Hepatic enzyme response and hyperpyrexia after severe liver injury

A multi-center experience with 210 severe liver injuries was reviewed to define postoperative changes in hepatic enzyme levels and body temperature profile. The 129 patients who survived initial operation comprised the data base. Serum glutamic oxaloacetic transaminase (SGOT) and lactate dehydrogenase (LDH) peaked within 24 hours (750 +/- 92 IU/L, 870 +/- 120 IU/L) and decreased rapidly during the first 4 days. Serum bilirubin was maximal at 7 days, while alkaline phosphatase rose slowly throughout 14 days. Hepatic enzyme elevations were more dramatic after blunt trauma, reflecting greater hepatocellular disruption. Maximum daily temperatures exceeding 38.0 degrees C and 39.0 degrees C were recorded for the first 3 postoperative days in 82 (64%) patients and 14 (11%) patients, respectively. No infectious source was evident in 13 (93%) of 14 patients with severe hyperpyrexia, implicating release of inflammatory mediators associated with major hepatic trauma. Convalescence from severe hepatic injury is marked by release of SGOT and LDH, as well as fever, which may be anticipated during the first 4 days postinjury.

Ruptured abdominal aortic aneurysms: repair should not be denied

The records of 231 patients (189 men, 42 women) treated during the last decade for ruptured infrarenal abdominal aortic aneurysm were reviewed to evaluate complications and mortality rates and to determine if preoperative factors would preclude attempt at surgical repair. Mean age was 73.7 years (range, 50 to 95 years). Fifty-seven patients (24.7%) were greater than or equal to 80 years of age. Sixty-eight patients (29.4%) had known abdominal aortic aneurysm before rupture. Preoperative systolic blood pressure was less than or equal to 90 mm Hg in 155 patients (67.1%). Fifty-six patients (24.2%) had cardiac arrest before operation. The overall mortality rate from admission until the end of the hospital stay was 49.4% (114 of 231). Seventeen patients (7.4%) died in the emergency department, 40 (17.3%) in the operating room, 27 (11.7%) during the first 48 postoperative hours, and 30 (13.0%) died later but during the same hospitalization. The 30-day operative mortality rate was 41.6%. Mean age of those who died was higher (75.3 years) than of those who survived (72.2 years) (p less than 0.02). Of patients greater than or equal to 80 years, 43.9% survived. Survival was lower among women (35.7%) than men (54.0%; p less than 0.04). A high APACHE II score, a low initial hematocrit, preoperative hypotension, and chronic obstructive pulmonary disease were associated multivariately with increased mortality rates (p less than 0.02). However, 59 of the 155 patients (38.1%) with preoperative hypotension survived. Deaths were high (80.4%) among patients with cardiac arrest (45 of 56); still, 28.2% of patients (11 of 39) survived repair after cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

Distal pancreatectomy for trauma: a multicenter experience

During a 5-year period, 74 patients with pancreatic injuries were managed by distal pancreatic resection at nine referral trauma centers. Patient ages ranged from 4 to 72 years. Injury mechanism was blunt trauma in 34 (46%) patients, gunshot wound in 27 (36%), stab wound in 11 (15%), and shotgun blast in two (3%). There were 19 class II, 50 class III, and 5 class IV pancreatic injuries. The resection comprised up to 33% of the pancreas in 21 (28%) patients, from 34% to 66% in 45 (61%), and greater than 67% in eight (11%). The pancreatic resection margin was closed with staples in 44 (59%), silk sutures in 20 (27%), and polypropylene sutures in eight (11%). Of 32 patients in whom the spleen was uninjured, the spleen was left intact in 17 (53%). There were nine (12%) deaths. The cause of death was irreversible shock in three patients, multiple organ failure in five, and severe head injury in one. Pancreas-related complications occurred in 32 (45%) of 71 patients who survived the initial operation. Intra-abdominal abscess developed in 24 patients; 11 were managed by percutaneous drainage alone. Pancreatic fistula developed in 10 patients; eight closed spontaneously from 6 to 54 days. Other pancreas-related morbidity included pancreatitis (6), pseudocyst (2), and hemorrhage (2). Exocrine insufficiency was not evident in any patient and diet-controlled hyperglycemia occurred in one individual following 80% pancreatic resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute posttraumatic renal failure: a multicenter perspective

