Aortic balloon control of a traumatic aortoenteric fistula after damage control laparotomy: a case report

Aortoenteric fistula is a rare complication of abdominal trauma. We present a case of a patient with multiple gunshot wounds to the abdomen and thorax in whom control of injury required staged operations. An aortoenteric fistula developed, presenting a diagnostic and therapeutic challenge. The operative control of aortic bleeding was by a retroperitoneal approach to the aorta and facilitated by the use of percutaneous aortic balloon catheters. The patient survived to leave hospital. This case highlights a rare trauma complication, the use of "damage control" for the severely injured abdomen and the technique of intra-arterial balloon control of bleeding from inaccessible locations.     

Risk factors of recurrence in 157 MB/PNET patients treated in one institution

BACKGROUND: Epistaxis is one of the most common otolaryngological emergencies. In cases of bleeding from the anterior or the lower posterior part of the nose, epistaxis could usually be treated with cauterization and anterior or posterior nasal packing. More invasive methods of treatment are the endonasal coagulation of the sphenopalatine artery and the transantral ligation of the maxillary artery. Bleeding from the upper posterior part of the nose usually originates from the anterior and the posterior ethmoidal artery. In most cases a specific styptic treatment in the upper posterior part of the nose is not possible because of a diffuse bleeding from the ethmoidal arteries into the ethmoidal sinus and the lateral wall of the nasal cavity. In this study the endoscopic ethmoidectomy is presented as the therapy of epistaxis from the ethmoidal arteries. PATIENTS AND RESULTS: In the retrospective study the charts of twenty patients with intractable epistaxis from the upper posterior part of the nasal cavity were reviewed. In all cases the bleeding could not be controlled with anterior and posterior nasal packing. In seventeen patients the bleeding could be controlled with a unilateral or bilateral endoscopic ethmoidectomy (average follow-up: 36.5 months). Three patients who complained of a coagulopathy and an arterial hypertonia developed diffuse recurrent bleeding from multiple sources. In one case the recurrent bleeding was controlled by an unilateral transantral ligation of the maxillary artery and a bilateral revision of the ethmoidectomy. In two patients the recurrent bleeding was treated with bilateral posterior nasal packing. CONCLUSION: The endoscopic ethmoidectomy is an efficient therapy of intractable epistaxis from the ethmoidal arteries if systemic coagulopathy and arterial hypertonia are excluded. The ethmoidectomy can be performed by any head and neck surgeon who is familiar with endonasal surgery.     

Shprintzen-Goldberg syndrome. A case report

Major hemorrhage after pulmonary resection is infrequent. It is usually due to an unsecured vessel, and immediate reoperation to control hemorrhage is indicated. Diffuse bleeding from raw chest wall surfaces can complicate pleurectomy. Control of bleeding from this cause is difficult, and standard techniques may fail. Thoracic packing is occasionally needed. The authors describe a technique for thoracic packing. This technique permits removal of thoracic packing at the bedside, and simplifies subsequent management of an empyema, should one develop.     

Anesthetic management of abdominal gunshot wound--a report of three cases

This is a case report of anesthetic management of abdominal gunshot wound. Two patients had upper abdominal wound involving the liver and the inferior vena cava. They died of uncontrolled bleeding. Third patient had lower abdominal injury involving the ascending colon and small intestine. The patient survived the injury and showed good recovery. In a case of the abdominal gunshot injury, prompt diagnosis and laparotomy are mandatory. Multiple intravenous routes are necessary in the upper part of the body for massive infusion and transfusion. Unusual hemostasis methods such as atrio-caval shunt or abdominal clamping of the aorta must be considered in case of injury in the inferior vena cava.     

Concentrated professional education to implement routine referral legislation increases organ donation

Penetrating injuries to the abdominal aorta most often result in rapid exsanguination and death. Immediate surgical intervention may result in control of hemorrhage and survival of the patient. Rarely, hemorrhage after aortic injury may be contained by surrounding tissues, resulting in pseudoaneurysm formation. Traumatic pseudoaneurysms may rupture at any time, and this is usually a fatal event. A 47-year-old man recently presented with a supraceliac abdominal aortic pseudoaneurysm that ruptured into the right chest 28 years after a gunshot wound to the back. This report describes the pathophysiology, diagnosis, and treatment of traumatic pseudoaneurysms of the abdominal aorta and includes a review of the literature. This is a case in which a traumatic pseudoaneurysm of the abdominal aorta was successfully repaired by surgery after rupture into the thorax and is the first such case to be reported in the literature.     

