Noniatrogenic pediatric vascular trauma: a ten-year experience at a level I trauma center.

We retrospectively reviewed all pediatric patients (< 18 years old) who presented to a Level I trauma center from 1984 to 1994 with noniatrogenic vascular trauma. There were 48 patients (42 male and 6 female) ages 2 to 17 years. Mechanism of injury included gunshot wounds (34) stab wounds (10), and blunt trauma (4). The lower extremities were most commonly injured (31), followed by upper extremity (17), trunk (8), and neck (4). Twenty-one (44%) patients had associated nonvascular injuries (primarily orthopedic or peripheral nerve). Eighteen (37%) patients underwent preoperative angiography for suspected extremity (15) or carotid injuries (3). Twenty-nine patients went to surgery without angiography based on severe ischemia (11) or hemorrhage (18). Arterial injuries (45) were managed by interposition reverse saphenous vein graft (16), primary repair (15), ligation (5), or other operative (5) and nonoperative treatment (4). Venous injuries (15) were treated with primary repair (8), patch (3), ligation (3), and nonoperative management (1). Fasciotomy was performed in six (12%). There were three deaths (6%), all due to aortic and/or caval injuries. Limb salvage in survivors was 100 per cent. There were no complications from angiography. Postoperative duplex scans demonstrated patency in six of the seven patients studied with venous injuries. We conclude that 1) noniatrogenic pediatric vascular trauma is uncommon, and 2) using an aggressive approach to both the diagnosis and treatment of these injuries can achieve excellent limb salvage rates with a low morbidity and mortality.

Outpatient laparoscopic appendectomy.

Laparoscopy has allowed surgeons the ability to perform procedures which result in less postoperative discomfort, earlier return to daily activities, and better cosmesis. For example, laparoscopic cholecystectomy has virtually replaced open cholecystectomy, and many of these operations are performed in the outpatient setting. The role of laparoscopic appendectomy is yet to be defined, however. Over an 18-month period from February 1992 to July 1993, 75 laparoscopic appendectomies were performed at Kaiser Permanente Medical Center in Los Angeles. Thirty-five of the patients undergoing this procedure were outpatients. While there were a total of three complications, including two intraabdominal abscesses, there were no complications in the outpatient appendectomy group. Laparoscopic appendectomy may be safely performed in the outpatient setting in patients with acute nonperforated appendicitis.

Gastrointestinal complications associated with cardiopulmonary bypass procedures.

Gastrointestinal complications after cardiopulmonary bypass (CPB) procedures are rare, but when they do occur, they carry a significant incidence of morbidity and mortality. Over a 5-year period spanning 1988-1992, 4923 CPB procedures were performed and 64 patients were identified who suffered a GI complication, giving an incidence of 1.3 per cent. The most frequent complications were GI bleeding (40%) and pancreatitis (34%). Other complications included acute cholecystitis (11%), perforated duodenal ulcer (8%), ischemic bowel (5%), and diverticulitis (2%). Complications occurred most frequently in patients undergoing procedures with longer pump and cross-clamp times, such as valvular and combination (CABG/valve) procedures. Redo procedures and the use of an intra-aortic balloon pump increased the risk of developing a GI complication 2.5 and 12 times, respectively. Patients were treated aggressively both medically and surgically, but suffered a higher mortality (16%) as compared to those not suffering a GI complication (3%). We conclude that GI complications after CPB procedures are infrequent but lethal. Clinical features are often subtle, and a high index of suspicion is needed for early diagnosis and aggressive treatment.

Small bowel cancer: a 30-year review.

BACKGROUND: Small bowel cancer is a relatively rare tumor with an incidence of 2,700 new cases and 900 deaths per year. The influence of stage on survival has been reported only once previously. Patterns of recurrence are unreported. METHODS: All cases of small bowel cancer treated at our hospital over a 30-year period (1960-1989) were reviewed. RESULTS: The site of most cancers was the duodenum (46%), followed in frequency by the jejunum (33%) and the ileum (21%). Adenocarcinoma was the most common histology (63%), followed in frequency by lymphoma (15%), leiomyosarcoma (13%), carcinoid tumors (6%), and miscellaneous (3%). Analysis of stage distribution by site showed a decrease in stages I and II with more distal locations. Associated cancers occurred in 11%, but none were seen in the group with carcinoid tumors. Actuarial 10-year survival rates were 24% for those with adenocarcinoma (all stages) 75% for stage I, 25% for those with stage II, and 0% for stage III. A subgroup of 10 patients who underwent a pancreaticoduodenectomy (one stage I, seven stage II, two stage III) had a 30% 10-year survival rate. Those patients with lymphoma had a 12% 10-year survival rate, and those with leiomyosarcoma had a 20% 10-year survival rate. A 100% 10-year survival rate was observed in those with carcinoid tumors. Peritoneal carcinomatosis was the most common failure pattern (33%), followed in frequency by local recurrence in 23% and abdominal wall recurrence in 15%. CONCLUSIONS: A correlation exists between the pathologic stage and the survival rate for adenocarcinoma. The most common recurrence pattern for adenocarcinoma was carcinomatosis, followed in frequency by abdominal wall recurrence. Leiomyosarcoma preferentially metastasizes to the liver.