Acute renal failure (ARF) following trauma is rare. Historically, ARF has been associated with a high mortality rate. To investigate this entity we conducted a retrospective review of 72,757 admissions treated at nine regional trauma centers over a 5-year period. Seventy-eight patients (0.098%) developed acute renal failure requiring hemodialysis. Detailed demographic, clinical, and outcome data were collected. Patients with pre-existing medical conditions (group I) had a 70% increase in mortality over those without pre-existing conditions (p less than 0.004). Twenty-four patients (31%) developed ARF less than 6 days after injury (group II). The remainder (group III) developed late renal failure (mean time to first dialysis, 23 days). The predominant cause of death was multiple organ failure (82%). There were no differences in mortality because of multiple organ failure among the three groups of patients. Of the 33 survivors, six (18%) were discharged with renal insufficiency, three (9%) were discharged on dialysis, 23 (70%) were discharged home or to rehabilitation, and 27 (82%) had no significant evidence of renal insufficiency.

CONCLUSION

Posttraumatic renal failure requiring hemodialysis is rare (incidence, 107 per 100,000 trauma center admissions), but the mortality rate remains high (57%). Two thirds of the cases of posttraumatic renal failure develop late and are secondary to multiple organ failure; one third of the cases of posttraumatic renal failure develop early and may result from inadequate resuscitation.

The diagnostic challenge of postoperative acute appendicitis

During the period 1979 to 1989, 0.1% of all cases of acute appendicitis at our institution occurred soon after another operative procedure. The interval between primary operation and appendectomy was 5 to 31 days (mean, 14 days). Signs and symptoms did not differ from those of classical acute appendicitis. Duration of symptoms ranged from 12 hours to 8 days (mean, 2.4 days). Perforation was present in 3 patients, suppurative appendicitis in 1 patient, and acute inflammation in 4 patients. Two of the perforations were associated with abscess formation. Morbidity related to the appendiceal condition included hepatic abscesses, septic shock, and prolonged ileus. There was no mortality. Hospitalization ranged from 6 to 80 days (mean, 12.5 days).

Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains

We reviewed our recent experience with management of 23 consecutive patients with acute necrotizing pancreatitis. All patients had documented necrotizing pancreatitis with parenchymal or peripancreatic necrosis. Our method of treatment has evolved from our previous approach of controlled open lesser sac drainage (marsupialization) to staged necrosectomy/debridement with delayed primary closure over drains. With this latter approach, hospital mortality was 4 of 23 patients (17 per cent), but significant morbidity still occurred in 12 of 23 patients (52 per cent). However, recurrent intra-abdominal abscess before discharge occurred in only one patient. We believe that this operative approach toward the severely ill patient with acute necrotizing pancreatitis who requires operative intervention will minimize the occurrence of intra-abdominal sepsis.

Conservative management of duodenal trauma: a multicenter perspective

The experience of eight trauma centers with duodenal injuries was analyzed to identify trends in operative management, sources of duodenal-related morbidity, and causes of mortality. During the 5-year period ending December 1988, 164 duodenal injuries were identified. Patient ages ranged from 5 to 78 years. There were 38 Class I, 70 Class II, 48 Class III, four Class IV, and four Class V injuries. Injury mechanism was penetrating in 102 (62%) patients and blunt in 62. Primary repair of the duodenal injury was performed in 117 (71%) patients, including 27 patients also managed with pyloric exclusion and 12 with tube duodenostomy. Duodenal resection with primary anastomosis was used in six (4%) patients and pancreatoduodenectomy was necessary in five (3%). There were 30 (18%) deaths. The cause of death was uncontrolled hemorrhage from severe hepatic or vascular injuries in 22 (73%) patients. In only two (1%) patients could death be attributed to the duodenal injury; each as the result of duodenal repair dehiscence and subsequent sepsis. Duodenal-related morbidity was documented in 29 (18%) patients, including 22 patients with intra-abdominal abscess, six with duodenal fistula, and five with frank duodenal dehiscence. In summary, this analysis demonstrated: 1) the great majority of duodenal injuries can be managed by simple repair; 2) tube duodenostomy is not a mandatory component of operative treatment; 3) pyloric exclusion is a useful adjunct for more complex injuries; 4) pancreatoduodenectomy is rarely necessary for civilian duodenal trauma; 5) morbidity following duodenal trauma is more dependent on associated intra-abdominal injuries than the extent of duodenal trauma; and 6) mortality following duodenal injuries is primarily related to associated vascular and hepatic trauma.