The postcholecystectomy syndrome and its prevention]

The authors have made an analysis of results of clinical observations of 953 patients with gunshot wounds of soft tissues. It was found that primary surgical treatment (PST) of the gunshot wounds often proved to be not radical. Later it required reoperations in 30% of the wounded. To get more exact indications for a repeated surgical treatment it is necessary to make a careful revision of the gunshot wound within 3-5 days after getting the wound. The indications for reoperations are as follows: the development of secondary necrosis of the tissues necessary removal of the foreign body, opening of the pockets and leaks in order to provide valuable drainage as well as nonradical PST due to various causes. Reoperations performed according to the indications allowed to make the duration of treatment at an average 7 days shorter and the development of suppurations two times less frequent.     

The features of the traumatogenesis and the ballistic characteristics of peacetime gunshot injuries

Features of traumatogenesis and wound ballistics of civilian gunshot wounds are studied on the basis of the International Humanitarian Law and basic principles of wound ballistics. Data of 130 lethal cases and 260 wounded are presented. Types of the weapons used were taken into account. A detailed analysis of gunshot wounds inflicted by TT and PM handguns was made. The main components of traumatogenesis of civilian gunshot wounds were established.     

Double pyloroplasty and vagotomy for gastric ulcers

A group of 31 patients with a variety of gastric ulcers were treated by vagotomy, biopsy, oversewing of bleeding points and a wide double pyloroplasty. On patient, a quadriplegic with multiple stress ulcers, rebled and had to undergo resection. He died a month later of progressive respiratory problems. A second quadriplegic died a month after a bleeding episode from myelitis and encephalitis resulting from a gunshot wound of the neck. He had no rebleeding. A third patient died two years after a gastric operation as a result of bronchial carcinoma. He had no recurrence of the ulcer problem. The remaining 28 patients were observed from six months to five years, an average of two and one-half years. There were no recurrences and only minimal untoward symptoms. It would appear that, for this period of observation, vagotomy with double pyloroplasty offers good treatment for patients with benign gastric ulcers.     

External dacryocystorhinostomy without mucosal flaps: comparison of petroleum jelly gauze nasal packing with gelatin sponge nasal packing

BACKGROUND AND OBJECTIVE: This study was designed (1) to determine the overall success of patients who underwent external dacryocystorhinostomy (DCR) using a modified Kasper technique without lacrimal sac and nasal mucosal sutured flaps, and (2) to investigate the possible impact of intraoperative petroleum jelly gauze nasal packing as compared with gelatin sponge nasal packing on the surgical results. PATIENTS AND METHODS: A retrospective review of 122 consecutive patients who underwent external DCR using a modified Kasper technique was performed. Patients were divided into two groups based on use of petroleum jelly gauze packing or gelatin sponge packing. Criteria for successful surgery included resolution of the main symptom(s) of tearing, chronic mucous discharge (chronic dacryocystitis), and/or recurrent acute dacryocystitis; and patency of the reconstructed lacrimal system. RESULTS: Ninety-four of 96 patients who had petroleum jelly gauze packing had successful DCRs, whereas only 21 of 26 patients who had gelatin sponge packing had successful DCRs (P < .005). Soft tissue rather than bony obstruction of the rhinostomy was the most common cause of DCR failure, as confirmed by office probing, endoscopy, and computed tomography. Three patients in the gelatin sponge packing group who experienced failure subsequently had bacterial sinusitis. CONCLUSION: This study strongly suggests that gelatin sponge nasal packing, at least when used for patients who undergo DCR without sutured mucosal flaps, may be associated with an increased number of failures as a result of scar tissue formation at the rhinostomy site, as compared with petroleum jelly packing. Petroleum jelly gauze nasal packing may enhance surgical results by reducing scarring between the lacrimal sac fistula and the nasal structures.     

Case report: wandering intravascular bullet with aortic pseudoaneurysm

A 26-year-old man received a gunshot wound to the left flank. No exit wound was seen. A plain abdominal film, computed tomography (CT) and angiography were performed. Abdominal aortic pseudoaneurysm with extravasation of contrast into the retroperitoneum and embolization of the bullet to the left iliac artery were shown. The diagnostic value of the CT was considerable, but angiography was still required for definitive localization of the bullet.     

