Cecal volvulus causing postoperative intestinal obstruction: report of a case.

Cecal volvulus is a rare cause of intestinal obstruction after major abdominal surgery. A case of cecal volvulus occurring in the early postoperative period after left colon resection for malignancy is presented. Clinical evaluation and plain abdominal radiographs suggesting cecal volvulus prompted laparotomy and correction. Delay in diagnosis results in high mortality, and treatment depends largely on the viability of the involved intestine. This report describes the second case of cecal volvulus complicating a left colectomy. It was treated by detorsion and reperitonealization cecopexy.

Institution and per-surgeon volume versus survival outcome in Pennsylvania's trauma centers.

BACKGROUND: The American College of Surgeons recommends minimum patient volumes for trauma centers and surgeons. Those numbers, however, are largely based on results from studies of surgical (but not trauma) relationships between volume and outcome. METHODS: Using stepwise regression, relationships were sought between measures of patient volume per trauma center and per surgeon and ana severity-controlled measure of survival outcome (W). For significant z values, W is the number of additional (or fewer) survivors, per 100 patients treated, than expected from ASCOT norms. W = 0 when z is nonsignificant. Data are from patients admitted in 1988 and 1989 to accredited Pennsylvania trauma centers. RESULTS: The relationships found for all patients and for adult blunt-injured patients are W = 0.3312 + 0.0200 (NSER/SURG) and W = 0.3638 + 0.0248 (NBSER/SURG), respectively, where NSER/SURG is the number of seriously, injured patients treated annually per surgeon and NBSER/SURG is the number of adult patients with serious blunt injuries treated annually per surgeon. Serious injury was defined, using the Injury Severity Scale, as > = 13 or, using the Abbreviated Injury Scale, as a head injury of > = 3. The relationships explained 36% and 61% of the variance in W (R2 for all patients and adult blunt-injured patients, respectively. To achieve normative survival (W =0), 95% confidence intervals suggest that a trauma surgeon should treat at least 35 seriously injured patients per year and at least 28 adult patients with serious blunt injury annually. No volume-related variable was a significant contributor to predictions of W for adult patients with penetrating injuries or for pediatric patients. CONCLUSIONS: These results support the regionalization of trauma care by affirming that increased per-surgeon experience in the treatment of seriously injured patients is associated with improved outcomes and help define the minimum experience needed to achieve normative survival. Prospective study of the relationship between volume and survival and other outcomes is required.

American College of Surgeons audit filters: associations with patient outcome and resource utilization.

OBJECTIVE: To determine if trauma patients qualifying by a 1990 American College of Surgeons (ACS) audit filter have the same outcomes and resource utilizations as similar (matching) patients not qualifying by the filter. DESIGN: Retrospective, case control study. MATERIALS AND METHODS: Data for 21,175 patients submitted during 1992 to the Pennsylvania Trauma Outcome Study (PTOS) were analyzed. Patients qualifying by each 1990 ACS audit filter were identified, except filters 13 and 22 that were not accommodated by the PTOS form. In addition, qualifiers by filter 21 (trauma deaths) were not analyzed. For each qualifier by a filter, matching patients who were not qualifiers by the filter were identified. Matching patients had the same cause of injury, A Severity Characterization of Trauma (ASCOT) age category, distribution of serious (Abbreviated Injury Score of > 2) injuries, intubation status, and coded Revised Trauma Score values on Emergency Department arrival. Qualifiers and matching patients were compared for their survival (z and W statistics), discharge disability (PTOS-Functional Independence Measure), and lengths of stay in the hospital (H-LOS) and in the Intensive Care Unit (ICU-LOS). MEASUREMENTS AND MAIN RESULTS: More than 57% of the study sample qualified by one or more filters. Filters 10 and 12 did not have sufficient qualifiers for evaluation. No filter's qualifiers were associated with significantly more disability at discharge than matching patients. The most frequently occurring filters (4, 2, and 5, respec-tively) deal with documentation deficiencies, but were not associated with significant results. Qualifiers by the nine filters below were associated with significantly greater mortality or H-LOS or ICU-LOS. [table: see text] CONCLUSIONS: Additional studies of the efficacy and efficiency of trauma quality assurance filters are needed. Objective criteria should be established for the definition, evaluation, modification, and adoption of trauma audit filters.

Acute diverticulitis under age forty.

Acute diverticulitis in the young is increasingly common and is not confined to a particular ethnic or socioeconomic group. The majority of cases are in men and occur in the fourth decade of life. Obesity is the major comorbid condition. The disease appears to be an early manifestation of that seen in the elderly based on identical anatomy and histology. The high incidence of surgical intervention and the high incidence of emergent or urgent intervention, particularly following the initial attack, suggests that this manifestation is a more virulent form of the disease. Because of this, any patient under age 40 should undergo resection following the first documented attack of acute diverticulitis.

Comparison of rapid versus slow tissue expansion on skin-flap viability.

The effect of rapid versus slow tissue expansion on random-pattern skin-flap survival lengths was evaluated in two groups of pigs. Each group (group 1--slow; group 2--rapid) was further evaluated for the effect that delay (A), delay plus expansion (B), expansion only (C), and acute flap elevation (D) had on flap length viability. Intergroup and intragroup comparisons were made. In the slowly expanded group, significantly greater flap length viabilities were demonstrated in the slow expansion flaps as compared with the delay plus expander flaps and the delayed flaps, respectively. In the rapidly expanded group, the flap length viabilities of flaps C, B, and A were statistically equal. However, the flap length viability of the rapidly expanded flaps was statistically equal to that of the slowly expanded flaps (C1 = C2). The effect tissue expansion has on improving flap length viability as compared with the delay phenomenon may be related to the combination of a delay effect plus increased nutrient flow density that slow expansion produces. This combined metabolic enhancement is preserved with rapid tissue expansion.

