[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.

Accidental injuries of the hepatoduodenal ligament

OBJECTIVE

To report our experience in the management of accidental injuries to the structures of the hepatoduodenal ligament.

DESIGN

Retrospective study of medical records.

SETTING

University department of surgery.

SUBJECTS

8 patients admitted after accidents (road traffic accidents, n = 4; falls, n = 2; and gunshot and stab wounds, n = 1 each) who were found at laparotomy to have injuries of the structures of the hepatoduodenal ligament.

INTERVENTIONS

Laparotomy in all cases.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

One patient died (13%) of multiple organ failure after a gunshot wound of the portal vein, liver, inferior vena cava, right renal artery, and right kidney. All patients had associated injuries. There were 3 complete transsections of the common bile duct, two of which were treated by Roux-en-Y cholecystojejunostomy and one by choledochojejunostomy over a T tube. Two lacerations of the common hepatic duct were treated by T tube choledochostomy. All injuries to blood vessels were sutured. Only one patient survived without any complications, and two developed cholangitis after cholecystojejunostomy that required further operation 5 and 16 months after the initial operation.

CONCLUSIONS

Blunt injuries to the hepatoduodenal ligament are easily overlooked, leading to delayed morbidity. Complete transsections of the bile duct are best managed by choledochojejunostomy with a Roux-en-Y loop; T tube choledochostomy is usually sufficient when treating small partial lesions of lobar bile ducts; and most non-circumferential vascular lesions are best treated by suture.

Negative trauma celiotomy

A retrospective review of 525 consecutive exploratory celiotomies for abdominal trauma occurring between January 1987 and June 1990 in an urban trauma center was conducted. One hundred-fifteen patients sustained blunt abdominal trauma (21%), and 410 patients sustained penetrating abdominal trauma (78%). Penetrating injuries included 260 gunshot wounds and 150 stab wounds. Patients were divided into three groups: Group A (16%), no visceral injuries identified at exploration (true negative); Group B, positive operative findings at celiotomy requiring no operative repair (10%) (nontherapeutic celiotomy); and Group C (74%), injuries encountered requiring operative repair (true positive). A positive exploration rate of 90 per cent with blunt trauma is acceptable using diagnostic techniques currently available. Similarly, a positive exploration rate of 85 per cent in gunshot wounds warrants our continued use of mandatory celiotomy. A 36 per cent combined incidence of true negatives and nontherapeutic celiotomies (Group A and B) is unacceptably high. To reduce this high incidence will require improved clinical surveillance and the controlled implementation of newer diagnostic techniques.

Metabolic changes in cimetidine treatment for scald injury on the peritoneo-serosal surface in far-advanced gastric cancer patients treated by intraperitoneal hyperthermic perfusion

Since pretreatment with cimetidine results in the prevention of scald injury on the peritoneo-serosal surface caused by intraperitoneal hyperthermic perfusion (IPHP) for advanced gastric cancer, the diverse influence of IPHP on patients who were either given or not given cimetidine was studied both during and after IPHP treatment. Cimetidine 50 mg/kg was injected intravenously into 12 patients immediately prior to IPHP. There were no statistical background differences between the cimetidine and control groups (those not given cimetidine). The inflow and outflow temperatures of the hyperthermic perfusate in the control and cimetidine groups were 46.1 +/- 0.1 degree C and 44.1 +/- 0.1 degree C and 46.3 +/- 0.1 degree C and 44.2 +/- 0.04 degree C, respectively. Either the pre-IPHP hypothermia or IPHP in the control group resulted in a considerable increase in serum noradrenaline and adrenaline. The intravenous administration of cimetidine led to a stransient but moderate drop in the mean blood pressure as well as a delayed appearance of high concentrations of noradrenaline and adrenaline, induced by high concentrations of circulating histamine released with cimetidine. These results suggest that the sympathetic nervous responses were activated either by hypothermia or hyperthermia. The transient hypotension and delayed increases of both serum catecholamines were attributed to a marked increase in circulating histamine, released with the intravenous cimetidine.

[Fatal complications of a colon contrast enema due to erroneous insertion of the infusion catheter in the vagina]

A 68-year-old woman was to have a barium enema of the colon to discover the cause of recurrent cramp-like symptoms in the lower abdomen. At the beginning of the examination the responsible radiologist saw, during a fluoroscopic check, that the contrast medium had not advanced beyond the region of the infusion catheter tip. Believing this to be due to blockage in the catheter he increased the infusion pressure. Suddenly the patient went into treatment-resistant shock and died. The autopsy revealed that the infusion catheter had by mistake been placed into the vagina. This had caused a tear in the vagina with resulting subperitoneal contrast-medium infiltration. Embolization of contrast medium to the lung was demonstrated both histologically and radiologically. The cause of death was the combined effect of the embolism and peritoneally induced vagal shock.

