Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies.

A perceived high rate of complicated (gangrenous or perforated) appendicitis, despite advances in laboratory and radiographic diagnostic modalities, prompted a review of our experience with appendicitis followed by a prospective analysis that examined the time course from presentation to definitive treatment in 218 consecutive patients. In 5755 appendectomies, our overall rate of complicated appendicitis was 32 per cent; higher in males, in the young, and in the elderly; and relatively stable over each year reviewed. Prospectively, we determined that of the various time intervals, the time from the onset of symptoms to first seeking medical attention is the only significant predictor of complicated appendicitis (39.8 vs 16.5 hours for acute appendicitis). On the other hand, the time from surgical evaluation to operative intervention was significantly shorter for complicated appendicitis (3.8 vs 4.7 hours for acute appendicitis). The high rate of complicated appendicitis with its subsequent sequelae of increased morbidity and resource expenditure is primarily the direct result of patient delay in seeking medical attention and not the result of diagnostic dilemma or surgical delay. Public education, specifically targeting those groups at risk, may provide a substantial and significant solution to the complicated appendix.

Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages.

BACKGROUND: Selective nonoperative management (NOM) of blunt splenic injuries is becoming a more prevalent practice. Inclusion criteria for NOM, which have been a source of controversy, continue to evolve. Age > or = 55 years has been proposed as a predictor for failure of and even a contraindication to NOM of blunt splenic trauma. Additionally, the high rate of NOM in children (up to 79%) has been attributed to their management by pediatric surgeons. We evaluated our experience with NOM of blunt splenic injury with special attention to these age groups. METHODS: By using our trauma registry, all patients with blunt splenic injuries (documented by computed tomography, operative findings, or both) cared for over a 36-month period, at a single American College of Surgeons verified Level I trauma center were reviewed. Detailed chart reviews were performed to examine admission demographics, laboratory data, radiologic findings, outcome measures, and patient management strategy. All patients were managed by nonpediatric trauma surgeons. We then compared our adult data with that in the recent literature and our pediatric data with that of the National Pediatric Trauma Registry over the same time period. RESULTS: We identified 251 consecutive patients with blunt splenic injuries. Eighteen patients who expired in the immediate postinjury period were excluded from statistical evaluation. No deaths occurred as a result of splenic injury. Of the remaining 233 patients, 73 patients (31%) required early celiotomy, 160 patients (69%) were selected for NOM, with 151 patients (94%) being successfully managed without operation. Blunt splenic injury occurred in 23 patients age 55 years or older. Eighteen patients (78%) were selected for NOM and 17 patients (94%) were successfully treated without operation. Blunt splenic injury occurred in 35 patients less than 16 years of age. Thirty-two patients (91%) were selected for NOM. Thirty-one patients (89% of all pediatric patients) were successfully treated without operation. CONCLUSION: Age > or = 55 years is not a contraindication to nonoperative management of blunt splenic injuries. Children with blunt splenic injuries can be successfully managed nonoperatively by nonpediatric trauma surgeons.

Is exploratory celiotomy necessary for all patients with truncal stab wounds?

Mandatory exploratory celiotomy was carried out in 1241 consecutive patients with truncal stab wounds. Four hundred seventy-one (38%) patients who had no intra-abdominal injury identified at operation developed 16 complications (3%), with one patient (0.2%) dying postoperatively. The average length of hospitalization (5 days) was increased if the patient: (1) required a simultaneous operation for associated site injuries (9 days), (2) developed postoperative complications (16 days), or (3) required reoperation (27 days). The 1990 projected cost per patient for routine celiotomy has increased 92% over that seen 10 years ago. Selective management protocols using observation, repeated physical examination, and special diagnostic procedures could be instituted for asymptomatic hemodynamically stable patients with truncal stab wounds if appropriate facilities and personnel are available. Successful implementation should preserve medical resources for those patients with trauma requiring a life-saving operation.

Angioplasty and stenting of completely occluded iliac arteries.

