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The trauma patient population is at special risk for fatal pulmonary embolism. We experienced 11 fatalities in one 12-month period. Specific risk factors for both deep venous thrombosis and pulmonary embolism can be identified among trauma patients. The latter usually cannot be offered prophylactic anticoagulation, and the nature of their injuries (e.g., long bone fractures) makes not only bedside surveillance difficult but also precludes use of pneumatic compression, etc. We have developed a protocol for prophylactic inferior vena caval filtration for our trauma patients deemed at particular risk for pulmonary embolism. Since 1986 we have inserted 205 Greenfield filters in 201 patients. Two hundred were inserted prophylactically. There was no mortality, and morbidity was minimal. No patient with a Greenfield filter sustained a fatal pulmonary embolism during this period. Four patients died from pulmonary embolism before vena caval filters could be inserted. We believe that the trauma patient, at risk for pulmonary embolism, should be offered a Greenfield filter prophylactically as soon after hospitalization as logistically possible.

All patients undergoing a post-traumatic colostomy closure at the New Jersey Medical School Affiliated Hospitals from 1974 to 1978 were studied for the effect of timing and technique of colostomy closure on postoperative complications. Analysis showed that patients in whom the colostomy was closed between six weeks and three months had a significantly shorter operating time when compared with those operated upon less than six weeks after formation of the colostomy. They also had a lower infection rate, shorter time to intestinal function and shorter postoperative hospital stay. Patients undergoing closure of a loop colostomy were analyzed for the technique of closure. Those patients undergoing a simple loop closure had a significantly shorter length of operation time, lower infection rate and shorter time to return of intestinal function. The safest time to close a colostomy created for trauma is between six weeks and three months. The reason for the increased complication rate in the early group is technical difficulty due to incomplete resolution of the edema and inflammatory reaction. Every effort should be made to close a loop colostomy without resorting to resection.

A case of giant recurrent intra-abdominal desmoid tumor is presented. A history of childbirth, antecedent surgery, multiple episodes of recurrence, resistance to excisional and radiation therapy, represent common features of desmoid tumors. The size of the recurrence (15.4 kg), the intra-abdominal presentation of the tumor, involvement of the chest wall and focal infiltration of the small bowel are unusual features of this case.

The reality of late overwhelming post-splenectomy sepsis in adults as well as children has led to more frequent attempts at splenic salvage following splenic trauma. Less attention has been paid to early septic postoperative complications in the splenectomized patient. Associated colon injury has been believed to be a relative contraindication to splenic conservation. If splenectomy enhances the chance of early postoperative infection, then associated colon injury should be an indication for splenic salvage One hundred sixty one patients who had either splenic trauma (58), colon trauma (90), or combined spleen-colon trauma (13) were studied. All patients with splenic trauma had a splenectomy. There was a significantly higher incidence of intra-abdominal sepsis requiring reoperation in the spleen-colon patients (46.7%) than in either of the other groups (spleen = 5.7%, colon = 8.9%, P less than .002 for both comparisons). It is concluded that splenectomy enhances infection in the early postoperative period. When possible, combined spleen-colon trauma should be an indication rather than a contraindication for splenic salvage.

A retrospective study of 50 patients undergoing reoperation for sepsis was performed to evaluate the ability of commonly available clinical and laboratory tests to predict the findings at reoperation and the outcome after operation. The influence of multiple organ failure on these parameters was also studied. No laboratory finding helped to predict operative findings. Computed tomographic scanning (80% accurate) was the most helpful radiographic procedure. A low total lymphocyte count and a high serum creatinine level both predicted a fatal outcome. No single organ failure or combination predicted a positive reexploration. Infection was found in 75 per cent of patients with multiple organ failure and 79 per cent of patients who did not have this syndrome. Patients having three-organ failure did have a significantly higher mortality. The mortality of a negative reexploration was 18.2 per cent, slightly lower than the 28.2 per cent mortality of patients with a positive exploration. No patient without organ failure died. The authors conclude that laboratory tests are not helpful in predicting the presence of infection on reexploration, that the decision to reoperate is one based primarily on clinical judgment, and that if reoperation is performed before the development of organ failure, the risk associated with a negative exploration is worth taking.

This report examines the efficacy of preoperative antibiotics in cases of nonperforated appendicitis. The charts of 61 patients who had an operative and pathologic diagnosis of acute nonperforated appendicitis were reviewed. Thirty-one patients received preoperative cephalosporins, and in one patient (3.2%) a subsequent wound infection developed. Of 30 patients who did not receive preoperative antibiotics, four (13.2%) patients developed septic complications. The difference in postoperative septic complications between these groups is not statistically significant (P = .3310). Preoperative prophylaxis with cephalosporins in cases of nonperforated appendicitis is not indicated.

It has been stated that breast cancer survival rates follow an exponential distribution. This would mean that the mortality rate is constant. Survival distribution was analyzed by the clinical life table method in one series of 10,752 patients and in another of 656 patients followed up to 8 and 18 years, respectively. Part of the larger series' table is (table: see text). Necessarily, clinical survival data are censored progressively. These kinds of data are analyzed best by examining the hazard function, which is the instantaneous death rate, or force of mortality. If an exponential distribution described survival in breast cancer correctly, the hazard function would be constant. These data clearly are not consistent with an exponential distribution, as the hazard function decreases. The survival distribution calculated from these data shows that the chance of dying of cancer decreases the longer a patient survives. This is more optimistic and consistent with clinical experience than is the exponential distribution.