Duodenal villous tumors

The treatment of 36 patients with duodenal villous tumors was reviewed to determine the long-term outcome of various surgical treatment options for specific adenoma histopathology. Duodenal villous tumors were typically solitary and periampullary in location. Villous adenomas contained epithelial atypia in 30% of patients, in situ carcinoma in 14%, and invasive carcinoma in 33%. Treatment consisted of transduodenal submucosal excision in 19 patients and radical pancreaticoduodenectomy in 15. There was no perioperative mortality. Perioperative morbidity for transduodenal excision and pancreaticoduodenectomy was 16% and 47%, respectively. Benign adenomas recurred more than 5 years postoperatively in 17% of patients undergoing transduodenal excision. Five-year survival following radical resection for invasive cancers was 45%. Overall median follow-up was 5.8 years. We conclude that duodenal villous tumors without invasive cancer can be managed successfully by local submucosal excision, but invasive carcinoma requires radical resection.

Nonoperative management of blunt splenic trauma: a multicenter experience

The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. The diagnosis was established by computed tomography in 89 (79%) patients, nuclear scan in 23 (21%), ultrasound in four (4%), and arteriography in two (2%). There were 28 Class I, 51 Class II, 31 Class III, two Class IV, and no Class V splenic injuries. Nonoperative management was unsuccessful in one (2%) child and 12 (17%) adults (p less than 0.05). Failure was due to ongoing hemorrhage in 12 patients and delayed recognition of pancreatic injury in one patient. Of the 12 patients ultimately requiring laparotomy for control of hemorrhage, seven (58%) were successfully treated with splenic salvage techniques. Overall mortality was 3%; none of the four deaths was due to splenic or associated abdominal injury. This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.

Management of retroperitoneal sarcomas

The records of 116 adult patients who underwent operative treatment for retroperitoneal sarcomas at the Mayo Clinic during the years 1963 to 1982 were reviewed. Clinical, pathologic, and treatment variables were analyzed for their influence on recurrence and death from disease. Leiomyosarcomas, liposarcomas, and malignant fibrous histiocytomas represented 93% of the tumors. The primary tumor was completely excised in 54% of patients. Recurrent tumor developed in 68% of patients (median time to recurrence, 1.3 years). Tumor fixation to adjacent structures (T3 tumor) or a high-grade tumor (G2-4) identified patients at increased risk for recurrent disease. Five-year and 10-year survival rates were 40% and 22%, respectively. Survival was significantly better for patients who had (1) complete surgical excision of their tumors, (2) low-grade tumors (G1), (3) tumors not fixed to adjacent retroperitoneal structures (T1 and T2 sarcomas), and (4) tumors without metastases when initially seen. Complete surgical excision offers patients with retroperitoneal sarcomas the best chance for long-term survival, but recurrent disease remains a vexing problem. The therapeutic challenges in the treatment of retroperitoneal sarcomas continue to be the development of therapy that will increase the rate of complete resection, decrease the rate of local recurrence, and enhance patient survival.

The complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma

To determine the roles of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (CT) in the evaluation of blunt abdominal trauma, we compared our results in the eras before and after the advent of abdominal CT. In the pre-CT era 1977 to 1980 (group 1; 365 patients), DPL was the diagnostic procedure of choice. In the CT era 1983 to 1986 (group 2; 282 patients), DPL was used for unstable, polytraumatized patients, and CT was reserved for stable patients. The rate of delayed recognition of documented visceral injury (7%) was similar for groups 1 and 2. Celiotomy was nontherapeutic in 21 (14%) patients in group 1 and in 5 (5%) in group 2 (p less than 0.02). Despite immediate availability of abdominal CT, clinical examination alone or in combination with DPL was the diagnostic procedure of choice in 41% of those with blunt abdominal trauma in group 2. The complementary use of abdominal CT and DPL in those with blunt abdominal trauma decreased the rate of nontherapeutic celiotomy, did not result in a significant increase in missed injuries, and allowed identification of candidates for nonoperative management of solid organ injury.