Percutaneous angioplasty and placement of balloon-expandable intraluminal stents were performed in 12 iliac occlusions in 12 patients. Indications were limb salvage in seven and claudication in five. After successful stenting, ankle-brachial indexes improved by 0.15 or more in 11 of 12 patients (mean increase, 0.40), transstenotic pressure gradients decreased to less than 5 mm Hg (mean, 0.58 mm Hg) in all patients, and improvement in clinical grade was seen in all patients. At follow-up at 1-14 months (median, 6 months), ankle-brachial indexes were stable (mean, 0.95), and clinical grades were unchanged in all patients. Complications occurred in two patients; both experienced distal embolization, and one, who was receiving corticosteroid therapy, also suffered stent thrombosis. Local surgical embolectomy was successful in both patients, and the thrombosed stent was recanalized with urokinase. This early experience suggests that stenting may play an important role in the management of iliac occlusions, especially in poor surgical candidates.

Cranial nerve injuries after carotid artery endarterectomy.

We present a seven-year experience with cranial nerve injuries due to carotid artery endarterectomy. A total of 433 carotid endarterectomies were done on 355 patients by senior surgical residents, with a staff surgeon assisting. Thirteen cranial nerve injuries were identified, five of which were permanent. Knowledge of the anatomic features of the cranial nerves and their branches in the operative field, as well as technical maneuvers during surgery, can reduce such injuries to a minimum.

Management of penetrating and blunt diaphragmatic injury.

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.

The continuing challenge of popliteal vascular injuries.

During a 6 year period, 35 patients with 56 popliteal vascular injuries were treated. Thirty-three arteries and 23 popliteal veins were affected. Fifty-four percent of the patients had both an arterial and a venous injury. Twenty injuries were due to penetrating trauma and 15 injuries to blunt force. An overall amputation rate of 16 percent followed attempts at vascular repair. Blunt injuries were associated with a 30 percent amputation rate, whereas penetrating injuries were associated with only a 5 percent amputation rate. When our results were reviewed and compared with those of others, several factors important for determining the rate of limb salvage in popliteal vascular injuries were noted: (1) early recognition and prompt treatment, (2) absence of blunt injury with attendant soft tissue damage; (3) resection of damaged arterial tissue with end-to-end anastomosis or saphenous vein grafting in conjunction with the liberal employment of local heparin and a Fogarty catheter thrombectomy, (4) repair of concomitant popliteal venous injuries; (5) use of completion arteriography to reveal technical errors amenable to correction at time of operation; and (6) fasciotomy, used liberally but selectively.

Truncal vascular injury--factors influencing survival.

During the 10-year period ending June 1982, 219 patients were treated for 269 injuries to the major vessels of the abdominal and thoracic cavities, with 28% morbidity and 32% mortality. One hundred eighty patients (82%) had 377 associated injuries consisting primarily of damage to the small intestine (79), liver (45), and large intestine (34). Factors associated with an increased mortality included: more than three associated injuries; two or more nonvascular complications; more than two vessels injured; admission to ER in shock; injury to abdominal aorta or inferior vena cava; and injury to the porta hepatis. The majority of deaths (73%) were due to acute blood loss and irreversible shock. Factors unrelated to acute blood loss and shock had minimal effects on survival.

Reassessment of the role of routine operative exploration in vascular trauma.

During the 5-year period ending December 1978, 390 patients were explored for suspected vascular injury either in the neck or in one of the extremities with 13% morbidity and a 1% mortality rate. Positive exploration for vascular injury in 139 patients (36%) resulted in 28% morbidity and 2% mortality. Negative exploration in 251 patients (64%) was associated with a 5% morbidity and 0.4% mortality. Per cent positive exploration by type of injury was: iatrogenic injury (100%), foreign body laceration (100%), blunt trauma (79%), stab wound (32%), and gunshot wound (31%). Per cent positive exploration by area was: brachium (68%), popliteal area (63%), femoral area (28%), axilla (27%), and neck (25%). Routine exploration of patients at risk for vascular injury can be accomplished with minimal morbidity and mortality but is associated with a low (36%) diagnostic yield. 'Exclusion' arteriography in hemodynamically stable patients with equivocal signs of vascular injury appears to be indicated to increase diagnostic accuracy.

