Vaginal evisceration resulting from a water-slide injury

A case of vaginal evisceration resulting from sliding on a water chute is described. The treatment and mechanism of this rare injury are discussed.

Histologic evaluation of preventive measures for scald injury on the peritoneo-serosal surface due to intraoperative hyperthermic chemoperfusion for patients with gastric cancer and peritoneal metastasis

To histologically assess the preventive efficacy of cimetidine against scald injury on the peritoneo-serosal surface during intraperitoneal hyperthermic chemoperfusion (IHCP) for advanced gastric cancer, a randomized histologic study using cimetidine, a histamine H2-receptor antagonist, was performed for 20 patients with advanced or recurrent gastric cancer and peritoneal metastasis. Cimetidine 50 mg/kg was administered intravenously to 10 patients just prior to the IHCP (cimetidine group), and the remaining 10 patients underwent the IHCP without cimetidine (control group). The background factors and IHCP treatments of these two groups were nearly the same. Although the antitumour efficacy of the IHCP was not histologically different between the two groups, the histological analysis revealed that the peritoneo-serosal surface in the cimetidine group was protected against scald injury, compared with the control group. This finding suggests that pre-IHCP cimetidine is of great benefit for protecting the peritoneo-serosal surface from scald injury due to IHCP.

A method of determining peritoneal penetration in gunshot wounds to the abdomen

BACKGROUND

It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA.

METHODS

DPL was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoracoabdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL was 10,000 red blood cells (RBC)/mm3. A prospective data base was kept with information on the location of the wound, DPL result, findings at laparotomy, and outcome.

RESULTS

During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/mm3. Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm3, 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication (n = 7) or by uneventful inpatient observation for 24 hours (n = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively.

CONCLUSION

For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.

Longitudinal follow-up of CA125 in peritoneal effluent

Mesothelial changes occur during peritoneal dialysis. CA125 provides a way to study the mesothelial cells in the in vivo situation. In the present study longitudinal changes of CA125 were analyzed. In addition, the appearance of CA125 in peritoneal effluent and day-to-day variability were studied. CA125 was measured in the effluent of five stable CAPD patients during four hour dwells with 1.36% glucose, with 3.86% glucose and with 7.5% icodextrin. In addition, CA125 was determined on six consecutive days in four hour effluents of three patients and appearance rates (AR) were calculated. Longitudinal follow-up was performed in 31 patients in whom three to seven yearly observations had been made. Linear appearance of CA125 was present in all dwells. No difference was found between the appearance rates of CA125 with 3.86% glucose, compared to either 1.36% glucose or icodextrin. Mean day-to-day coefficient of variation was 6.4% for CA125 AR, but a wide variation existed in stable CA125 values among patients (mean 22.1, range 2 to 48 U/ml). A negative trend with duration of CAPD was present in the longitudinal study. A mean decrease of 2.2% per year could be calculated, but substantial interindividual differences existed. Sudden decreases of CA125 AR were found in five patients. Possible causes were found in all of them and included a severe or recurrent peritonitis, and temporary cessation of peritoneal dialysis. In one patient a sudden decrease preceded the manifestation of peritoneal sclerosis. It can be concluded that CA125 can be used for the in vivo follow-up of the mesothelium in peritoneal dialysis patients. The appearance of CA125 in effluent is linear in time and not influenced by the initial lysis of mesothelial cells. A gradual loss of mesothelial cells is likely to occur, although interindividual variability is substantial. An acceleration of the process may be caused by severe peritonitis and perhaps by temporary cessation of peritoneal dialysis. A sudden decrease in CA125 may be an alarming sign for the development or manifestation of peritoneal sclerosis.

A cost-effectiveness evaluation of laparoscopic disposable versus nondisposable infraumbilical cannulas

STUDY OBJECTIVE

To compare the safety and cost-effectiveness of disposable and nondisposable infraumbilical laparoscopic cannulas.

DESIGN

Retrospective review of consecutive laparoscopic procedures performed from July 1, 1988, to June 30, 1994.

SETTING

A university-affiliated hospital. Patients. The 10,459 consecutive women who underwent laparoscopies.

INTERVENTIONS

A 10-mm disposable cannula was used in 529 laparoscopies and a nondisposable cannula in 9930, based on physician preference.