Effect of radiotherapy on peritoneal function in continuous ambulatory peritoneal dialysis

A 25-year-old male patient underwent abdominal radiotherapy following the discovery of lymphadenopathy associated with a testicular teratoma. Prior to treatment, his peritoneal mass transfer area coefficients were within normal limits. One and 2 months after treatment, peritoneal permeability had increased to the extent that continuous ambulatory peritoneal dialysis was rendered impractical.

The surgical significance of Persian Gulf sand

Foreign bodies, in particular sand and soil particles, can cause considerable reaction in wounds and remain in tissues indefinitely. The introduction of foreign material as a contaminant in wounds and intracavitary injuries to military personnel deployed in the Persian Gulf region can be a complicating factor in treatment. Samples of desert sand from the military operational areas of the Persian Gulf were analyzed and the acute local and systemic responses of intraperitoneal contamination determined in an experimental rat model.

The hemostatic effect of deacetylated chitin membrane on peritoneal injury in rabbit model

In this study, we determined the effect of 80% deacetylated chitin (DAC-80) membrane on postsurgical bleeding after visceral and parietal peritoneal abrasion. Japanese white rabbits underwent a midline laparotomy followed either by a bilateral peritoneal sidewall abrasion (4 x 4 cm) or an abrasion of liver surface (3 x 2 cm). The injured surface was then covered with a 0.2 mm thick DAC-80 membrane. On postsurgical day 2, the rabbits were sacrificed and the amounts of postsurgical bleeding was determined by quantitating the number of red blood cells recovered in 50 ml peritoneal lavage fluid. The DAC-80 membrane was found to reduce postsurgical bleeding after the abrasion of liver surface (treated with DAC-80 membrane: 2.9 +/- 0.8; control: 24.6 +/- 5.9 x 10(8) cells/peritoneal cavity, P less than 0.005). This same hemostatic activity was not observed after application in the peritoneal sidewall abrasion model. We also measured plasminogen activator activity (PA) and urokinase inhibitory (PAI) activity in the spent culture media of macrophages recovered from the postsurgical peritoneal exudate. The DAC-80 membrane reduced the PA secretion from postsurgical macrophages after liver surface abrasion (treated with DAC-80: 2.8 +/- 0.7; control: 3.9 +/- 0.9 mPU/ml). The DAC-80 membrane also showed similar effects on PA secretion after peritoneal sidewall abrasion. No significant effects were found in the secretion of PAI by postsurgical macrophages in both surgical models. These findings suggest that the DAC-80 membrane may have hemostatic activity through the modulation of fibrinolytic activity of peritoneal exudative macrophages.

Iatrogenic peritoneopericardial hernia following coronary artery bypass surgery

Intrapericardial diaphragmatic herniation of the stomach is reported in a patient who had undergone coronary artery bypass surgery 6 years earlier. The peritoneopericardial defect was iatrogenic and emphasizes the danger of inadvertent diaphragmatic injury during cardiac surgery.

Management of transperitoneal gunshot wounds of the spine

To evaluate the results of a conservative approach to gunshot wounds of the spine with a transperitoneal trajectory, we analyzed our 4-year experience with 21 patients. The management protocol consisted of standard treatment of the intra-abdominal injuries, vigorous irrigation of the missile track, and a 48-hour course of antibiotic therapy. The lumbar spine was involved in 14 patients (67%) and the thoracic spine was injured in seven (33%). Eleven patients (52%) were paraplegic on admission and ten patients (48%) had a fixed partial neurologic deficit. One patient with an ISS of 75 died intraoperatively from exsanguination (mortality, 5%). Early morbidity correlated with ISS greater than 40 and spinal AIS greater than 3. Late nonneurologic morbidity was independent of ISS and spinal AIS. One patient required reoperation for a retroperitoneal abscess secondary to a leak from a repaired ureter. Another patient had a retroperitoneal collection on a CT scan which resolved spontaneously. There were no spinal or paraspinal infectious complications in the presence (five cases) or absence of a colonic injury. No change in neurologic status was observed in any patient during a mean follow-up period of 3 months. This preliminary experience suggests that a conservative approach consisting of irrigation of the missile track and short-term antibiotic therapy without laminectomy or removal of fragments from the spinal canal yields optimal results without increasing infectious complications of the spine.

