Faculty Bibliography

Hepatic artery injuries sustained as a result of blunt abdominal trauma are rare. This case represents the first reported hepatic artery transection and the second hepatic artery injury described in children. Hepatic artery injuries are associated with high mortality, and their management is complex and controversial

OBJECTIVE: Stercoral colitis is an inflammatory process involving the colonic wall related to fecal impaction. Our purpose was to describe the imaging findings of stercoral colitis and ulceration and to emphasize the potential serious clinical implications of the condition. CONCLUSION: Fecal impaction may lead to ischemic pressure necrosis and subsequent colonic perforation. In the appropriate clinical setting, the imaging findings that should prompt the radiologist to consider this diagnosis are the presence of fecal impaction, focal colonic wall thickening, and adjacent stranding of the fat. If the fecal impaction is not promptly relieved, the condition can lead to colonic perforation, peritonitis, and patient demise

Although gallstone disease is highly prevalent, cholelithiasis causing gallstone ileus is uncommon. Consideration has been given for nonoperative strategies to resolve obstruction due to the significant age and comorbidities afflicting this population. A 94-year-old man presented with a 5-day history of abdominal distension and tenderness. CT scan revealed multiple large gallstones within the gallbladder, pneumobilia, and two ectopic gallstones (antrum of the stomach and distal ileum). The patient was taken to the operating room where an enterolithotomy and gastrotomy was performed with removal of gallstones and subsequent relief of obstruction. During the postoperative course, the patient developed symptoms of gastric outlet obstruction and underwent gastrointestinal endoscopy for diagnosis and treatment. Two large gallstones, present in the duodenum, were retracted into the stomach using a Roth net but could not be retrieved beyond the upper esophageal sphincter. A holmium: yttrium-aluminum-garnet (Holmium: YAG) laser was used for fragmentation of the stones, with subsequent successful removal. This is the first documented successful use of the holmium: YAG laser for the treatment of recurrent gallstone ileus. Physicians should remember that in a small but important subgroup of patients, endoscopy accompanied by laser lithotripsy may prove beneficial

BACKGROUND: We describe the surgical response of two affiliated hospitals during the day of, and week following, the September 11th, 2001 terrorist attack at the World Trade Center in New York City. The city of New York has 18 state designated regional trauma centers that receive major trauma victims. The southern half of Manhattan is served by a burn center, two regional trauma centers, and a community hospital that is an affiliate of one of the regional trauma centers. This report accounts for the surgical response by a regional trauma center (Hospital A, located 2.5 miles from the World Trade Center) and its affiliate hospital (Hospital B, located 5 city blocks from the World Trade Center) on September 11th when two commercial jets crashed into the Twin Towers at the World Trade Center mall. METHODS: Hospital A maintained a concurrent log of patients received during the first 5 hours, the first day, and the first week after the disaster which was kept by the Surgical Triage Officer. The trauma registry completed and verified this data by September 18th. Hospital B collected its data by hand counting and verification by chart review. Both hospitals, A and B, had established disaster plans that were implemented. RESULTS: Nine hundred eleven patients were received by two affiliated hospitals from the World Trade Center attack. Seven hundred seventy six patients (85%) were walking wounded, sustaining mild inhalation and eye irritant injuries. One hundred thirty five (15%) were admitted with 18 (13%) of these undergoing surgery. Twenty two of the 23 transfers were from the community hospital to specialized orthopedic or burn centers. Of the 109 patients admitted to Hospital A, 30 were to the surgical service. The mean ISS score of these patients was 12. There were 4 deaths (within minutes of arrival at the hospital) and 6 delayed deaths (day 1-14). Excluding walking wounded and DOAs, the critical mortality rate was 37.5% overall. CONCLUSION: The September 11th, 2001, terrorist attack in New York City, involving two commercial airliners crashing into the World Trade Center, led to 911 patients received at two affiliated hospitals in lower Manhattan. One hospital is a regional trauma center and one was an affiliate community hospital. Eighty five percent of the patients received were walking wounded. Of the rest, 13% underwent surgical procedures with an overall critical mortality rate of 37.5%

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN: We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS: There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. CONCLUSION: SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries

HYPOTHESIS: Decreased length of stay (LOS) after pancreatoduodenectomy is due to multiple factors, including a lower complication rate and more efficient perioperative care for all patients, with and without complications. DESIGN: A retrospective review, validation cohort. SETTING: A single university hospital referral center. PATIENTS: A consecutive sample of patients undergoing pancreatoduodenectomy from January 9, 1986, to December 21, 1992 (group 1 [n = 104]) and from February 16, 1993, to November 9, 1998 (group 2 [n = 111]). INTERVENTION: Mann-Whitney test and linear [correction of logistic] regression analysis applied to clinical variables and LOS. MAIN OUTCOME MEASURES: Difference in median LOS between early and late groups and identification of factors predictive of decreased LOS. RESULTS: Total LOS decreased between the 2 groups (26 days [range, 13-117 days] vs 15 days [range, 5-61 days]; P<.001), with a decrease in preoperative (4 days [range, 0-28 days] vs 2 days [range, 0-36 days]; P<.001) and postoperative (19 days [range, 11-95 days] vs 12 days [range, 4-58 days]; P<.001) LOS (data given for group 1 vs group 2). Major complications decreased from 49% in group 1 to 25% in group 2 (P<.001). Postoperative LOS decreased for patients with (25 days [range, 15-95 days] vs 20 days [range, 8-58 days]; P = .05) and without (15 days [range, 11-47 days] vs 11 days [range, 4-55 days]; P<.001) major complications (data given for group 1 vs group 2). Multivariate analysis identified age (P = .01), pancreatic fistula (P<.001), delayed gastric emptying (P<.001), biliary complications (P<.001), operative time (P<.005), extra-abdominal infection (P<.005), use of a percutaneous stent (P = .04), and year of operation (P<.001) as independent predictors of total LOS. CONCLUSION: A reduction in complications in combination with factors leading to a streamlining of perioperative care has contributed to the decreased LOS after pancreatoduodenectomy

The recognition of the fundamental role of the spleen in the immune response has led to greater efforts to preserve the spleen after injury. Whenever possible, splenic preservation is the preferred treatment modality for both blunt and penetrating injuries. The past 2 decades have seen an evolution in the way this goal is accomplished. Operative splenic preservation achieved by splenorrhaphy as the most prevalent method for the management of splenic trauma has progressed to the nonoperative management of these injuries. The factor most responsible for bringing about this change has been the development of more sophisticated and accurate imaging techniques in the evaluation of these patients. Splenectomy should be avoided whenever possible, as the procedure continues to be associated with excessive transfusion requirements and increased postoperative sepsis rates