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We demonstrated that the standard clinical criteria of fever, leukocytosis, purulent sputum, and infiltrate on chest radiograph are nonspecific for the diagnosis of post-traumatic pneumonia, and only ∼50 per cent of patients with these conditions have pneumonia. Quantitative cultures of bronchoalveolar lavage effluent will differentiate pneumonia (requiring antibiotic therapy) from systemic inflammatory response syndrome (not requiring antibiotics). Early identification of patients at risk for pneumonia can target populations for clinical research. Because risk factors for pneumonia when diagnosed by quantitative cultures have not been defined we reviewed our recent experience to identify variables predictive of pneumonia. Patients over a 22-month period who survived >48 hours were identified from the trauma registry. Pneumonia was defined as growth of ≥10⁵ organisms per milliliter in the bronchoalveolar lavage effluent. Risk factors evaluated included injury severity and severity of shock. There were 7503 patients (75% with blunt and 25% with penetrating injuries). The incidence of pneumonia was 6 per cent (7% of patients with blunt and 2% of patients with penetrating injuries). Logistic regression analysis identified age; Glasgow Coma Scale score; Injury Severity Score; transfusion requirements during resuscitation; spinal cord injury; chest injury severity; and emergent femur fixation, craniotomy, and laparotomy as being independent predictors of pneumonia. We conclude that multiple risk factors, which are all able to be determined early after injury, are predictive of post-traumatic pneumonia. Prompt identification of this high-risk group of patients allows prognostic considerations relative to patient management schemes and targets populations for prophylactic measures or immunomodulation.

Metastatic squamous cell carcinoma of the soft tissue is extremely rare. We report two patients with soft tissue metastasis from squamous cell carcinoma of the cervix in one and scalp in another. Case 1: A 63-year-old black woman with a history of cervical cancer presented with a painful mass over the right scapula. An incisional biopsy revealed squamous cell carcinoma. She underwent radiation treatment followed by wide local excision with en bloc resection and a myocutaneous flap closure. Case 2: A 46-year-old white man with a history of squamous cell carcinoma of the scalp and two kidney transplantations requiring long-term immunosuppression presented with a 2-month history of a left proximal arm mass. Magnetic resonance imaging revealed that the mass was within the triceps muscle and fixed to the humerus. Biopsy revealed squamous cell carcinoma. He underwent a shoulder disarticulation for tumor invasion into the adjacent humerus and neurovascular bundles. The patients remain disease-free at 12 and 8 months, respectively. To our knowledge there are no reports of soft tissue squamous cell carcinoma metastatic from the cervix and only rare cases from the lung, head, and neck. The optimal mode of treatment and prognosis is undefined in these patients because of its rare incidence. Surgery and radiation with curative intent were used.

Controversy persists regarding the most effective inguinal hernia repair. The purpose of this study is to compare the complications, charges, patient satisfaction, and recovery time between laparoscopic (LH) and open mesh herniorrhaphy (OH). A nonrandomized prospective analysis of 233 consecutive inguinal hernia repairs was performed over a 12-month period by 27 surgeons. The type of repair was determined by surgeon preference. Cost analysis was performed using anesthesia records and hospital cost. Patient satisfaction and recovery time were evaluated by third-party interview. A total of 113 OHs and 120 LHs were performed; 11 OHs and 42 LHs were bilateral. Patient demographics were equivalent for the two groups. No statistical difference was noted when comparing anesthesia/operating room time between the two groups. The LHs accrued an additional charge of $2254 per case. Complication rates were 4.4 per cent for the OHs and 8.3 per cent for the LHs. All complications were considered minor. No infectious complications or recurrences were noted in either group. Satisfaction rates and pain indices were nearly identical for both OHs and LHs. The LHs had a shorter recovery time by 5.5 days. We conclude that LH is associated with a higher complication rate and cost than OH. Pain indices are similar, but LH has a shorter recovery time.

Patients with epilepsy refractory to medical therapy or who experience intolerable side effects from the medication may benefit from placement and activation of a vagus nerve stimulator (VNS) (Cyberonics, Houston, TX). We present our experience with the VNS implanted by a pediatric surgeon and its activation managed by a pediatric neurologist. Six patients (one male and five females) with average age 11 years, 10 months (range 7 years, 4 months to 18 years, 1 month) received VNS implants at a community-based teaching hospital. One patient developed a self-inflicted wound complication secondary to persistent trauma at the implant site that led to removal of the implant. Before VNS implantation the frequency of seizures among the remaining five patients averaged 73 per patient per month (range 20–165). Length of follow-up averaged 6.5 months (range 1.5–11 months). At most recent follow-up seizure frequency averaged 14 per month (range 1–42); this represents an average reduction of 78 per cent (range 30–99%). We conclude that a pediatric surgeon with pediatric neurologic support can safely and effectively perform the VNS implantation at a hospital equipped to administer anesthesia to pediatric patients.