Life-threatening fluid extravasation of central venous catheters

The majority of life-threatening injuries secondary to the placement of central venous catheters, such as bleeding and pneumothorax, occur at the time of initial insertion. When a catheter extravasates in the neck, edema of the neck wall or chest is usually seen, and the pump indicates occlusion. We present four cases in which an uneventful, successful placement of four central lines (three superior vena cava, one inferior vena cava) were followed at greater than 48 hours by either hydrothorax or hydroperitoneum, which resulted in either cardiorespiratory collapse or intraabdominal sepsis. In reviewing these cases, all showed both a change in catheter location on a subsequent x-ray and poor or no blood return on aspiration; paradoxically, the infusion pump in each case did not sense a catheter malposition or occlusion. We conclude that, although the success of central line placement may be documented on insertion, a continual reappraisal of both the function and location of the line is necessary.

Prediction of injury caused by penetrating wounds to the abdomen, flank, and back

Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. Of 236 patients sustaining stab wounds (140 abdominal wounds, 51 flank wounds, 26 back wounds, and 19 wounds to multiple sites), 147 were treated according to a selective protocol, based on results of physical examination, wound exploration, peritoneal lavage, and ancillary diagnostic studies. No injuries were found at celiotomy in three (2%) of these 147 patients. One false-negative result of evaluation of a flank wound occurred. Significant injuries were found in 13 patients (68%) with stab wounds to multiple sites, 61 patients (44%) with abdominal stab wounds, 15 patients (29%) with flank stab wounds, and four patients (15%) with back stab wounds. Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.

Local and systemic effects of repeated intraperitoneal epirubicin treatment

The local toxicity, general morbidity and mortality of repeated intraperitoneal administration of epirubicin (0.5 mg/kg in 100 ml isotonic saline) was investigated using a rat model. This dose is equivalent to that which would be used in the human. After six perfusions, the incidence of peritoneal inflammation was similar in the epirubicin group and saline controls. The vesicant properties of the drug were reflected in a significantly higher incidence of peritoneal fibrosis (P = 0.0015) but adhesions were more common in the controls (29%) than in the epirubicin perfused animals (4%). Animals from both groups showed inflammatory collections within the liver. There were no chronic hepatic lesions such as fibrosis/cirrhosis. This may be owing to portal bacteraemia caused by repeated cannulation of the peritoneal cavity. Evidence of microabscess formation in the hepatic parenchyma was observed in both animals. No histologically demonstrable toxicity was observed in the heart or gastrointestinal tract of the animals included in this study. The mortality of the epirubicin treated rats (2/146 perfusions) was similar to that of the saline controls (2/84 perfusions). These findings indicate that repeated intraperitoneal perfusion with epirubicin is not associated with significant toxicity. This anthracycline is therefore suitable for prolonged cyclical intraperitoneal chemotherapy.

Prevention of scald injury on the peritoneo-serosal surface in advanced gastric cancer patients treated with intraperitoneal hyperthermic perfusion

In attempts to avoid the side-effects derived from a scald on the peritoneo-serosal surface during intraperitoneal hyperthermic perfusion (IPHP) for advanced gastric cancer, a randomized study using cimetidine, a histamine H2-receptor antagonist, was carried out on 18 patients with advanced gastric cancer. Cimetidine, 50 mg/kg, was administered intravenously and immediately before IPHP. The background characteristics of the patients and the types of surgical treatment used were almost the same between each group of patients, whether or not cimetidine was given. The perfusion time in the cimetidine and control groups was 123 +/- 9 and 117 +/- 9 min, respectively. The inflow and outflow temperatures of the perfusate were 46.3 +/- 0.4 and 44.2 +/- 0.1 degrees C in the cimetidine group, respectively, whereas in the control group the temperatures were 46.0 +/- 0.3 and 44.1 +/- 0.2 degrees C, respectively. In the nine patients who were given cimetidine, the histamine concentrations in the peripheral blood increased significantly, compared to those in the nine controls; this resulted from the release of histamine into the circulating blood. Higher concentrations of protein were observed in the post-hyperthermic intraperitoneal exudate of the control group for 3-24 h after IPHP and, consequently, post-hyperthermic hypoproteinaemia was remarkable in the control group. These data suggest that when pre-IPHP cimetidine was prescribed for patients with gastric cancer treated with IPHP, the peritoneo-serosal surface was protected from scald injury and the side-effects of IPHP were reduced.