Controversy persists regarding the use of antibiotics in association with t tube thoracostomy for trauma patients. We conducted a prospective randomized study of patients requiring tube thoracostomy for pneumo- and/or hemothorax complicating blunt or penetrating thoracic trauma in an attempt to assess the efficacy of prophylactic antibiotic therapy. Fifty-eight patients were included in the study. The control group (Group I) included 28 patients who received no antibiotic therapy: the experimental group (Group II) included 30 patients who received cefoxitin (1.0 gm IV q 6 h) commencing before tube thoracostomy and terminating 12 hours after its removal. The incidence of infectious complications (pneumonia and/or empyema) was recorded. Among the patients not receiving antibiotics, eight of 28 (29%) developed infectious chest complications. Of the patients receiving antibiotics, there was one infectious complication (3%). This difference is statistically significant (p = 0.0227). Cultures demonstrated significant conversion from negative to positive both within each group and between groups. The organism most commonly recovered was S. aureus. Our findings strongly suggest that patients requiring tube thoracostomy for trauma, whether blunt or penetrating, should receive the benefit of systemic prophylactic antibiotic therapy.

Responses of general surgeons to a questionnaire on breast cancer were analyzed to determine the current trends in the management of this disease. A 21-item questionnaire was mailed to members of the New Jersey Chapter of the American College of Surgeons in 1982 and the responses, received on noncoded, anonymous answer sheets, were analyzed for frequency distribution. These responses were compared to previously recorded responses to the same questions for 1971 and 1977. Seventy-six percent of the respondents in 1982 performed needle aspirations often or always, compared to 36% in 1971 and 80% in 1977. The use of routine mammography has increased from 16% in 1971 and 20% in 1977 to 38% in 1982. Modified radical mastectomy is now the most common type of procedure employed in the management of stage I breast cancer, with 89% of respondents in favor of this approach compared to 15% in 1971 and 60% in 1977. Fifty-nine percent of the respondents are not opposed to breast reconstruction following mastectomy versus 14% in 1971 and 49% in 1977. For patients with axillary nodes, chemotherapy with multiple agents was recommended by 76% of general surgeons in 1982, compared to 58% in 1977. These results indicate a continuing trend towards increasing use of needle aspiration and routine mammography for diagnosis and for employment of chemotherapy with multiple agents in the adjuvant treatment of patients with positive axillary nodes. Furthermore, modified radical mastectomy is the operation of choice for stage I cancer of the breast for increasing numbers of surgeons.

Trauma is an unusual cause of fistula formation between the aorta and the inferior vena cava. Two cases of traumatic aorto-caval fistula treated at the New Jersey Medical School affiliated hospitals are presented and the literature on traumatic aorto-caval fistula reviewed. We found 14 previously reported cases. Delayed repair was performed in 12 (86%). Delays ranged from 5 days to 12 years postinjury. Cardiac decompensation, judged either clinically or by cardiomegaly evident on chest X-ray, was present in 75% of the patients undergoing delayed repair. The techniques available for repair and the criteria for utilizing delayed repair are discussed. In young, previously healthy patients, usually with smaller fistulae, we conclude that delayed repair can be used.

Various types of drains were inserted into the peritoneal cavity of twenty-eight dogs. After one to seven days, all drains failed to show the presence of 200 cc of colored fluid injected intraperitoneally. On autopsy, all tubes were surrounded and occluded by omentum.

In planning the management of a colonic injury, several factors must be taken into account, including the age of the patient, the cause of the wound, the time lapse from injury to operation, area and the type of wound, the amount of fecal soilage, and the number and extent of associated injuries. For extensive wounds with associated injuries, fecal contamination of the abdomen, or delay from injury to treatment, a two-stage procedure is preferred. Primary closure or primary resection is the preferred treatment for right colon injuries, depending on the severity of the injury. Resection and anastomosis should not be performed in the left colon without a diverting colostomy. Exteriorization is a satisfactory procedure for major colon injury; however, exteriorization and repair have a higher associated complication rate than exteriorization alone. Primary repair is a safe and acceptable procedure, irrespective of the site of injury. Indications for primary repair may, in the future, be expanded to include those wounds presently being treated by exteriorization.

To determine the amount of exposure to technical procedures received by students at the New Jersey Medical School, Newark, NJ, during their first surgical clerkship, a prospective study was carried out over a 3-year period. Students completing each 12-week clerkship filled in a questionnaire to indicate whether they had received exposure to a series of technical procedures. The study showed that students received relatively little experience in some important, though less commonly employed, techniques. It is therefore recommended that: (a) the instruction in technical procedures be carried out on a planned basis; (b) performance of some routine laboratory tests by students be curtailed to permit more time for technical experience in other areas; and (c) the dog laboratory be utilized for the teaching and practice of surgical procedures.

Mortalities in a surgical intensive care unit during a three year period were reviewed. The over-all mortality was 8.2 per cent. Sixty-four per cent of the deaths followed nontraumatic surgical illness and 36 per cent followed trauma. Eighty-one per cent of patients died as a direct result of traumatic injuries, while only 19 per cent died of sepsis or multiple organ failure. On the other hand, 62 per cent of the nontrauma related deaths were a consequence of sepsis or multiple organ failure. Further research into cellular support is needed to reverse the problem of sepsis related organ failure.