Endoscopic management of subcutaneous gunshot wound with irrigation technique

The application of the endoscope to the treatment of gunshot wounds has never been reported to our knowledge, with the exception of the laparoscope and the sigmoidscope in abdominal gunshot wounds. We report a patient with a subcutaneous gunshot wound who was treated endoscopically using the irrigation technique. The patient was a 25-year-old man who had been shot in the upper arm. The bullet was found near the thoracic spine via radiograph. At surgery the endoscope was inserted into the wound and irrigation was started. Excellent views could be obtained by irrigation, and the endoscope was advanced along the path of the bullet. The bullet and several fragments were removed with two additional small incisions. The method described herein seems beneficial in that (1) it is less invasive than conventional surgical debridement with a long incision, (2) it may provide information helpful in diagnosing the condition and the location of the bullet and its path, and (3) saline irrigation may have a cleansing effect.     

Is cervical spine imaging indicated in gunshot wounds to the cranium?

BACKGROUND, MATERIALS AND METHODS: Because there is no consensus regarding the necessity of imaging the cervical spine of patients who sustain a gunshot wound to the cranium, the cervical spinal radiographs of 53 consecutive patients with gunshot wounds to the cranium admitted to Hermann Hospital, a Level I trauma center, from January of 1993 to January of 1996, were reviewed. RESULTS: The cervical spine radiographs of all 53 patients were negative. CONCLUSIONS: Cervical spine injury is not associated with gunshot wound to the cranium. Therefore, patient management decisions/procedures, including endotracheal intubation, should not be delayed pending cervical spine imaging.     

An unusual embolization of a projectile in the superficial femoral artery

The authors present an account on a gunshot wound which penetrated into the lateral side of the distal chest on the right. They describe acute treatment of severe haemorrhagic shock by suture of a lacerated with liver segment and resection of the upper pole of the right kidney. The projectile was not searched for because of the patients general serious condition. After 30 days the patient was discharged in a good condition. Shortly after discharge, i.e. cca one month after the injury, the patient developed signs of chronic ischaemia of the left lower extremity-finally claudications after 150 meters. Based on peripheral arteriography, which revealed the projectile in the area of the beginning of the superficial femoral artery and an ample collateral circulation, surgery was initiated. The bullet was extracted from the lumen of the superficial femoral artery from longitudinal arteriotomy. The artery was then treated by thrombectomy and a venous patch. Peroperative arteriography indicates satisfactory passage into the periphery. The authors try to reconstruct the pathway of the shot and in particular how the projectile penetrated into the artery. They emphasize the necessity to look for the projectice at the site of the shot wound. The objective of the paper is to make readers familiar with a case of uncommon embolization of a projectile into the superficial femoral artery and mistakes which may occur during treatment of a gunshot wound. The result is that the patient is quite free from complaints, as was confirmed by repeated out-patient check-ups.     

Vaccines by agriculture

Hemorrhage from pancreatic pseudocyst or a pseudoaneurysm is a rare, fatal complication of chronic pancreatitis. Elastase may cause erosion of adjacent vessels in the course of acute pancreatitis and spontaneous bleeding may occur. One therapeutic modality is embolotherapy, but surgery is the traditional therapy. Resection of the bleeding site of the pancreas, ligation of the affected vessels or compression by occluding the cyst with a balloon are good alternatives. We present a case having massive gastric hemorrhage from the splenic artery after cystogastrostomy, treated by occluding the artery with a foley catheter.     

Effects of nasal packing on eustachian tube function

Eustachian tube function was assessed by tympanometry in 47 patients (94 ears) with anterior nasal packing placed after nasal surgery and in 12 patients (24 ears) requiring anterior and posterior packing for epistaxis. Twenty-four of the 94 ears (25.5%) in patients with anterior packing exhibited reductions in middle ear pressure (greater than or equal to --100 mm H2O), whereas 12 of 13 ears (92.3%) ipsilateral to and six of 11 ears (45.4%) contralateral to the posterior pack demonstrated comparable reductions in middle ear pressure. The observation that posterior packing is associated with a greater incidence of eustachian tube dysfunction than anterior packing suggests that the mechanism of this dysfunction may be related to stasis in the peritubal lymphatic plexus rather than to nasal obstruction per se.     

