Is computed tomographic grading of splenic injury useful in the nonsurgical management of blunt trauma?

Seventy adult and pediatric patients with blunt splenic injury were managed nonsurgically using previously published clinical criteria without regard to the appearance of the spleen on computed tomographic (CT) scans. Seven patients (10%) who underwent delayed surgery were considered failures of nonsurgical therapy; all recovered after total splenectomy. Two radiologists, blinded to patient outcome, retrospectively reviewed the admission CT scans of all 70 patients and graded them according to three published scoring systems. Higher grades of splenic injury on CT were not associated with an increased risk of failure (Fisher's exact test, p > 0.05). Nine of ten patients with very high scores on each of the scales were successfully managed without surgery; conversely, three patients with very low scores required urgent surgery. An elevated Injury Severity Score significantly increased the risk of failure of nonsurgical management (Chi-square test of trend, p = 0.001). No failures occurred in patients under age 17 years. Our data support the hypothesis that properly selected patients can be safely observed regardless of the magnitude of splenic injury on CT scans. A decision to undergo early exploration should be based on clinical criteria, including the patient's age and associated injuries.

MR imaging of Asherman syndrome: total endometrial obliteration.

We present a case of Asherman syndrome involving severe intrauterine adhesions in a 31-year-old woman. Findings at hysterosalpingography and hysteroscopy are correlated with MR findings.

Blunt hepatic trauma. Nonoperative management in adults.

Fifty-six adults were identified with blunt hepatic trauma. Sixteen patients (29%) were treated successfully with nonoperative management. There were no delayed laparotomies or deaths in the nonoperative group. All patients required close observation. Eight (50%) of 16 patients required transfusion of no more than 3 U of packed red blood cells. There were two significant late complications requiring readmission. Four (25%) of 16 patients had complex fractures, yet were treated successfully without laparotomy. The quantity of fluid in the abdomen, as estimated by computed tomography, did not predict failure of treatment. Nonoperative management of blunt hepatic injuries is a useful alternative in selected patients when the course of therapy is based on the hemodynamic stability of the patient and supported by computed tomographic findings.

Selective nonoperative management of blunt splenic trauma in adults.

The use of selective nonoperative management of blunt splenic trauma in adults is based on the undeniable benefits of this approach in children. Proper patient selection requires hemodynamic stability, lack of generalized peritoneal irritation, and minimal blood transfusion needs. Computed tomography is now used to make the diagnosis, but the decision for laparotomy is based on clinical grounds. Forty-one (87%) of 47 patients selected for nonoperative management were treated successfully without laparotomy, while the remaining 6 patients underwent delayed operations for persistent splenic bleeding. Blood transfusion requirements were significantly less in the observed group than in the operative group for patients with isolated trauma and for patients with polytrauma. There were no known missed intra-abdominal injuries and no deaths with the nonoperative approach. Analysis of our results has confirmed that nonoperative management is a safe and effective alternative to immediate laparotomy in properly selected patients and it can result in splenic salvage without the need for an operation.

Supplementary tissue-core histology from fine-needle transthoracic aspiration biopsy.

Biopsies of 150 consecutive suspected lung cancers were performed with fine needles having circumferentially beveled tips that produced cytology and tiny tissue cores suitable for histology. Visible tissue cores were aspirated in 92% (n = 138) and histologic diagnoses were obtained in 72% (n = 108). There were 118 (79%) proven malignant and 27 (18%) proven benign lesions. Sensitivity and specificity of cancer diagnoses were 97% and 100%, respectively. Biopsy histology was the only positive cancer specimen in two biopsies (1.7%). Biopsy cytology was the only positive cancer specimen in 20 cases (17.2%). Biopsy cytology and histology agreed with the proven cell type in 71.8% and 78.6% of cancers, respectively. As expected, when large-cell undifferentiated carcinoma was regarded as a nonspecific cell type consistent with either poorly differentiated adenocarcinoma or poorly differentiated epidermoid carcinoma, biopsy-cell-type accuracy increased greatly. Specific benign diagnoses were obtained in 44% of the 27 biopsies of proven benign lesions: cytology (four), core histology (five), and bacteriology (nine). Simple and complicated pneumothorax occurred in 10% and 4% of biopsies, respectively. It was concluded that biopsy with fine, circumferentially beveled needles can produce useful histology to supplement biopsy cytology.

