How interventional radiology changed the practice of a trauma surgeon.

Trauma Surgery, with the assistance of advanced technology especially in Imaging (formerly Radiology), enables it to have patient management approaching John Hunter's ideal of treatment by stratagem rather than the "force" of an open operation.

Total mediastinal traverse with isolated internal mammary artery transection.

Transmediastinal gunshot wounds are infrequent but life-threatening injuries. The course of the projectile and the bullet track often is unpredictable. Prompt and specific diagnostic and therapeutic interventions are necessary to quickly identify and repair potentially life-threatening injuries to the heart, great vessels, and the aerodigestive tract. Multiple diagnostic algorithms exist for work-up of these injuries, and the therapeutic interventions are diverse and challenging. We describe a patient with total mediastinal traverse, who presented with right-sided hemopneumothorax. The work-up revealed surprisingly an isolated left internal mammary artery transection with a significant hemorrhage that mandated surgical intervention in left chest.

Emergency cricothyrotomy.

Emergency cricothyrotomy is a potentially lifesaving surgical procedure used to gain prompt access to an otherwise compromised and inaccessible airway. The purpose of this photoessay is to demonstrate the technique of the procedure in a step-by-step manner so that the physician can perform this intervention with ease and facility in the most stressful of circumstances.

The effect of diabetes on endothelin, interleukin-8 and vascular endothelial growth factor-mediated angiogenesis in rats.

In diabetes mellitus, there is a problem of both premature atherosclerosis as well as impaired collateralization. Studies were performed using the rat corneal angiogenesis model as a surrogate for collateralization to determine the effect of diabetes mellitus on endothelin (ET)-1, ET-3, vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8)-mediated angiogenesis. In an initial group of experiments, streptozotocin-induced diabetes resulted in impairment of ET-1-mediated angiogenesis from 69% to 32%, but was only impaired from 74% to 59% for ET-3. When rats were fluid-resuscitated, mortality fell, and the incidence of inhibition of angiogenesis decreased for ET-1, but was still at 47%. Inhibition of ET-3-mediated angiogenesis in fluid-resuscitated rats was essentially unaffected from 74% to 75%. Studies of VEGF and IL-8 in fluid-resuscitated rats demonstrated that VEGF-mediated angiogenesis was only inhibited from 49% to 45%, but there was inhibition of IL-8-mediated angiogenesis from 62% to 31%. We concluded that there may be two mechanisms by which ET-1-mediated corneal angiogenesis is inhibited: a decrease in intravascular volume and dynamic forces affecting angiogenesis, and a direct effect of diabetes on some aspect of cell growth or angiogenic process. Diabetes also appeared to inhibit IL-8-mediated angiogenesis, but had very little or no effect on ET-3- or VEGF-mediated angiogenesis.

Diagnostic and therapeutic laparoscopy for trauma: a technique of safe and systematic exploration.

Laparoscopy has a limited role in the evaluation of a stable trauma patient. The main concern addressed in the literature is a significant potential for missed visceral injury and a minimal role for therapeutic application. We present a simple technique for systematic abdominal exploration for a suspected intraabdominal injury in a series of three consecutive trauma patients (two penetrating injuries, one blunt) at a level-one trauma center. Three 5-mm ports and a 30-degree laparoscope were used for exploration. Additional ports for retraction were used as needed for therapeutic procedures. All patients underwent complete exploration of the abdominal cavity. Therapeutic procedures consisted of suturing an intraperitoneal bladder rupture, draining a lacerated tail of the pancreas, and cauterizing an actively bleeding penetrating wound to the left lobe and caudate lobe of the liver. All patients experienced prompt and uncomplicated recovery. There were no missed injuries. The presented technique enables a systematic laparoscopic exploration of the abdomen, which follows the same principles as open exploration. The role of laparoscopy in the treatment of a stable trauma patient is likely to increase as more surgeons acquire advanced laparoscopic skills, and as systematic exploration techniques are used.

Lower extremity compartment syndrome following a laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. CASE REPORT: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy, which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4-month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. CONCLUSION: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.