Mortality Prediction Model before Surgery for Acute Mesenteric Infarction: A Population-Based Study.

Surgery for acute mesenteric infarction (AMI) is associated with high mortality. This study aimed to generate a mortality prediction model to predict the 30-day mortality of surgery for AMI. We included patients ≥18 years who received bowel resection in treating AMI and randomly divided into the derivation and validation groups. After multivariable analysis, the 'Surgery for acute mesenteric infarction mortality score' (SAMIMS) system was generated and was including age >62-year-old (3 points), hemodialysis (2 points), congestive heart failure (1 point), peptic ulcer disease (1 point), diabetes (1 point), cerebrovascular disease (1 point), and severe liver disease (4 points). The 30-day-mortality rates in the derivation group were 4.4%, 13.4%, 24.5%, and 32.5% among very low (0 point), low (1−3 point(s)), intermediate (4−6 points), and high (7−13 points)-risk patients. Compared to the very-low-risk group, the low-risk (OR = 3.332), intermediate-risk (OR = 7.004), and high-risk groups (OR = 10.410, p < 0.001) exhibited higher odds of 30-day mortality. We identified similar results in the validation group. The areas under the ROC curve were 0.677 and 0.696 in the derivation and validation groups. Our prediction model, SAMIMS, allowed for the stratification of the patients' 30-day-mortality risk of surgery for acute mesenteric infarction.

Retromammary approach for endoscopic resection of benign breast lesions.

BACKGROUND: One of the merits of endoscopic surgery is that it can be performed through small remote incisions made in inconspicuous areas. To improve cosmetic outcomes of surgical treatment of benign breast lesions, we performed endoscopic surgery through minimally sized axillary incisions with the goal of achieving scar-free breasts. METHODS: From August 2007 to August 2008, 18 patients with 20 benign breast lesions underwent endoscopic breast excision in our institution. Endoscopic resection of benign breast lesions was performed via the retromammary route with video assistance. Cosmetic results were evaluated using the five-item, four-step ABNSW scoring system, assessing breast asymmetry, breast shape, nipple shape, skin condition, and wound scars. RESULTS: The median age of the patients was 27 years (IQR 23.0, 29.0). Median resected lesion size was 3.3 cm (IQR 2.9, 3.9). Median operative time was 85.0 min (IQR 70.0, 100.0). A marginally significant difference in operative times was noted between fibroadenoma and/or juvenile fibroadenoma cases and mastopathy or benign phyllodes cases (80.0 vs. 100.0; p < 0.06). Median total ABNSW score was 14 points. Postoperatively, 5 patients had mild local subcutaneous emphysema, and one had transient brachial palsy. No breast ecchymosis or deformity was noted. No major complications developed in any patient, and 89% of patients had good or excellent results. CONCLUSIONS: Video-assisted endoscopic breast surgery has changed routine breast surgery, manifesting cosmetic effects that cannot be achieved by previous routine surgical techniques. Patients with multiple or large benign tumors who desire excellent cosmetic results are good candidates for this approach.

Lesser-sac lavage for intraoperative detection of blunt pancreatic duct injury.

BACKGROUND/AIMS: Blunt pancreatic duct injury is difficult to differentiate, especially during surgery. In terms of demonstration of pancreatic duct injury, endoscopic retrograde pancreatography (ERP) is the gold standard imaging study, however, availability can be problematic. Therefore, we have designed a method utilizing lesser-sac lavage to differentiate pancreatic duct injury. METHODOLOGY: Patients sustaining blunt pancreatic trauma treated at our institution over a two-year period were retrospectively enrolled in this study. Based on computed tomography (CT), these patients were divided into two groups: deep laceration or complete transection (Group 1) and superficial laceration (Group 2). Additionally, ten patients sustaining blunt abdominal trauma who had undergone emergency laparotomy for other visceral organ injury (Group 3) and four undergoing pancreatoduodenectomy (Group 4) were selected as controls. For laparotomy in Groups 1-3, the lesser sac was opened for lavage, with 50 mL of 0.9% normal saline inserted, and 3mL of the sample fluid withdrawn at four time points (15, 30, 45 and 60 mins) with the fluid immediately replaced with 3 mL of saline. Lavage-ascites amylase (LAA) and lipase (LAL) levels were measured. Serum amylase and lipase activities were measured intraoperatively from 3mL of the patient's blood. RESULTS: Over the two-year study period, there were four pancreatic duct transections (Group 1), five partial pancreatic lacerations confirmed by post-ERP CT (Group 2), ten non-pancreatic traumas (Group 3), and four pancreatoduodenectomies due to pancreatic-head cancer (Group 4). The LAA and LAL for Group 1 were significantly higher than those for Group 2 or 3 at each of the four time points. The LAA and LAL ratios for Group 1 relative to Group 2 or 3 decreased gradually over time. These LAA ratios ranged from 7-13 for Group 1 to Group 2, 138-232 for Group 1 to Group 3, and 17-21 for Group 2 to Group 3. By contrast, the LAL ratio ranged from 3.0-3.4 comparing Group 1 to Group 2, 3180-29124 for Group 1 to Group 3, and 1058-8705 for Group 2 to Group 3. CONCLUSIONS: Using lesser-sac lavage for measurement of LAA and LA L constitutes a rapid, non-invasive and effective method for detection of pancreatic duct injury, especially transection of the main duct. LAA appears to be a better indicator for differentiation of minor (superficial laceration or side branch) or major (MPD) pancreatic injury at the first time point (15 minutes post lavage) compared to LAL. By contrast, LAL appears to be a better indicator with respect to differentiation of the injured pancreas from the normal organ at this time point.