Multiple organ dysfunction syndrome (MODS) is the leading cause of late deaths after traumatic injury. The relative importance of dysfunction of individual organ systems in determining outcome from MODS has not been clearly defined. Some studies have suggested that hepatic dysfunction associated with MODS increases mortality, whereas others have suggested that it contributes little to outcome in trauma patients. To clarify the role of the hepatic dysfunction after traumatic injury we retrospectively reviewed all trauma patients with an Injury Severity Score ≥14 admitted from January 1, 1994 through June 30, 1997 for the presence of hepatic dysfunction defined as a serum bilirubin ≥2.0 mg/dL. Of the 1962 patients who met the entry criteria 154 developed hepatic dysfunction during their hospital stay. Patients with hepatic dysfunction were older (46 ± 2 versus 41 ± 1 years), were more severely injured (Injury Severity Score 31.5 ± 0.9 versus 23.3 + 0.2), and had a lower prehospital blood pressure (102 ± 3 versus 117 ± 1 mm Hg) compared with patients who did not develop hepatic dysfunction. Patients with hepatic dysfunction were more likely to present with shock as reflected in a lower initial emergency room blood pressure (109 ± 3 versus 128 ± 1 mm Hg) and base deficit (-6.9 ± 0.6 versus -3.5 ± 0.1 mEq/L). Patients who developed hyperbilirubinemia had longer lengths of stay in the intensive care unit (15.8 ± 1.2 versus 3.4 ± 0.2 days) and the hospital (27.4 ± 1.7 versus 11.1 ± 0.2 days) and a higher in-hospital mortality (16.2% versus 2.5%). These data demonstrate that the development of hepatic dysfunction reflects the severity of injury and is associated with a significantly worse outcome after traumatic injury.

Nonoperative management of splenic injuries in children is well accepted. However, the need for follow-up abdominal CT to document splenic healing has not been well studied. We retrospectively reviewed initial and follow-up abdominal CT examinations of pediatric patients admitted to our institution with documented splenic trauma who were managed nonoperatively. Eighty-four patients were admitted to our pediatric surgical service with splenic injury documented by CT from 1994 through 1998. The standard approach for splenic injury was bedrest for 5 to 21 days and limited activity for up to 90 days at the discretion of the attending surgeon. Thirty-five of the 84 had follow-up CTs during outpatient follow-up to evaluate and document splenic healing by CT criteria. The initial and follow-up studies were randomized and read blindly by pediatric radiologists using a modified American Association for the Surgery of Trauma grading system (I–V). The age range of the patients was 6 months to 17 years (mean ± SE; 11 ± 1 years). Nineteen (54%) were male and 16 (46%) were female. Causes of splenic trauma included motor vehicle accident (22), fall (seven), assault (four), pedestrian versus vehicle (one), and sports injury (one). Eight children (23%) had grade II injuries, 14 (40%) had grade III injuries, and 13 children (37%) had grade IV injuries on initial CT scan. Seven (88%) of the grade II splenic injuries were healed by 64 ± 11 days. The remaining grade II injury had healed by 210 days. Thirteen (93%) of the grade III splenic injuries were healed by 76 ± 7 days. The remaining grade III injury was healed by 140 days. Spleens in 10 (77%) of the 13 patients with grade IV injuries were healed by 81 ± 8 days. Of the three remaining grade IV injuries two were healed by 173 ± 14 days. The remaining patient's spleen was radiologically considered to have a grade III defect 91 days from the time of injury, and no further CTs were obtained. Of the 34 patients who underwent follow-up CT imaging until splenic healing was demonstrated the mean time to complete healing was 87 ± 8 days postinjury (range 11–217 days). These data suggest that routine follow-up abdominal CTs may not be necessary to allow children to resume their normal activities after an appropriate time of restricted activity.

