Penetrating cardiac injury--to close the pericardium or not? A case report.

Many trauma surgeons who treat penetrating cardiac injuries do not routinely suture the pericardium closed after repairing the heart. The patient reported here died from exsanguination during attempts to mobilise the heart which had adhered to the sternum. With the increasing demand for coronary artery surgery and the high incidence of carcinoma of the oesophagus in South Africa, both of which require access to the mediastinum, we recommend that in the trauma setting, the pericardium be closed to facilitate future surgery if required.

'Missed stabbed hearts'--pitfalls in the diagnosis of penetrating cardiac injuries. Report of 4 cases.

Classically, penetrating injuries of the heart present with clinical signs of an ongoing massive haemorrhage or cardiac tamponade. In a few patients, however, none of these signs are present and the diagnosis is overlooked. Diagnostic aids, such as ultrasonography or angiography, are occasionally misleading. Four cases of penetrating cardiac injuries that were not diagnosed on initial presentation, but which subsequently manifested with a secondary and sometimes fatal haemorrhage, are presented. Recommendations are made for preventing diagnostic delays.

Intrapericardial herniation. A report of 2 cases.

Traumatic intrapericardial rupture is an infrequent occurrence and often associated with other fatal injuries. Two cases of delayed presentations of central tendon defects and intrapericardial herniation after blunt trauma to the chest and abdomen are reported.

Subxiphoid pericardial windows--helpful in selected cases.

There is a small group of patients who sustain multiple penetrating injuries who present with haemodynamic changes, making it difficult to clinically exclude or prove the presence of penetrating cardiac injury. It is in this select group of patients that we found subxiphoid pericardial windows to be extremely useful to prove or disprove the existence of a cardiac injury and thereby prevent a delay in diagnosing these injuries.

Groin hernias--beware!

Groin hernias usually present no specific problems to the surgeon, and are a common complaint. There are, however, a select group of patients in whom a sudden change in the status of the hernia should alert the clinician to the possibility of the existence of underlying disease. These patients should be recognised and thoroughly evaluated before the hernia is repaired.

Surgery for the complications of peptic ulceration in urban black patients.

We report on a series of 63 urban black patients who required surgical treatment for duodenal or gastric ulcers. Intractable pain from duodenal ulceration was an uncommon indication for surgery, which was mostly required for the complications of perforation, haemorrhage and stenosis. Perforation was the most common indication for surgery in these patients, while in rural black patients pyloric stenosis is reported to be a common complication. It appears that the complications of duodenal ulcers in the urban black population now resemble those occurring in white patients. Giant duodenal ulcers were present in almost 25% of these patients and those presenting with haemorrhage required aggressive surgery to control the bleeding. Twenty-five per cent of cases of gastric ulceration proved to be malignant. These were mostly prepyloric ulcers, suggesting the need for vigorous investigation of such ulcers to exclude gastric carcinoma and early surgery if a conservative regimen fails to heal them. There was a 100% mortality rate among patients with perforated benign gastric ulcers, largely the result of late presentation.