Comparison of the clinical presentations of ingested foreign bodies requiring operative and nonoperative management.

Foreign body ingestion is commonly seen in emergency departments. Although most cases have a clear history, foreign bodies in the gastrointestinal tract can be an unexpected finding after operations for other conditions. This study compares the clinical presentations and outcomes for patients requiring or not requiring operations. Between January 1998 and December 2001, 80 patients with foreign body ingestion were included and divided into two groups. Specifically, group 1 patients were managed nonoperatively, and group 2 patients were managed operatively. The patient demographics, symptoms, foreign body ingestion mechanisms, type of diagnostic studies and management, and outcomes were compared between the two groups. Group 1 contained 44 patients, and group 2 contained 36 patients. Group 1 patients were significantly younger, but the incidence of underlying disease and the proportion of patients who ingested foreign bodies intentionally or incidentally was similar in groups 1 and 2. Most of the ingested foreign bodies in group 1 were in the esophagus and stomach, but for group 2 patients they were mostly in the small bowel. Moreover, most of group 1 patients were asymptomatic, which was not the case in group 2. Most group 2 patients had no known history of foreign body ingestion, and diagnoses generally were established during surgery. Neither group of patients displayed any mortality. Nonoperative management of foreign body ingestion usually can succeed in asymptomatic patients with a clear history; however, ingested foreign bodies can cause serious problems for those patients without a clear history of foreign body ingestion.

Liver abscess after non-operative management of blunt liver injury.

BACKGROUND: The non-operative management of blunt liver trauma can be applied in almost 80% of patients with this type of injury, with the advantages of the need for fewer blood transfusions, less intra-abdominal sepsis, and a better survival rate, than with the operative approach. However, liver abscess, as a known complication of the non-operative management of blunt liver trauma, is discussed infrequently. Therefore, we herein review our experience and describe this complication in detail. MATERIALS AND METHODS: From 1995 to 2001, 674 patients were admitted to our hospital due to blunt hepatic trauma. Among these patients, 279 underwent laparotomy and the remaining 395 patients were treated non-operatively. Twenty-two patients were identified as having liver abscess, with 16 of them belonging to the operative group, and six to the non-operative group. A retrospective review of these six patients and their characteristics, as well as pathogenesis, diagnosis, and the management of the liver abscesses, was conducted. RESULTS: These six patients were all male, with a median age of 19.5 years (range 3-24). The median injury severity score was 16.5 (range 9-25); three patients sustained grade-3 hepatic injury, and the other three were grade 4. The main diagnostic tool was abdominal computed tomography, and the abscesses took a median of 6 days (range 1-12) to form and be diagnosed. The abscesses were usually caused by infection from mixed organisms, and an abscess resulting from Clostridium infection developed within 1 day after injury. These abscesses were treated with antibiotics and drainage, and the median length of hospital stay was 26 days (range 8-44), without mortality or long-term morbidity. CONCLUSION: Liver abscess as a complication of the non-operative management of blunt hepatic trauma is a rare entity, with an incidence of 1.5% (6/395). It is usually seen in severe liver injury (grade 3 and above), but all our patients were all treated successfully, with no mortality. However, prolonged hospitalization may be required in this patient group.