Prospective, randomized trial of rapid venous access for patients in hypovolemic shock

The placement of central venous catheters was studied prospectively in 138 selected adult patients with hypovolemic shock or in whom rapid volume replacement was needed. The patients were randomized into two groups to receive a central vein catheter: one by basilic vein cutdown and the other by percutaneous subclavian vein placement. The groups were analyzed for success rate, time required for insertion, and complications. The techniques were equally successful (87% in the basilic vein group compared with 91% in the subclavian vein group), and their complication rates were similar (10% compared with 12%). The subclavian vein catheter was inserted more quickly (8.3 minutes compared with 14.4 minutes [P = .0001] for the basilic vein group). Percutaneous subclavian vein catheters can be used successfully in patients with hypovolemic shock and can be place quickly with low complication rates.

Acute acalculous cholecystitis

Acute acalculous cholecystitis occurs infrequently, but the incidence seems to be increasing. Its attendant high associated morbidity and mortality dictate prompt diagnosis. Diagnosing this condition is often difficult because of the patient's debilitated medical condition and the limitations of biliary imaging techniques. During a 5-year study period (1981 through 1986), 20 patients underwent assessment and treatment for acute acalculous cholecystitis at our institution. This observation suggests an increase in incidence in comparison with a previously reported review of 28 such patients during a 16-year period at our institution. Initial treatment consisted of cholecystectomy in 18 patients, and percutaneous transhepatic cholecystostomy was successfully used in the other 2 patients. The postoperative mortality and morbidity for these 20 patients were 30% and 55%, respectively. Percutaneous transhepatic cholecystostomy should be explored further as a treatment option for acute acalculous cholecystitis.

Volvulus of the small intestine

At the Mayo Clinic, six patients with primary volvulus and 51 with secondary volvulus were treated during a 10-year period. Volvulus of the small intestine must be considered when a patient presents with small-bowel obstruction, and early operative intervention should be undertaken to prevent vascular compromise.

Severe hepatic trauma: a multi-center experience with 1,335 liver injuries

The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative management of blunt hepatic trauma in adults

Although well accepted in pediatric patients, nonoperative management of blunt hepatic trauma in adults remains controversial. From January 1981 through May 1987, 66 adults were identified with blunt hepatic trauma that had been confirmed by abdominal exploration or abdominal computed tomography (CT): 46 underwent immediate operation, and 20 were initially managed nonoperatively. Patients were considered for nonoperative management only if they were hemodynamically stable and had no significant peritoneal irritation. CT criteria for nonoperative management included contained subcapsular or intrahepatic hematoma, unilobar fracture, absence of devitalized liver, minimal intraperitoneal blood, and absence of other significant intra-abdominal organ injuries. The predominant CT pattern in the 17 patients successfully managed nonoperatively included unilobar right-lobe fracture or intrahepatic hematoma. A small amount of blood in either gutter or in the pelvis did not portend failure of nonoperative management. No delayed complications were noted during an average follow-up of 27 months. Nonoperative management of blunt hepatic injury based on abdominal CT findings is a useful alternative in a select group of hemodynamically stable patients.

Obturator hernia

Obturator hernias are relatively rare. In the past 15 years at the Mayo Clinic, eight patients underwent nine operations for repair of 11 obturator hernias, which represented 0.073 per cent (11 of 15,098) of all hernias repaired at this institution. Elderly women with chronic disease were most frequently affected. Symptoms were usually intermittent; mechanical small intestinal obstruction was the most common presenting condition, followed by pain in the thigh or groin area. The Howship-Romberg sign was found in only two patients, and a correct preoperative diagnosis was made in only one patient. Midline abdominal incisions were made in all patients. Incarcerated ileum was the most frequently encountered organ in the hernia sac. Surprisingly, foci of endometriosis in the obturator defect accounted for symptoms in two patients with three obturator hernias. Right-sided obturator hernias outnumbered left, and bilateral obturator hernias were found synchronously in two instances and metachronously in one instance. The often debilitated state of the patients with obturator hernia and the frequent delay of diagnosis combined to produce significant operative morbidity and mortality rates.