Morbidity and mortality of carotid endarterectomy: rates of occurrence in asymptomatic and symptomatic patients.

During a six-year period ending December 1979, a retrospective study of 252 carotid endarterectomies in 211 patients was undertaken to review morbidity and mortality, and factors related to them. For purposes of the study, patients were categorized into asymptomatic and symptomatic groups. Indications for operation were internal carotid artery stenosis that occluded 50% or more of the vessel, an ulcerated plaque proved by angiography, or both. There were no postoperative deaths or neurological complications in the asymptomatic group. In the symptomatic group, there was an overall postoperative mortality of 2% and a stroke rate of 2%. All postoperative CNS deaths and strokes occurred in patients in whom there was difficulty in controlling blood pressure postoperatively. We conclude that with regard to carotid endarterectomy for treatment of extracranial occlusive disease (1) there is an acceptable morbidity and mortality in the symptomatic patient, (2) in the asymptomatic patient the procedure is associated with minimal complications, and (3) strict control of blood pressure in the immediate postoperative period is a critical factor in preventing neurological morbidity and mortality.

Diagnosis and management of major tracheobronchial injuries.

From 1968 to 1978, 14 patients were treated for major tracheal or bronchial injury. Five injuries resulted from blunt trauma and nine from penetrating injury. Of the 5 patients with injury due to blunt trauma, three had avulsions of the right main bronchus from the trachea. In 2 of them, the injury was associated with stellate tears of the distal trachea and bronchus. The simple avulsion was repaired by a primary anastomosis of the right main bronchus to the distal trachea. For the other 2 patients, treatment consisted of right pneumonectomy. The remaining 2 patients in this group had complete transection of the trachea and underwent primary repair. Of the 9 patients with a penetrating injury, 4 had lacerations of the cervical trachea which were treated with neck exploration and tracheostomy. Three patients with partial transections of the cervical or upper mediastinal trachea were treated by primary closure. The other 2 patients had gunshot wounds to the distal right lateral trachea, which were treated by right thoracotomy and primary closure. There were no deaths, and the subsequent course was generally good in all patients.

Upper extremity wringer injury.

A clinical survey of 92 upper extremity wringer injuries over the past four years at the Bexar County Hospital are presented. Our treatment regimen and results are outlined. Complex injuries occurred infrequently (7%). No vascular insufficiency developed and no fasciotomies were required. We are of the opinion that hospitalization is necessary in all but a small number of selected cases. Close observation is necessary to prevent edema progression and further tissue loss. Ninety-two upper extremity compression injuries secondary to washing machine wringers were reviewed. Seventy-six percent of the injuries occurred in persons under 10 years of age. Extremity distribution was equal. Injury occurred below the elbow in 72% of the extremities. Soft tissue injury was manifested by swelling and tenderness in 96%. Twenty-one percent had no violation of the skin. Major avulsion, such as third degree skin loss, crush injury, dislocation, and tendon avulsion, occurred in 8%. The treatment regimen consisted of surgical preparation with Betadine, compressing dressing, and elevation. Observation of the involved extremity is made every hour for development of vascular insufficiency. Fractures and other major injuries were treated as indicated. No fasciotomy was required. No vascular insufficiency developed. SKin slough was present in 16 of 92 extremities and skin graft was required in 5 of the 16. Results of treatment reveal 87% with no functional impairment of the involved extremity. Varying degrees of impairment are present in 6% of the injured extremities with all localized to the major avulsion group of injuries.

Traumatic injuries of the duodenum: a comparison of 1 degrees closure and the jejunal patch.

Twenty-two traumatic injuries of the duodenum were reviewed. In this series either primary closure, or primary closure plus the jejunal serosal patch prove satisfactory methods of repair. The addition of the jejunal serosal patch may be more secure but its superiority could not be documented in this small series. The mortality was related to the associated organ injuries. When blunt or penetrating injuries to the duodenum alone occur, there should be minimal mortality.