Diagnosis and management of bladder injury by trauma surgeons.

BACKGROUND: Bladder injuries constitute one of the most common urological injuries involving the lower urinary tract. The methods of diagnosis and management of bladder trauma have been well established and accepted. However, bladder injuries are usually associated with other major injuries, and it is our concern here how bladder injuries have been managed as part of multiple trauma. METHODS: From 1991 to 2000, a total of 51 cases of bladder injury were retrospectively reviewed. The mechanisms of trauma, types of bladder injury, time needed to diagnosis, methods of treatment, and patient outcome, were analyzed. Diagnosis time was defined as the time interval from patient arrival to the establishment of a diagnosis either by image studies or laparotomy. Management followed the general rule that bladder contusions or extraperitoneal ruptures were treated non-operatively, and that those with intraperitoneal rupture or combined rupture underwent operative repair. If bladder injury was noted after the patient left the emergency room (ER), it was defined as a delay diagnosis. The Injury Severity Score (ISS), length of hospital stay, and morbidity were used to evaluate patient outcome. RESULTS: The mean age of all the patients was 31.4 years old, and most of them had sustained an injury from a motor vehicle accident (40 of 51). All but 3 patients had gross hematuria. Ten of the patients underwent emergency laparotomy, and 2 of them underwent emergency neurosurgical procedures, therefore no image studies were performed for these 12 patients. A total of 33 patients underwent abdominal computed tomography (CT), but only 20 were correctly diagnosed, yielding an accuracy rate of 60.6%. There were 3 delay diagnoses, due to either a lack of gross hematuria on presentation or the patient leaving the ER before any bladder injury study could be performed. A retrograde cystogram was performed in 24 patients, with an accuracy rate of 95.9% (23 of 24). The mean diagnosis time of the 48 bladder injuries presented in the ER was 3.2 hours and the time needed to reach a diagnosis was not related to the severity of bladder injury. Those patients who underwent operation immediately did not seem to have a quicker diagnosis. Those patients with a higher injury score (ISS >16), and those patients who suffered from pelvic fracture, stayed in the hospital longer. However, the severity of the bladder injury was not related to the length of hospital stay. There was no bladder-related mortality in our series. CONCLUSIONS: We report our results of dealing with bladder injuries from the point of view of trauma surgeons who treat bladder injury as part of multiple injuries. Although known as a procedure of choice for diagnosis of bladder injury, the retrograde cystogram was performed in fewer than half of the patients (24 of 51), which means it is not feasible in many situations. The patient outcome was determined by the severity of injury of the patient but not by the severity of bladder injury.

Activation of muscarinic M1 receptors by acetylcholine to increase glucose uptake into cultured C2C12 cells.

Regulation of glucose metabolism by cholinergic nervous activation has been demonstrated. In an attempt to evaluate the role of cholinergic receptor subtype in this regulation of glucose metabolism, we employed cultured myoblast C2C12 cells to investigate the glucose uptake in the present study. Acetylcholine (ACh) enhanced the uptake of radioactive glucose into C2C12 cells at the concentration range of 0.001 to 1.0 micromol/l. This effect was suppressed by the muscarinic antagonist atropine. Effect of ACh on muscarinic receptors was further supported by the blockade of scopolamine, another classical antagonist. Thus, activation of muscarinic receptors to enhance the radioactive glucose uptake into C2C12 cells can be considered. Moreover, pirenzepine, the antagonist of muscarinic M1 receptors, competitively antagonized the action of ACh in C2C12 cells. However, methoctramine at concentration sufficient to inhibit the muscarinic M2 receptors failed to produce similar effect. Similarly, 4-DAMP at effective concentration to block muscarinic M3 receptors lacked the influence. An activation of muscarinic M1 receptors seems responsible for the action of ACh in C2C12 cells. Pharmacological inhibition of phospholipase C by U73312 resulted in a concentration-dependent decrease in ACh-stimulated uptake of radioactive glucose into C2C12 cells. However, treatment with U73343, the inactive congener, failed to block the action of ACh. Moreover, both chelerythrine and GF 109203X diminished the action of ACh at concentrations sufficient to inhibit protein kinase C. Therefore, the obtained data suggest that increase of the glucose uptake evoked by ACh is mainly due to the activation of muscarinic M1 receptors in cultured myoblast C2C12 cells.