MEASUREMENTS AND MAIN RESULTS

The only intraabdominal injuries associated with insertion of disposable and nondisposable cannulas were bowel injuries in one and three patients, respectively. The injury rates for the instruments were 19 and 3/10,000 cases, respectively, but were not statistically different (P <0.05, Fisher's two-tail exact test). The hospital cost per disposable cannula in 1994 was $63.71; the cost per procedure with the nondisposable cannula was amortized and was less than $1.35, including maintenance.

CONCLUSION

Disposable cannulas were not cost effective and were associated with a higher but not statistically significant complication rate. Therefore, the more expensive disposable cannulas are not recommended.

Laparoscopy for triage of penetrating trauma: the decision to explore

The role of diagnostic laparoscopy in penetrating trauma continues to evolve. We reviewed our experience to determine the effect of laparoscopy on therapeutic laparotomy rates, length of hospital stay, and hospital charges. Laparoscopy was performed on 106 hemodynamically stable patients with penetrating abdominal injuries (66 had gunshot wounds, 40 had stab wounds). All patients with laparoscopically identified peritoneal penetration underwent open laparotomy. At laparoscopy, 41 (39%) had positive findings, whereas 65 (61%) had none. Two patients with retroperitoneal hematomas and one with ecchymosis of the peritoneum were not explored. Thus 68 (64%) did not require laparotomy. Among the 38 who underwent laparotomy, 29 (76%) had positive findings and 9 (24%) had a negative laparotomy. Nineteen patients (50%) had a therapeutic laparotomy. This compares with a therapeutic laparotomy rate of 18% had all 106 patients undergone mandatory laparotomy. Data for length of stay and hospital charges were analyzed. Due to the extended stay associated with tube thoracostomy (n = 21), a subgroup excluding patients with chest tubes was also analyzed. In this subgroup, there was a significant difference in hospital stay between those who had only a laparoscopy and those who underwent a negative laparotomy (2.6 +/- 1.7 vs. 4.7 +/- 1.6, p < 0.01). The average nonsurgical charge for patients who had a negative laparotomy was more than double that for those who had laparoscopy only ($8275 +/- 4692 vs. $3762 +/- 3786, p < 0.01). We conclude that the use of diagnostic laparoscopy to identify peritoneal penetration resulted in an improved therapeutic laparotomy rate as well as significant reduction in hospital stay and hospital charges.

Peritoneal healing after fibrin glue application: a comparative study in a rat model

The influence of fibrin glue on adhesion formation and peritoneal healing is evaluated in a prospective, randomized, controlled study. In all, 20 Wistar rats underwent microsurgical suturing of two silicone sheets, one covered with a fibrin glue barrier, to the anterior peritoneum. Each animal thus served as its own control. After 10 days, adhesions and peritoneal healing were evaluated by a blinded observer through a second-look laparotomy. Adhesions were scored using a modification of the classification of Diamond. Tissue around the silicone sheet was examined histologically and by scanning electron microscopy to evaluate the inflammatory reaction and peritoneal healing (ingrowth of blood vessels and quality of peritoneal cells). Adhesion scores for treated and control sides were (mean +/- SD) 2.89 +/- 4.68 and 6.79 +/- 9.09 (P = 0.181) respectively, and the percentage of the sheet covered by peritoneum was 26.25 +/- 31.50 and 29.21 +/- 40.21 (P = 0.226) respectively. Using the paired Wilcoxon rank test, the P values for the ingrowth of blood vessels and peritoneal healing evaluated by histology and scanning electron microscopy were 0.842, 0.692 and 0.695 respectively. We conclude that although the mean adhesion score was reduced by > 50% by fibrin glue, there is no statistically significant difference concerning adhesion formation or peritoneal healing with the use of fibrin glue.