[A role of postsurgical macrophage activation by peritoneal injury]

At a site of peritoneal injury after abdominal surgery, macrophages are thought to be a principle type of inflammatory cells. Therefore, we determined the metabolic activities of postsurgical peritoneal exudate macrophages using standardized rabbit model. Rabbits underwent midline laparotomy followed by resection and reanastomosis of the ileum. At various days after surgery, peritoneal exudate macrophages were recovered from lavage fluid. Postsurgical Day-5 macrophages expressed significantly high potential to produce superoxide anion even without PMA stimulation compared to non-surgical control macrophages, although an activity of Day-10 macrophages was similar to control. The conditioned media from postsurgical Day-1 macrophage culture strongly inhibited urokinase type plasminogen activator (PA) and this plasminogen activator inhibitor (PAI) activities decreased following the extension of postsurgical time. Conversely, PA activities of macrophage-conditioned media decreased by day 1 and then gradually increased reaching control levels by day 10. Elastase activities of macrophage-conditioned media gradually decreased until postsurgical day 10. These data suggest that surgical injury activates postsurgical exudate macrophages. However, a time course of metabolic activities of these cells was dependent upon each secretory products. This differential secretion might express the stage of activation and differentiation of postsurgical macrophages. Moreover, postsurgical activated macrophages may control the tissue repair through a digestion of injured matrix and fibrinolytic process.

[Perforation of an automatic implantable cardioverter-defibrillator into the peritoneal cavity]

The automatic, implantable cardioverter-defibrillator is a new therapy for life-threatening ventricular tachyarrhythmias that are resistant to other therapy. Only a few complications, such as infections, lead defects, and interactions with pacemakers have been reported. We report on a patient whose AICD-generator perforated into the peritoneal cavity.

The impact of peritoneal trauma on intra-abdominal fibrinolytic activity, adhesion formation and early embryonic development in a rabbit longitudinal model

Intra-abdominal adhesions may interfere with fertility following gynaecological surgery and injury to the peritoneum plays a central role in the pathogenesis. Tissue plasminogen activator and its antagonists play a pivotal role in the intra-abdominal balance between fibrinolysis and adhesion formation. This process may be cycle-dependent in women. In order to establish the impact of the fibrinolytic activity on adhesion formation after a standardized trauma, a rabbit longitudinal model was developed, which allowed the study of possible differences between the periods before and after ovulation. The influence of extra-genital adhesions on early embryonic development was investigated. No cycle-dependent changes in fibrinolytic activity of the peritoneal fluid (PF) or of the serum could be demonstrated. No correlation was found between post-operative adhesion formation and the fibrinolytic activity during surgery. Three weeks after surgery, a significant increase in fibrinolytic activity of the PF was observed. The rank order of sampling is suggested to account for these differences. Extra-genital adhesions did not markedly influence ovulation, ovum pick-up and fertilization in this hormonally controlled rabbit model.

Adhesion formation associated with the use of absorbable staples in comparison to other types of peritoneal injury

Adhesion formation was assessed after inducing peritoneal injury with absorbable staples, absorbable suture, surgical excision or thermal injury. In addition, adhesion formation was assessed in the presence of Hyskon. Absorbable staples were associated with increased adhesion formation when compared to the other methods of injury. Hyskon appears to significantly reduce the formation of peritoneal adhesions at sites of peritoneal suturing, excision, and thermal injury, but did not reduce adhesion formation in the area of stapling.

Selective management of anterior abdominal stab wounds

A policy of selective management of anterior abdominal stab wounds was evaluated in 333 consecutive patients. Laparotomy was performed based upon initial clinical assessment in 165 patients. There were six deaths (3.6%), major complications in 23 patients (14%), and 28 negative laparotomies (17%). Eighteen patients developed indications for laparotomy after 10.7 +/- 2.2 hours of observation. There were no deaths, major complications in two patients (11%), and four negative laparotomies (22%). One hundred fifty patients were observed and discharged after 1.8 +/- 0.1 days. Sensitivity, specificity, and positive and negative predictive values for initial clinical evaluation were 91%, 85%, 92%, and 83%, respectively. Length of hospitalization in the initially operated and in the delayed group was 9.5 +/- 0.6 and 10.6 +/- 2.6 days (NS), respectively. Most serious intra-abdominal injuries will declare themselves on initial clinical assessment. The remainder are less severe injuries and these patients can be safely observed without undue sequelae due to delay. The use of clinical assessment alone to prompt laparotomy is also cost effective based on analysis of hospital days for initial illness. No procedures are necessary to define penetration.