Transection of the first portion of jejunum from blast injury in accidental discharge of a (2.75-inch aircraft) rocket from an F-15.

Injury to the small intestine and its mesentery, while common with penetrating abdominal wounds, is relatively uncommon in patients who have received nonpenetrating abdominal trauma. Review of larger series indicates that small bowel injuries occur in only 5-10% of trauma patients. The focus of this paper is: 1) to present a case of transected jejunum and retroperitoneal hematoma incurred through a blast injury from accidental discharge of a 2.75-inch folding fin aircraft rocket from an F-15; and 2) to discuss pathogenesis, diagnosis, and treatment that apply specifically to injuries of the small intestine exclusive of the duodenum.

Late complications of traumatic arteriovenous fistula. Case report and overview.

Traumatic arteriovenous (AV) fistulas produce several profound pathophysiologic and structural changes in the circulatory dynamics of the vessels associated with the fistula. Most of the changes are reversible with surgery. However, in longstanding AV fistulas, irreversible degenerative changes occur in the arterial wall and result in dilatation and thrombosis. This can make late closure technically difficult. This report presents a case of peroneal AV fistula of 18 years duration. The diagnosis, management, and complications of long-standing AV fistulas are discussed.

Risk factors for survival following surgical treatment of traumatic aortic rupture.

Linear discriminate analysis was used to determine the effects of age and Injury Severity Score on survival in 37 consecutive patients treated surgically for traumatic rupture of the thoracic aorta. Pearson product moment correlations were calculated between associated injuries and survival. The age of the injured patients was the only variable that correlated statistically with survival: the lower the patient's age, the greater the chance of survival (r = 0.3535; p = 0.016). The severity of the injury, as represented by the Injury Severity Score, showed a tendency toward decreased survival with increasing Injury Severity Score (r = -0.2523; p = 0.066). Specific types of associated injuries did not correlate with survival. Survival rates were not statistically different for patients who underwent cardiopulmonary bypass compared with those in whom a temporary plastic shunt was used (chi-square = 1.72; p = 0.19). We conclude that age is the most significant factor in predicting survival in patients who undergo surgical repair of traumatic aortic rupture.

Harvesting the greater saphenous vein with a subcutaneous vein remover.

A subcutaneous vein remover has been developed to facilitate harvesting of the greater saphenous vein. The technique described is applicable only to the segment of saphenous vein above the knee. This technique was used in 19 selected patients without complication; however, intraoperative and postoperative precautions are necessary to prevent bleeding and injury to the vein.

Nasotracheal intubation and pulmonary parenchymal perforation. An unusual complication of naso-enteral feeding with small-diameter feeding tubes.

If not used cautiously, the rigid guide wire used with small-diameter feeding tubes can promote nasotracheal intubation in patients with diminished tracheobronchial sensation. Patients with endotracheal tubes are also at risk. To prevent pulmonary complications with small-diameter feeding tubes, the wire introducer should not be advanced beyond the nasopharynx, and x-ray verification of catheter location should be mandatory.

Pleuroperitoneal shunt for intractable pleural effusion.

Intractable pleural effusion secondary to malignant disease is often managed by thoracentesis or sclerotherapy, painful time-consuming procedures that may be ineffective. An alternative technique is to place a pleuroperitoneal shunt as in a 73-year-old man, described in this paper, who had recurrent right and left pleural effusions secondary to inoperable squamous cell carcinoma of the right lung. In his case, sclerotherapy was not attempted on the left side because a pericardial window was functioning. The left pleural effusion was successfully managed by inserting a pleuroperitoneal (LeVeen) shunt.

The management of subclavian artery injuries following blunt thoracic trauma.

The records of 15 patients who sustained blunt rupture of the subclavian artery were reviewed. The findings on physical examination included arterial hypotension, unilateral absence of the radial pulse, brachial plexus palsy, and supraclavicular hematoma. The chest roentgenographic findings included wide mediastinums, apical pleural hematomas, and first rib fractures. Fourteen patients survived to undergo angiography and operation. Arterial continuity was restored by primary anastomosis, synthetic grafts, and venous interposition grafts. Ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. Amputation of an upper extremity was required in 1 patient. Two patients died postoperatively. We conclude that blunt subclavian artery injuries may be suspected clinically. Absent upper extremity pulses, a wide mediastinum, unrelenting thoracic hemorrhage, and persistent hypotension dictate the necessity for aortography. Relative indications for angiography include brachial plexus palsy, apical pleural hematoma, and a fractured first rib.

Coronary bypass operation for early postinfarction angina.

A consecutive series of 38 patients who were hospitalized in the CCU for acute myocardial infarction and who had early postinfarction angina develop were operated upon on an emergency basis within two weeks after the initial infarction. The average time for the reapperance of angina was 1.7 days. Ten patients had reinfarction which occurred on an average of 3.2 days after the reappearance of the angina. Cardiogenic shock occurred in six patients between one to six days after the angina recurred. Three of these patients had severe mitral insufficiency that required mitral valve replacement in addition to the coronary bypass operation. Delay in evaluating these patients angiographically led to complications requiring the use of the intra-aortic balloon pump in 12 patients. The mean time for the angiographic evaluation was 6.8 days after the angina had recurred and the average time for surgical intervention was 1.2 days. The operative mortality in the patients undergoing coronary angiography and surgical treatment within 24 hours after the reappearance of angina (15 patients) was zero per cent; however, when this was delayed up to 48 hours (12 patients), the mortality increased to 8.3 per cent (one patient) and if the angiographic evaluation was delayed over 48 hours after the patient became symptomatic, the operative mortality rose substantially to 27.2 per cent (three patients). Most of the delay in obtaining angiocardiographic evaluation was caused by the attempt to use additional drug therapy or the introduction of new drugs, most of them calcium-blocking agents (nifedipine). It is our belief that physicians caring for patients who have recurrent angina after acute myocardial infarction should be aware that they represent a high risk group that should be studied angiographically promptly to determine operability in order to avoid a high rate of complications and death.

Aortic insufficiency after implant of an intraluminal ascending aortic graft prosthesis.

A case is presented in which an intraluminal aortic graft prosthesis (ILAP) was implanted in the ascending position for acute dissection. Although the patient had a perfectly competent aortic valve at the time of the implant, he developed severe aortic insufficiency, angina, and arrhythmia within 7 months. The symptoms disappeared after the prosthetic device was removed and replaced by a composite graft. The use of ILAP in the ascending aortic position in cases with dilated aortic root is not recommended since it seems to cause further dilatation and weakening, leading to aortic valve insufficiency.