Hemorrhage in major pelvic fractures

Significant hemorrhage following major pelvic fractures should always be expected. Early recognition of such fractures during the resuscitation of any multiply injured patient is essential before instituting measures that might combat blood loss. In the majority of patients, simple resuscitative measures, including employment of the pneumatic antishock garment, will suffice. With certain types of fracture geography, the early application of external fixation devices may also play an important role. Increasingly popular has been the technique of diagnostic angiography and therapeutic embolization, applicable to approximately 3 per cent of all pelvic fracture patients. With exsanguinating hemorrhage, even the best equipped and most sophisticated major trauma centers can be taxed. The decision whether a patient should be taken directly to the operating room or to the angiography suite remains one of the most difficult for even the most highly skilled trauma surgeon. Patients with rapidly expanding or free rupture of pelvic hematomas noted at the time of celiotomy, or those with large open wounds, usually leave no recourse but to attempt direct operative control, to include even the most morbid option of a life-saving hemipelvectomy or corpectomy. More often, however, once other sources of surgically correctable hemorrhage are controlled or ruled out, diagnostic angiography followed by therapeutic embolization is a mainstay in the modern-day management of pelvic fracture hemorrhage.

Physical and psychological outcome after burns

The relationship between compliance of moderately or severely burned patients with suggested plans of treatment and outcome was examined retrospectively by reviewing medical records. This review was limited to patients admitted to our facilities between 1977 and 1982 with burns in the moderate or major burn category and admitted within seven days of their injuries. The outcome measures included the following: limitation in range of motion (ROM), hypertrophic scar formation, total days of care required, quality of life, and impact of event. Noncompliance was related to the outcome as measured by limitation in ROM (P less than 0.01) and total days of care required (P less than 0.0001). A trend for diminished quality of life was related to noncompliance (P less than 0.08). Extent of injury (measured by total body surface area involved) was not related to ROM, quality of life, or impact of event but was related to total days of care required (P less than 0.01); there was also a trend toward scarring (P less than 0.06).

Small intestinal obstruction

Small intestinal obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding operative delay whenever surgery is indicated, not every patient is always best served by immediate operation. Certain entities, such as SBO secondary to incarcerated abdominal wall hernia, and patients with clinical signs and symptoms suggestive of strangulation do require prompt operative intervention. Other conditions, however, such as postoperative adhesions and neoplastic-associated SBO, particularly in patients with numerous previous abdominal procedures, concomitant medical problems, or incomplete or partial obstruction, often justifiably benefit by a trial of nonoperative management. The risk of strangulation with adhesive and neoplastic SBO is relatively low as compared with incarcerated hernia and small bowel volvulus. Close and careful clinical evaluation, in conjunction with laboratory and radiologic studies, will usually dictate the proper course of management in any given case. If any uncertainty exists, prompt operative intervention is indicated. Because over 50 per cent of all cases of SBO are the direct result of postoperative adhesions, it is probably just as important as the actual management of SBO for all practicing abdominal surgeon to familiarize themselves with the widely accepted "ischemic theory" of adhesion formation. A number of intraoperative measures, many of which go against established surgical principles, are now encouraged during routine elective abdominal surgery to reduce the incidence of detrimental adhesions that might subsequently produce SBO. At the same time, surgeons should continue their aggressive attitude towards elective repair of any and all abdominal hernias, which continue to account for close to 15 per cent of all cases of small intestinal obstruction and still remain the most common cause of strangulation.

Selective management of blunt splenic trauma

During a recent 8-year period, 235 patients with documented blunt splenic trauma were treated. After exclusion of 39 patients with early deaths (19 dead on arrival, nine died in emergency room, and 11 died in operating room), the 196 remaining patients were treated in accordance with an evolving selective management program. Definitive management included splenectomy in 117 patients (59.7%), repair in 32 (16.3%), and nonoperative treatment in 47 (24%). A spectrum of blunt splenic trauma, as manifested by the degree of associated injuries (Injury Severity Scores), hemodynamic status, and blood transfusion requirements, was identified and permitted application of a rational selective management program that proved safe and effective for all age groups. Comparative analysis of the three methods of treatment demonstrated differences that were more a reflection of the overall magnitude of total bodily injury sustained rather than the specific manner in which any injured spleen was managed. Retrospective analysis of 19 nonoperative management failures enabled establishment of the following selection criteria for nonoperative management: absolute hemodynamic stability; minimal or lack of peritoneal findings; and maximal transfusion requirement of 2 units for the splenic injury. With operative management, splenorrhaphy is preferred, but it was often precluded by associated life-threatening injuries or by technical limitations. Of 42 attempted splenic repairs, ten (24%) were abandoned intraoperatively. There were no late failures of repair. In many cases of blunt splenic trauma, splenectomy still remains the most appropriate course of action.