Iodine-125 brachytherapy is an effective well-tolerated treatment for localized prostate cancer. Gastrointestinal complications of brachytherapy (minor rectal bleeding or tenesmus) are uncommon. Rectal ulceration or rectourethral fistulas after prostate brachytherapy are rare. We present a case of massive refractory rectal bleeding and rectourethral fistula, a complication of prostate brachytherapy never before reported. As a result of the patient's life-threatening symptoms aggressive surgical therapy was necessary.

Gastrointestinal mesenchymal tumors have been classified as benign (leiomyoma) or malignant (leiomyosarcomas). More recently, these tumors have been termed gastrointestinal stromal tumors (GISTs). GISTs have a highly variable clinical course. This review analyzes the clinical presentation, pathologic examination, and long-term follow-up of patients with GIST. A retrospective analysis of the clinical course of patients with GIST at a single institution from 1986 to 1998 was performed. Nineteen patients with GIST (12 gastric, two duodenal, three jejunal, and two rectal) were treated. The most common clinical presentation was gastrointestinal bleed. CT scans, contrast studies, and endoscopy were used to identify a tumor mass. Diagnosis of GIST was made in only two patients preoperatively. Tumor size ranged from 0.8 to 23 cm. Histology of the tumors was variable. All patients underwent surgical resection with curative intent. Follow-up ranged from 2 to 55 months. There were two perioperative deaths. Local recurrence occurred in one patient. GISTs are uncommon. Preoperative diagnosis can be difficult, and often the diagnosis is made at the time of surgery. With complete resection of the tumor the clinical course is favorable with very few local recurrences. Therefore complete resection of the tumor is recommended.

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children ≤16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean ± standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 ± 1.0 years (range 3–16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 ± 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.

The purpose of this study was to evaluate the impact of adjuvant chemotherapy on survival after surgery for T₃N₀ colon cancer. All patients with node-negative (N₀) colon cancer with tumor invasion beyond the muscularis propria (T₃) treated with colectomy between 1982 and 1995 at a single institution were included. Patients were divided into two groups depending on postcolectomy treatment with or without adjuvant chemotherapy. Groups were evaluated to determine perioperative and pathologic variables that could potentially influence outcome and surveillance data to determine disease-free and overall survival. In 253 patients with T₃N₀ colon cancer 226 remained under observation and 27 were treated with adjuvant chemotherapy. The groups were similar (P = not significant) when compared for tumor location, size, differentiation, number of nodes harvested, and transfusion requirements. Four of the 27 patients who received chemotherapy developed a recurrence (14.8%), whereas 22 of the 226 observation patients developed a recurrence (9.7%). Disease-free survival for the chemotherapy group at 5 years was 84 per cent and for the observation group 87 per cent. Statistical analysis (Mantel-Cox) showed no significant difference between the groups on the basis of survival (P = 0.3743). We conclude that resection alone is a highly effective treatment for T₃N₀ colon cancer leaving limited opportunity for adjuvant chemotherapy to significantly impact survival. Adjuvant chemotherapy for T₃N₀ colon cancer patients should be limited to patients enrolled in clinical trials designed to identify subgroups of T₃N₀ colon cancer patients at a survival disadvantage or less toxic adjuvant chemotherapies.

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.

This study attempts to determine by independent review the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair for hernias with increased risk for recurrence. Indicators used for increased recurrence risk were recurrent hernias or simultaneously repaired bilateral inguinal hernias. Office and hospital records of all such patients who had undergone TAPP repair were reviewed from one surgeon's 242-patient laparoscopic inguinal hernia database from 1992 to 1998. All were called for assessment by an independent surgeon at least 4 months postoperatively (median 34 months). Those unable to come in person were interviewed by telephone. There were 121 hernias: 34 recurrent and 100 bilateral (13 overlap). Recurrence rate was 3 per cent, which was similar for repair of bilateral and recurrent hernias. All recurrences occurred within 3 months of surgery. No unknown recurrence was detected by the independent observer. Laparoscopic TAPP inguinal hernia repair, often claimed as the method of choice for bilateral and recurrent hernia repair, is indeed a safe and effective procedure with a low early recurrent rate in these higher-risk situations.