Oto-palato-digital syndrome, type II--an X-linked skeletal dysplasia.

We report on two male infants with a lethal skeletal dysplasia characterized by cleft palate, midface hypoplasia, downward-slanting palpebral fissures, small thorax, and bowed limbs with absent fibulae. The clinical and radiographic changes are similar to those seen in the recently proposed oto-palato-digital syndrome, type II [Fitch et al, 1983]. The disorder is X-linked with heterozygous females being more mildly affected.

Antenatal ultrasound detection of cystic adenomatoid malformation of lung: report of a case and review of the recent literature.

We have described a case of cystic adenomatoid malformation of the lung, detected before birth. The ultrasound findings demonstrated in this case correlated well with both the radiographic appearance of the lesion and with the gross pathology. Though we do not feel that the ultrasonic findings described are specific for this entity, they are believed to be characteristic of at least one type of cystic adenomatoid malformation. The prognostic significance of associated polyhydramnios and fetal anasarca is discussed. The importance of detecting this lesion antenatally is highlighted in this case in which the malformation would most likely have gone undetected in the perinatal period were it not for the antenatal ultrasonic findings.

Percutaneous core biopsy of abdominal tumors using 22 gauge needles: further observations.

Percutaneous needle sampling of suspected malignant tumors was carried out in 150 patients using a technique providing specimens for both cytologic and histologic analyses. Adequate samples for pathologic analysis were obtained in 97% and 89%, respectively. An overall accuracy rate of 85% was achieved with histologic results providing a positive diagnosis in 7% of patients in whom corresponding cytologic information was falsely negative. Both in vivo and in vitro experiments suggest no superiority in the tissue retrieval rate of the different 22 gauge needles used for biopsy. Since the core biopsy technique adds no increase in complication rate and provides a small but definite incremental gain in accuracy, its routine use is suggested.

The apical cap.

Apical caps, either unilateral or bilateral, are a common feature of advancing age and are usually the result of subpleural scarring unassociated with other diseases. Pancoast (superior sulcus) tumors are a well recognized cause of unilateral asymmetric apical density. Other lesions arising in the lung, pleura, or extrapleural space may produce unilateral or bilateral apical caps. These include: (1) inflammatory: tuberculosis and extrapleural abscesses extending from the neck; (2) post radiation fibrosis after mantle therapy for Hodgkin disease or supraclavicular radiation in the treatment of breast carcinoma; (3) neoplasm: lymphoma extending from the neck or mediastinum, superior sulcus bronchogenic carcinoma, and metastases; (4) traumatic: extrapleural dissection of blood from a ruptured aorta, fractures of the ribs or spine, or hemorrhage due to subclavian line placement; (5) vascular: coarctation of the aorta with dilated collaterals over the apex, fistula between the subclavian artery and vein; and (6) miscellaneous: mediastinal lipomatosis with subcostal fat extending over the apices.

Tissue core biopsy of abdominal tumors with a 22 gauge cutting needle.

Percutaneous needle sampling of malignant tumors carried out by fine-needle cytologic aspiration and large-needle cutting techniques both possess certain limitations. A fine caliber 22 gauge cutting needle and a modified sampling technique used in 78 patients with suspected abdominal neoplasms are described. Both cytologic and histologic samples were sought in each case and overall successful diagnoses were made in 88% of 50 proved cases, with specific histologic diagnoses in 56%. Cytologic specimens were more sensitive in 14 cases in the detection of malignancy, while histologic results were more specific in nine cases. No significant complications were encountered. This modified method has not replaced the former cytologic aspiration technique in this institution.

Postcholecystectomy bile duct dilatation: myth or reality?

Postcholecystectomy dilatation of the common duct has been a matter of controversy in the surgical, radiographic, and sonographic literature. In this study, 40 patients who had biliary sonography before cholecystectomy and were asymptomatic 6 months or more after surgery were returned for sonography of the biliary ducts. Of these, 38/40 showed no evidence of postcholecystectomy dilatation of the common duct. There was diminution of the common duct in one and enlargement in another patient. One patient had a duct that was dilated before surgery and remained the same size after surgery. It is concluded that postcholecystectomy dilatation of the common bile duct does not occur in most normal patients.