Characteristics of pancreatic injury in children: a comparison with such injury in adults

A retrospective study of eight pediatric patients (under 15 years of age) who had pancreatic injuries was undertaken. Comparisons were made with 59 adult patients who sustained pancreatic injuries over the same 15-year period. All the pediatric injuries and 96.6% of the adult resulted from blunt abdominal trauma. Bicycle accidents (children, 75.0%; adults, 0%; P < .001) and automobile accidents (children, 0%; adults, 61.0%; P < .01) were the most common causes of pancreatic injury in the two groups. There was no significant difference in the incidence of abdominal pain or peritoneal irritation between the groups. However, abdominal pain in the adults was poorly localized. Isolated pancreatic injuries were noted in 62.5% of the pediatric patients and in 15.3% of the adult patients (P < .05). Associated intraabdominal injuries were present in 25.0% of the children and in 69.5% of the adults (P < .05). The duodenum was injured in two (25.0%) pediatric patients and in 10 (16.9%) adult patients. Whereas the duodenal injuries in pediatric patients were intramural hematomas without perforation in both cases, all but one of these injuries in adults were perforations or transections (P < .05). There was a significant difference in the type of pancreatic injury between the two groups (P < .05). Surgery was performed in 12.5% of the pediatric cases and in 78.0% of the adult cases (P < .01). There were no deaths among the pediatric patients, but 8.5% of the adults died in the hospital. The difference with respect to clinical course might be related to the differences in cause of injury.

Laparoscopy in trauma

Laparoscopy is a nearly century-old technique that has experienced a resurgence of interest from surgeons since the development of technology that has broadened its applications. Although laparoscopy has been used to evaluate patients with possible abdominal trauma, its use for this purpose is limited by the availability of other diagnostic procedures that may be more suitable for particular circumstances and are more accurate for certain injuries. Laparoscopy is contraindicated in patients who are hypovolemic or hemodynamically unstable and should not be performed in patients with clear indications for celiotomy. It may not be appropriate for patients with cardiac dysfunction, nor for those with significant head injuries who are at risk for intracranial hypertension. Its best applications may be in stable patients with stab wounds or those with tangential gunshot wounds of the abdomen. The likelihood of missing hollow visceral injuries depends upon the indications for conversion to celiotomy. If peritoneal violation or the presence of a small amount of blood in the peritoneal cavity is used as an indication for celiotomy, then the missed injury rate will be low but the unnecessary celiotomy rate will be diminished only slightly compared with a policy of mandatory celiotomy. Excessive enthusiasm for laparoscopy in trauma might result in its use when other diagnostic measures or simple observation are more appropriate. The desire to perform a procedure can be compelling, especially in circumstances in which the general surgeon would not operate upon a patient but simply provide postoperative care after other surgeons have operated. The use of laparoscopy for these purposes can only be condemned, as it increases the costs and risks of care without improving the outcome. The role of laparoscopy in trauma is evolving, and further research into its diagnostic role and therapeutic applications is clearly needed.

[Intestinal obstruction caused by transitional carcinoma]

OBJECTIVES

To draw attention to the possibility that distant intestinal metastasis can arise from transitional urothelial carcinoma located in the bladder.

METHODS

Two female patients developed distant metastasis during treatment of the tumor by transurethral resection of the bladder.

RESULTS

Following complicated transurethral resection with perforation of the peritoneal cavity, the patients developed intestinal obstruction from metastatic transitional cell carcinoma.

CONCLUSIONS

Direct or distant seeding of tumor cells on previously undamaged peritoneal serosa produced with the resectoscope may not be exceedingly unlikely.

Laparoscopic repair of intraperitoneal bladder injury: a simple new technique

Laparoscopy is advocated to lessen morbidity associated with more traditional open procedures. Both diagnostic and therapeutic laparoscopy may result in complications, including injury to bowel and vascular structures. Injury to the bladder during laparoscopy is a rare complication. Prior to the advent of laparoscopy, laparotomy and open repair of intraperitoneal bladder injuries was thought to be necessary in all cases. The following illustrates a safe, effective, easily learned alternative in selected cases.

Advanced glycation end-products in the peritoneal fluid and in the peritoneal membrane of continuous ambulant peritoneal dialysis patients

In patients on continuous ambulant peritoneal dialysis (CAPD) treatment, the peritoneal membrane is continuously exposed to the high glucose concentration contained in the dialysate. This may lead to the local generation of advanced glycation end-products (AGEs). To test this hypothesis we evaluated the plasma and dialysate AGE concentrations in five CAPD patients. The dialysate was measured after a 1 h and after a 12 h dwell time. Additionally, in two patients an immunohistochemical investigation of the peritoneal membrane for AGE was performed. For the determination of AGE an ELISA using a polyclonal antibody against AGE bovine serum albumin was used; the immunohistochemical staining was performed using the streptavidin-biotin complex method. We found only low concentrations of AGE in the dialysate after a 1 h dwell time; after 12 h, however, the dialysate AGE was even greater than the plasma concentration. In both peritoneal specimens we found positive staining for AGE in the interstitium of the mesothelial layer. The dialysate AGE contained a high proportion of high-molecular-weight AGE proteins and low-molecular-weight AGE was found to be in the same concentration range as the total serum AGE. We conclude that there is local generation of AGE in the peritoneal membrane and a 'washing out' of AGE from the peritoneal membrane during longer dwell times. We speculate that the accumulation of AGE might lead to some of the functional and morphological alterations observed after long-term CAPD.