Hemangiomas represent the most common primary tumor of the liver. Clinically the significance of these lesions is highly variable. The management of hemangiomas is controversial and is intimately related to the size, symptoms, and associated comorbidities of the patients who harbor these benign tumors. Series suggest that the vast majority of hemangiomas are less than 4 cm, asymptomatic, and clinically incidental findings. Symptomatic hemangiomas are large and associated with a constellation of vague upper abdominal complaints including pain, mass, distention, early satiety, and weight loss. A number of small series of surgically treated symptomatic hemangiomas have demonstrated enucleation as a safe and effective intervention. We report a collection of case reports using embolization as a primary treatment of symptomatic hemangiomas. The first patient is a 73-year-old black man previously treated for prostate cancer by radical prostatectomy and radiation. He developed weight loss, abdominal fullness, and early satiety. His symptoms were attributed to a large left lateral segmental liver mass that was biopsy proven to be a hemangioma. The second patient is a 49-year-old black women who complained of weakness, fatigue, night sweats, and anemia. The only abnormality discovered was a large right posterior hemangioma. The third patient is a 49-year-old black women with unexplained right upper quadrant pain and anemia who was found to have a 19 x 11 x 7.5-cm left hepatic hemangioma by CT. All three patients underwent elective treatment of their hemangiomas with highly selective hepatic embolization. There were no significant complications related to the procedures. Symptoms resolved for all patients acutely after treatment. The use of embolization for hepatic hemangiomas provides safe and effective treatment of the patient's symptoms while avoiding operative intervention, extended hospitalization, or postoperative recuperation. This treatment modality should be considered for the symptomatic hemangioma under elective conditions.

Since the Vietnam War experience we have known that there is a high association between knee dislocations and popliteal artery injuries. In an effort to improve the quality of care we asked whether every patient with a knee dislocation needs an arteriogram. This is a retrospective chart review of all injured patients who presented to Louisiana State University Health Science Center with knee dislocations between January 1, 1993 and March 31, 1998. Twenty-one patients met the study criteria. There were no deaths in this series. Twelve patients presented with normal palpable pulses. Nine of these 12 patients underwent an arteriogram. There was only one abnormal arteriogram (intimal defect) in this group. None of the patients who presented with normal pulses were operated on. There were no in-hospital complications from this nonoperative management. In the group of patients with either diminished pulses or no pulses arteriograms were performed on all patients. Fifty-five per cent of these arteriograms were abnormal, and one-third of these patients (two) were taken to the operating room for repair. In the group of patients who present with knee dislocations and normal peripheral vascular examination arteriograms are not helpful.

Hyperkalemia is a regularly encountered electrolyte abnormality. Less commonly recognized is pseudohyperkalemia. In vitro clotting results in the release of potassium from the formed elements of blood; this falsely elevates the serum potassium concentration. Usually attributed to thrombocytosis, leukocytosis, or hemolysis it is rarely reported in the postsplenectomy trauma patient. A 49-year-old man underwent splenectomy for a grade IV splenic injury. He developed an elevated serum potassium on postoperative day 16. His renal function remained normal, and an active search for causes of hyperkalemia failed to delineate a source for his elevated potassium. Pseudohyperkalemia was proposed as an etiology and confirmed by analyzing simultaneous serum (5.9 mEq/L) and plasma potassium levels (3.9 mEq/L). The serum potassium showed a concomitant rise with the evolution of the patient's postsplenectomy thrombocytosis. This is a case report of our patient and a literature review of this rarely reported and underestimated cause of a potentially serious electrolyte abnormality. We found through our patient that pseudohyperkalemia does occur in the postsplenectomy population and that this should be included in the differential diagnosis of any patient with an elevated serum potassium level and thrombocytosis.

True vaginal metastases from colonic cancer are exceedingly rare. This often signals an ominous prognosis. More frequently the vagina is synchronously involved by direct contiguous spread from the colonic lesion. We present a case of sigmoid carcinoma with true metastasis to the vagina that was discovered after an interval of 3 weeks when vaginal discharge became evident. To our knowledge, there are only two other papers in the English language previously documenting this phenomenon.

