperative vascular mapping of the feet can be helpful in planning patient management.

The Natural History of Traumatic Branch Renal Artery Injury

Between 1979 and 1984, 24 patients with traumatic branch renal artery injuries documented by selective angiography were managed at our center. A total of 7 patients (29 per cent) died of nonurological organ system injury during the initial hospitalization. Of the remaining patients 10 were followed for 1 to 5 years after injury. None of these patients required immediate or delayed surgical intervention for complications, while 2 had hypertension after injury that resolved spontaneously by 1 year. The eventual renal function attained by these patients remained normal, the mean creatinine was 0.9 plus or minus 0.1 mg. per dl. and there were no other urological complications. Patients who sustain branch renal artery injuries should be managed nonoperatively unless they exhibit cardiovascular instability. Excision of ischemic parenchyma is indicated only when intractable hypertension associated with increased renin secretion can be identified.

The management of splenic injury.

Increased concern over the potential immunologic consequences of splenectomy has prompted surgeons to attempt salvage of traumatized spleens. We report a retrospective study of 172 consecutive patients with documented splenic injury treated over a 2-year period: 107 patients underwent splenectomy; 65 were managed without total splenectomy; 32 were not explored. The overall mortality rate was 27%; the overall complications were 30%, including a 13% incidence of post-splenectomy subphrenic abscess. The incidence of infectious complications after splenectomy was 36%, while the incidence in nonsplenectomized patients was 9%. The Injury Severity Scores (ISS) in the two groups were significantly different (p less than or equal to 0.05). When the group whose spleens were salvaged was compared to an equivalent group matched for ISS, age, and sex, there was no significant difference in sepsis rates (23% vs. 10.7%; 0.10 greater than or equal to p greater than or equal to 0.05). Survival in those with postinjury infectious complications was significantly improved in patients with a remaining spleen (p less than or equal to 0.01). Abdominal computerized tomography was used successfully as a method of following injured and repaired spleens in order to predict return to full activity.

Angiography and peritoneal lavage in blunt abdominal trauma.

Records of 123 consecutive patients who underwent abdominal angiography for blunt trauma were reviewed. Twenty-four patients underwent abdominal angiography on the basis of positive physical findings. Seven (29%) required intervention as determined by angiography and the diagnosis was confirmed. Ninety-nine patients had abdominal angiography in association with angiographic evaluation of the chest, pelvis, or extremities. In 14 (14%) the angiogram indicated the need for intervention. In 13 this diagnosis was confirmed at laparotomy. The fourteenth patient was embolized angiographically and did well. Fifty-four patients had peritoneal lavage in addition to their angiograms. Sixteen were positive and 38 were negative. In four patients the lavage was negative and the angiographic findings indicated need for intervention. Three of these four were confirmed at laparotomy and the fourth patient was embolized angiographically. Indications for abdominal angiography in blunt trauma are: 1) incidental to needed thoracic aortography; 2) incidental to angiography when done for pelvic fractures; 3) suspected intra-abdominal injuries when clinical and lavage data are not definitive.