Ultrasonographic examination of wound tracts

OBJECTIVE

To determine if ultrasonography is useful in evaluating penetrating injuries of the trunk to assess whether violation of the peritoneum or pleura has occurred.

METHODS

The study group was 29 patients who suffered gunshot (n = 17), stab (n = 10), or shotgun (n = 2) wounds. The abdomen was at risk in 21 injuries, the thorax in eight. The results of physical examination and plain x-rays suggested the pleura and or peritoneum might be intact in all patients. Using a 7-MHz transducer, wound tract(s) were images, looking for the presence of soft-tissue air and/or echolucent areas consistent with soft-tissue blood. Injuries were deemed extraperitoneal or extrapleural if (1) the entire tract was visualized; (2) it appeared superficial to the deepest fascial structure in that area; and (3) in shotgun injuries, all visible pellets on x-ray films were identified by ultrasound in the abdominal wall.

RESULTS

Evidence of penetration occurred in four abdominal wounds and one thoracic wound. These were confirmed by operation in the abdominal cases and by subsequent chest x-ray examination in the one thoracic wound. The diagnosis of nonpenetration was confirmed in all the remainder by serial benign abdominal examination (n = 15), chest x-ray examination (n = 8), and laparoscopy (n = 1). Positive and negative predictive accuracy were thus 100% in this pilot series.

CONCLUSIONS

Ultrasonographic exploration of penetrating truncal injuries is feasible and accurate. Ultrasonographic wound exploration may serve as a noninvasive and safe replacement for diagnostic laparoscopy, conventional local wound exploration, peritoneal lavage, and 6-hour chest x-rays (repeated chest x-rays taken 6 hours after initial chest x-ray examination). If used as part of the initial physical examination, cost-effectiveness can also be realized.

Is laparoscopy associated with a lower rate of postoperative adhesions than laparotomy? A comparative study in the rabbit

This trial set out to test the hypothesis that there is no difference in the incidence of intra-abdominal adhesions after a stereotyped intraperitoneal injury created via laparoscopy or laparotomy. Twenty New Zealand White rabbits had a 2 x 2 cm area of peritoneum stripped off their caecum and adjacent parietal peritoneum, either by laparotomy or laparoscopy. Outcome was assessed by the incidence of adhesions to the test site and the wound. There was no difference in the rate of adhesions at the test site in the two groups. The rate of adhesions to the wound was different in the two groups (70% laparotomy, 0% laparoscopy; P = 0.003). In a rabbit model, comparing laparoscopy and laparotomy in a strictly controlled operative environment, a stereotyped intraperitoneal injury results in similar rates of postoperative adhesions. Laparoscopy is, however, associated with a much lower incidence of wound adhesion. The potential for postoperative adhesions is real after laparoscopic surgery.

Traumatic hemoperitoneum in 28 cases: a retrospective review

This study was conducted to evaluate and describe presenting clinical signs, course, management, and outcome of small animal patients that suffered severe traumatic hemoperitoneum. The medical records of 28 blunt trauma patients diagnosed as having hemoperitoneum and requiring the transfusion of blood products for stabilization were analyzed. The survival rate was 16/28 (57%). Six patients died from natural causes, and six patients were euthanized. Euthanized patients were not considered for the analysis of outcome. The survival rates for six animals that had surgical intervention and 16 animals that were treated medically were 67% and 75%, respectively. Statistically, larger animals had a better prognosis (p less than 0.05, unpaired t-test) for survival. Presenting clinical signs, packed cell volume (PCV), peripheral pulse rate, effusion PCV, site of intra-abdominal hemorrhage, and age were not found to correlate statistically with survival nor with the decision to perform an abdominal exploratory.