High-grade immature teratoma of the testis in infancy.

Teratomas of the testis in infants are rare tumors which often display immature elements, disturbing in their histologic appearance. Although the presence of similar histologic features worsens prognosis in testicular teratomas in adults and in teratomas of infants and children presenting at other anatomic sites, the presence of immature elements in testicular teratomas of infancy does not appear to affect prognosis. Therefore, orchiectomy alone is adequate therapy for these neoplasms. The case of an 8-month-old infant with a teratoma of testis is presented.

Should survivors with an injury severity score less than 10 be entered in a statewide trauma registry?

The necessity of including survivors with minor (ISS less than 10) injuries in a statewide trauma registry with a quality assurance focus was evaluated. During a 3-month period, data for 3,594 admissions to 28 trauma centers were entered into the registry. Of these admissions 1,696 patients (50.8% of patients studied) had an ISS less than 10. Of those, 10 (0.6%) were nonsurvivors and 67 (3.9%) had severe disability (66) or were in a persistent vegetative state (PVS) (1) at hospital discharge. Five nonsurvivors were 65 years of age or older. Four were injured in falls and one was an injured pedestrian. The disabled subset included a high percentage of older patients (61.2% greater than or equal to 55). Minor falls, including those from a bed or chair or from the same level accounted for nearly one half (46.2%) of the disabling injuries. Fifty-one disabled patients had isolated extremity or pelvic fractures. Their hospital stays ranged from 1 to 42 days and averaged 13.0 days. The proportion of elderly in the United States is increasing substantially. Because of the significant risk of death or serious disability to elderly patients, even with minor injuries, we conclude it is appropriate to include data for elderly patients with an ISS less than 10 who meet other registry inclusion criteria. We also recommend the entry of data for patients with an ISS less than 10 and significant disability at discharge who qualify by other criteria. Exclusion of remaining patients with an ISS less than 10 would reduce qualifying cases by 38%.

Measured energy expenditure in severe head trauma.

Metabolic profiles of 20 patients admitted to the Conemaugh Valley Memorial Hospital Trauma Unit from July 1987 through June 1988 with Glasgow Coma Scale Scores of 7 or less were retrospectively reviewed. Analysis of Injury Severity Scale (ISS) determinations indicated that all patients had major closed head injury, and associated injuries were minor in nature. No significant co-morbid disease states were present in this patient population. All patients required mechanical ventilatory support, and within 48 hours of admission measurements of oxygen consumption (VO2), carbon dioxide production (VCO2) and respiratory quotient (VCO2/VO2) were made using a Beckman Metabolic Measurement Cart which employs indirect closed calorimetry to assess resting energy expenditure (REE). When predicted values of REE and VO2 (derived from the Harris-Benedict equation) were compared to actual measured data, the percentage increase over predicted was 160 +/- 37 (p less than 0.005) and 166 +/- 43 (p less than 0.005), respectively. Based on these observations it is evident that patients with severe head trauma are physiologically in an early hypermetabolic state, and that values of REE derived from standard formula are grossly inaccurate, leading to inadequate nutritional support.

Splenic rupture and infectious mononucleosis.

Infectious mononucleosis is an acute viral illness associated with a high incidence of splenomegaly, although the incidence of splenic rupture is low. When rupture occurs, the mortality has been significant, presumably, because a history of trauma is not present. The spleen may be vulnerable to injury due to the histopathologic changes that occur as a result of this illness. Essentially all patients with spontaneous rupture related to infectious mononucleosis have epigastric or upper abdominal pain. The diagnosis of splenic rupture may be confirmed in a variety of ways. In those patients who are hemodynamically stable, CT scan, ultrasound, or radionuclide scan may aid in establishing the diagnosis. Selective splenic angiography is very accurate but has been largely abandoned because of the invasive nature of the study. Peritoneal lavage is efficacious in establishing the diagnosis in hemodynamically unstable patients. The treatment of choice, at this time, is splenectomy. Current interest in splenic salvage has resulted in reports of nonoperative therapy in stable patients and splenorrhaphy in one instance. Due to the extent of the histologic changes in the spleen, caution is urged in electing the conservative approach to this clinical situation.

Milk curd syndrome in neonates.

Intestinal obstruction caused by the inspissation of formula feedings should be considered in any infant presenting with distal small bowel obstruction. There are typical radiographic changes that suggest the diagnosis. Relief of the obstruction is often possible without surgery.

Torsion of undescended testis.

Torsion of an undescended testis is uncommon. When encountered, this entity represents a surgical emergency and must be dealt with immediately. A report of 2 cases, one in a five-month-old child and the other in a twelve-year-old mentally retarded child, is made and the pertinent literature is reviewed.

Pyloric atresia.

A case of pyloric atresia was treated successfully with side-to-side gastroduodenostomy. The mortality in treated cases is high, due to delay in diagnosis and inadequate relief of the obstruction. Side-to-side gastroduodenostomy or excision of the atresia with pyloroplasty offer the greatest opportunity for a successful outcome, as indicated by a review of the world literature.