From 1983 through 1997, our center diagnosed 130 cases of benign neoplasms: 27 with focal nodular hyperplasia (FNH), 25 with hepatic adenoma, 71 with cavernous hemangioma, and seven with mixed tumors of different diagnoses. Most often these lesions were seen in females [female-to-male ratio (f/m): 5.5/1]. Hepatic adenomas and mixed tumors were seen exclusively in females and FNH predominantly in females (f/m: 26/1). Hemangiomas, however, were not uncommon in men (f/m: 52/19) relative to the other tumors (P < 0.001). Furthermore patients with hemangioma were older (mean age: 49 years) whereas patients with hepatic adenoma, FNH, and mixed tumors were often younger (mean age: 33, 35, and 44 years respectively; P < 0.004). Oral contraceptive steroid use was related by 21 of 25 patients (84%) with hepatic adenoma, 22 of 26 (85%) females with FNH, five of seven (71%) females with mixed tumors, and 10 of 52 (19%) patients with hemangioma. Ninety-five of the 130 patients (73%) had one or more symptoms. There was no statistically significant correlation between symptoms and the size of the lesion, the final diagnosis, and whether there were solitary or multiple masses. Three of 25 (12%) with hepatic adenoma presented with rupture, and one of 27 (4%) with FNH had such a consequence. None of the hemangiomas presented with rupture or progressed to such a state. One patient with hepatic adenoma (4%) had a focus of malignancy. Surgical removal of benign tumors was performed in 82 of 130 patients (63%), and there was one operative mortality (1.2%) in a patient who had a caudate lobe FNH. The types of surgical procedures included segmentectomy (62%), lobectomy (34%), and trisegmentectomy (4%). In two of 84 patients who had undergone laparotomy resection was not technically possible. Resection is recommended in all cases of hepatic adenoma because of fear of rupture or associated focus of malignancy. FNH was not observed to undergo a malignant transformation and will rarely rupture. Surgery is only recommended for symptomatic hemangioma, and size of the lesion is not a criterion for excision.

The accuracy of skin wire markers on surgical incision scars during mammography to locate the primary tumor excision site was prospectively determined for 100 women. The shortest distance between the excision site and skin scar wire on either the craniocaudal or mediolateral oblique projection was 10 mm or greater in 48 per cent of patients and 20 mm or greater in 30 per cent of patients. Wire markers placed on skin incision scars during mammography after breast-conserving surgery are inadequate for the localization of the primary excision site and should not be used routinely.

Hereditary pancreatitis is an uncommon cause of chronic pancreatitis in Western society. It should be suspected when chronic pancreatitis presents in young adults. The diagnosis is made when chronic pancreatitis is present in several members of the same family who are determined not to have other risk factors for chronic pancreatitis. Molecular research focusing on mutations in the tripsinogen gene has uncovered the genetic defects associated with hereditary pancreatitis, and this knowledge has suggested the possible pathophysiologic mechanism of this disease. Because patients with hereditary pancreatitis develop their disease early in life they are very likely to require treatment for complications. As in patients with chronic pancreatitis of other etiologies those with hereditary pancreatitis should be treated medically for acute exacerbations. When complications occur or when the disease causes intractable pain surgery is recommended. Surgical therapy is tailored to the patient's pancreatic anatomy based on endoscopic retrograde cholangiopancreatography or CT scan. The two patients described in this report underwent successful longitudinal pancreaticojejunostomy (Puestow procedure) with good results. Finally it has been shown that patients with hereditary pancreatitis are at increased risk for developing pancreatic adenocarcinoma. Although not widely used pancreatic cancer screening programs have been suggested for surveillance of these patients.

A 20-year retrospective case series was analyzed to identify the brown recluse spider bite as a cause of necrotizing fasciitis. Data from 31 consecutive patients with necrotizing fasciitis were analyzed. Of the 31 patients with necrotizing fasciitis a brown recluse spider bite was found to be the initial cause in two patients. Both patients with spider bites delayed in obtaining medical treatment, and secondary infection of the necrotic tissue occurred. One patient was diagnosed by frozen section tissue biopsy, and the second patient was diagnosed by clinical examination. All patients in this series had immediate aggressive operative debridement. Both patients survived with functional limbs. There were no deaths in this large series. Necrotizing fasciitis can be caused by a secondarily infected brown recluse spider bite. Successful treatment of necrotizing fasciitis from any cause is associated with early diagnosis, immediate surgical debridement, and supplemental enteral or parenteral nutrition.

Although it is a rare occurrence among all pelvic hernias diagnosed the obturator hernia continues to be a diagnostic challenge for surgeons today. These patients, who often have multiple concurrent medical problems, are subject to high morbidity and mortality rates resulting from late presentation and delayed surgical intervention. The vast majority of patients with obturator hernias are admitted with signs and symptoms of intestinal obstruction, namely anorexia, nausea, vomiting, constipation, and distension of 2 to 3 days’ duration. In this paper, however, we highlight a small subset of obturator hernia patients who present without obstructive symptoms and do well after elective repair. The case reports that follow serve to compare and contrast two very different presentations of this surgical problem.

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