Low-velocity gunshot wounds to the spine with an associated transperitoneal injury

Twenty-nine patients who incurred a transperitoneal low-velocity gunshot wound to their spine were evaluated for the occurrence of spinal infectious complications. All patients underwent an exploratory laparotomy to determine the extent of viscera involvement. No attempt was made to debride the involved spinal area, and the bullet was not removed unless it was easily accessible. Of the 21 patients with a parenchymal and/or noncolonic viscous injury, 17 (77%) were treated with intravenous (i.v.) antibiotics for a minimum of 5 days the remainder received treatment for a maximum of 48 h. All 8 patients with colonic injuries received a minimum of > or = 5 days of antibiotic treatment. Follow-up averaged 44.9 months (range 3-144 months). Only 1 (4.7%) patient with either a noncolonic or parenchymal perforation developed an infectious complication (subdiaphragmatic abscess); two patients (25%) with colonic perforations developed a psoas abscess. No patient developed a spinal infection. This study suggests that patients who sustain a transperitoneal low-velocity gunshot wound to their spine do not need to undergo spinal debridement and may be treated with parenteral antibiotics. Any course of broad-spectrum antibiotics for 5 days appears to minimize infectious complications. Bullet removal and missile tract debridement of the spine is not routinely necessary.

Experimental animal model for readhesion formation study

The problem of postoperative adhesions remains unsolved. The formation of readhesions after tubal reconstructive surgery reduces the success rate. We have developed a modified uterine horn model in the rat to study the influence of peritoneal transplants on readhesion formation. A total of 58 rats were operated. In 25 animals (group III) the uterine horn was scratched on both sides and then sutured together. During relaparotomy 14 days later the tight connection between both sides was cut. The resulting defect was covered by a peritoneal transplant on one side (group IIIb) and was left open on the control side (group IIIa). After 14 days the presence or absence of adhesions was explored. There was a significant difference (p < .001) between the covered (28%) and uncovered (84%) peritoneal defects with respect to incidence of adhesions. To compare the different characteristics of visceral and parietal peritoneum, a pelvic sidewall defect was induced in 33 animals. There was no significant difference between covering the defect by a peritoneal transplant (group II; 42.9%) and the control side (group I; 33.3%). These data suggest that defects on visceral peritoneum should be closed to prevent adhesion formation. The incidence of adhesions after injury of parietal peritoneum seems to be much lower and of less clinical significance.

Triage by laparoscopy in patients with penetrating abdominal trauma

Laparoscopy was performed on 33 patients with penetrating abdominal injuries to identify those with peritoneal penetration. Diagnostic or therapeutic manoeuvres were not attempted; evidence of peritoneal penetration mandated exploratory laparotomy. Twenty-two patients had gunshot wounds and 11 stab wounds. Ten patients had multiple penetrating injuries. Intraperitoneal injury was not evident by clinical assessment in any patient and all were haemodynamically stable. Twenty-three patients underwent negative laparoscopy and no intraperitoneal injury was subsequently detected. Laparoscopy demonstrated peritoneal penetration in ten patients and subsequent laparotomy detected intraperitoneal injuries in nine. No complications of laparoscopy occurred. In stable patients with penetrating trauma and no clinical evidence of intraperitoneal injury, laparoscopy effectively and safely detects those with peritoneal penetration.

[The surgical procedure in a case of accidental lesion due to impalement]

The authors describe a case of intraperitoneal anorectal injury. Such injuries now have an improved survival rate as a result undoubtedly of superior resuscitation, early operative management and early use of antibiotics. Civilian life rectal wounds are usually of the penetrating type. Major complications, both of intra and extraperitoneal injuries, are related to infection. The surgical management of these lesions is primarily a proximal diversion of the fecal stream. This is accomplished by a divided--end colostomy. Local wound care must be given for the inevitable infected foreign tract. When sepsis occurs, the surgeon must be prepared to handle it adequately by appropriate incision and drainage.

Laparoscopy in abdominal gunshot wounds

The role of laparoscopy in the evaluation of abdominal trauma continues to evolve. It has been successfully used in blunt and penetrating trauma. We report our experience with diagnostic laparoscopy in 28 patients with abdominal gunshot wounds. We found a 100% accuracy and a 0% morbidity in patients with negative laparoscopy. We report a case in which laparoscopy was used to demonstrate an isolated nonbleeding liver injury due to a gunshot wound to the abdomen. Nontherapeutic laparotomy was avoided.