Gunshot wounds to the mandible and midface: evaluation, treatment, and avoidance of complications

As American society becomes progressively violent, an ever-increasing number of gunshot wounds are being seen across the United States. Particularly challenging are injuries that involve the mandible and midface, not only because of problems with reconstructing bone and soft-tissue defects but also because of emergent problems with airway obstruction and neurovascular compromise. We present 40 cases of gunshot wounds to the mouth, mandible, and maxilla treated at Wake Forest University Medical Center during the past 7 years. The focus of this retrospective analysis is on emergency evaluation and treatment, complications encountered, and operative techniques used for reconstruction. Special emphasis is placed on recognizing and avoiding the complications of these injuries.     

Arterial blood gas determination in patients with anterior packing

Twenty-two healthy males ranging in age between 18 and 43 years were studied by arterial blood sample obtained before nasal surgery and again after complete bilateral nasal obstruction produced by nasal packing. Five of these patients had a third sample drawn after pack removal. The pO2 dropped from a preoperative mean of 85 mm Hg to 74 mm Hg. This difference is statistically significant; pCO2 did not change between the two measurements. This result is attributed to hypoxia caused by acute total nasal obstruction. It suggests that anterior packing alone may cause a clinically important hypoxia in patients with inadequate pulmonary reserve and that these patients merit close observation when bilateral anterior packing is placed. The early removal of anterior packing in patients where possible seems indicated. Supplemental O2 (40%) for patients over 40 years of age requiring nasal packing is practiced at this Center.     

Fatal air embolism following gunshot wound of the lung

Air embolism following penetrating lung trauma has been reported infrequently and its existence is questioned. A death resulting from air embolism following a high-velocity gunshot wound is presented. Appropriate treatment and preventive measures are discussed.     

Efficacy of ceftriaxone versus cefazolin in the prophylactic management of extra-articular cortical violation of bone due to low-velocity gunshot wounds

One hundred patients sustained gunshot wounds involving bone but not joint with a low-velocity bullet. Soft-tissue involvement was less than 1 cm at its greatest diameter. All patients were free from artery or nerve damage. No formal fixation of fracture was required. The results of the study suggest that patients need not be hospitalized longer than 2 days after an extra-articular, low-velocity gunshot wound that violates the cortex. In addition, through the use of long half-life antibiotics, such as ceftriaxone, the length of hospitalization may further be reduced to a day, while the potential for morbidity from infection is not increased.     

Macroscopic and pathohistological investigation of endarterial plaque after intraoperative balloon dilatation of the carotid artery during carotid endarterectomy

Twelve patients associated with stenosis of the extracranial carotid artery underwent intraluminal balloon dilatation during carotid endarterectomy (CEA). There were 11 men and 1 woman, and age ranged from 56 to 73 years old. The rate of stenosis, shown by angiography, in each patient was from 60 to 85% in width. After securing carotid blood flow by a T-shaped shunt tube, a balloon catheter was inserted from the exposed common carotid artery into the internal carotid artery. The balloon was inflated three or four times with 2.5-3.5 atm. for 30-40 seconds. Immediately after balloon dilatation, endoscopic investigation was performed (Wolf; hard type endoscope, 2.7 mm diameter). Then CEA was performed using the usual procedure. The removed endarterial plaque was investigated pathohistologically. In macroscopic and endoscopic findings, there were 6 patients with mural thrombosis, 4 patients with laceration of the intima, and one patient with outflow of atheroma from the intima. Only 3 patients had increase in lumen after balloon dilatation. In pathohistological appearance, all patients had a moderate degree of fibrosis, calcification, and atheroma in the cross section of the plaque. Ten patients had intramural hemorrhage. Three typical patients were revealed by the use of angiographical, ultrasonographical, endoscopic, and pathohistological presentation. Case 10 showed laceration of the intima by balloon dilatation, and had moderate increase in lumen size macroscopically and endoscopically. There were moderate cases of fibrosis, calcification, atheroma, and intramural hemorrhage. Dilatation of the lumen seemed to be accomplished by a decrease in thickness of the atheroma and intramural hemorrhage. Case 8 demonstrated an increase in lumen size, but also laceration of the intima and outflow of atheroma from the arterial wall. There were much atheroma and large intramural hemorrhage in the intima, which might become a source of enbolism. Case 7 revealed no laceration of the intima and no increase in lumen size. Preoperative ultrasonography showed hyperechoic finding and postoperative pathohistological findings showed severe fibrosis and calcification, which were thought to have interrupted balloon dilatation. There have been small numbers of reports about pathohistological presentation after percutaneous transluminal angioplasty (PTA), because it is very difficult to take a specimen after PTA. In this report we were able to present the necessity of preoperative investigations by angiography, ultrasonography, and 3D-CT.