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The Midwest Surgical Association (MSA) was created to combine surgical science with extracurricular amenities, such as family, collegiality, and history. As such, one of the members of the council serves as the official historian. Thank you, Dr. Bill Cirocco, our former president, Dr. Jeffrey Hardacre, our current president, and Dr. Rick Berg, our historian, for the opportunity to present this lecture on Dr. Alexander J. Walt: historian, philosopher, and surgical educator. His friends called him Alec.

Background and Aim Pancreaticobiliary anomalies are rare and often present with cryptic signs and symptoms, thus delaying appropriate treatment. Methods Endoscopic retrograde cholangiopancreatography (ERCP) was used to define pancreaticobiliary anomalies. A retrospective review was performed of 5522 ERCPs conducted at a tertiary care center from 1972 to 2015. Results There were 249 (4.5%) patients with pancreaticobiliary anomalies, including 179 patients with pancreas divisum (PD), 44 patients with choledochal cyst (CC) (Todani's classification Type I: extrahepatic cyst 31, Type III; choledochocele 9, Type V: Caroli's disease 4), 20 patients with anomalous pancreaticobiliary ductal union (APDU), and 6 patients with other abnormalities. Of 179 patients with pancreas divisum, 8 (4.5%) required minor sphincterotomies for multiple unexplained acute pancreatitis. Of the 31, 15 (48%) Type I CC patients underwent an operation. In patients with Type III CC (choledochocele), seven of the nine were treated by endoscopic sphincterotomy, and two patients were treated by surgery. Four patients with Type V CC (Caroli's disease) were managed nonoperatively. Of the 20 patients with APDU, 8 (40%) required operative intervention. Six patients were found to have other anomalies: two with pancreas bifidum, one with a duplication of the gallbladder, one with a cystic duct diverticulum, one with an annular pancreas, and one with an abnormal cystic duct origin. These patients were treated based on their etiology. Conclusion Pancreaticobiliary anomalies are rare and can be defined using ERCP. The appreciation of these abnormalities is important for the proper diagnosis and treatment of these rare biliary and pancreatic disorders., Pancreaticobiliary anomalies were analyzed using endoscopic retrograde cholangiopancreatography (5522 patients) in an urban medical center in the United States. A total of 249 (4.5%) patients were found to have a pancreaticobiliary anomaly. There were 179 patients with pancreas divisum, 44 patients with choledochal cyst, 20 patients with anomalous pancreaticobiliary ductal union, and 6 patients with other abnormalities.

Purpose Measuring total blood volume (TBV) in critically ill patients, using isotope techniques to determine red cell volume (RBCV) and plasma volume (PV) is laborious. Recently, PV measurement using a single bolus dose of tracers has been validated, thus, allowing TBV calculation using large venous hematocrit (LVHCT). However, this technique relies on using a correlation factor, the f-cell ratio, to adjust for differences in LVHCT and total body hematocrit (TBHCT). The normal f-cell ratio is 0.9 but has never been studied in patients recovering from hemorrhagic shock (HS). This study assesses the f-cell ratio at different phases after HS to determine accuracy in calculating TBV. Methods 114 injured patients requiring immediate operation for HS were studied. All patients had measurements of PV and RBCV via isotope dilution enabling measurements of TBHCT. Correlation of LVHCT and TBHCT were used to calculate the f-cell ratio in the fluid sequestration (n = 81) and in the fluid mobilization period (n = 108). Results The f-cell ratio (mean ± SD) averaged 0.89 ± 0.15 and 0.90 ± 0.01 in the first and second halves of the fluid sequestration period versus 0.90 ± 0.2 and 0.80 ± 0.07 in the first and second 48 h of the fluid mobilization period. The f-cell ratio was significantly lower (p=, Highlights • Accurate measurements of total blood volume in critically injured patients would be very helpful. • Direct measurements of total blood volume blood components are very laborious. • Total blood volume can be estimated using large venous hematocrit and a correction factor. • The value of f cell ratio is not static during phases of recovery from hemorrhagic shock. • Variability of f cell ration limits utilization in patients recovering from hemorrhagic shock.

Objective:To review the history of the innovation of damage control (DC) for management of trauma patients.Background:DC is an important development in trauma care that provides a valuable case study in surgical innovation.Methods:We searched bibliographic databases (1950–2015), conference abstracts

Background Nonoperative management (NOM) of most liver injury (LI) compromises teaching of technical skills required for intraoperative LI hemostasis. This study assesses this void. Methods The records of patients (pts) admitted for LI during two years (1/1/16–12/31/17) were compared to pts treated during two-year intervals for the last six decades. Treatment included NOM, operation only (OR/only), suture (Sut), tractotomy (Tra), dearterialization (HAL), and resection (Res). Results During 2016/2017, 41 pts had penetrating (23) or blunt (18) LI. Treatment for penetrating LI was NOM (4), OR/only (12), and hemostasis (7) with Sut (3), HAL (1), Tra (1), and Res (2). Treatment for blunt LI was NOM (16) and OR/only (2). 14 residents performed an average of 0.5 procedures. During six decades, LI requiring hemostasis was 121, 114, 30, 48, 17, and 7 per decade. Concomitantly, the percent having NOM or OR/only was 46%, 47%, 62%, 59%, 72%, and 83%. Conclusion NOM precludes adequate training for hemostasis of LI. Technical proficiency for LI hemostasis requires training in Advanced Trauma Operative Management (ATOM), Advanced Surgical Skills for Exposure in Trauma (ASSET), and rotation through a liver transplant or hepatobiliary service.

Introduction Acute hemorrhagic rectal ulcer (AHRU) is a rare entity which has most frequently been described in Japan and Taiwan literature. This study characterizes 11 AHRUs identified and managed at an urban acute care hospital in the United States of America (USA). Methods A total of 2253 inpatients underwent colonoscopy. In 1172 patients (52%), colonoscopy was performed for evaluation of lower gastrointestinal (LGI) bleeding. Eleven (0.9%) of the 1172 patients with LGI bleeding had AHRU. Results AHRU is characterized by a sudden onset of painless and massive lower rectal bleeding in elderly, bedridden patients (pts) with major underlying diseases. The endoscopic findings were classified into 4 types. All 11 ulcers were located in the distal rectum within 10 cm of the dentate line. All 11 patients required blood transfusion (mean = 3.7 units; range 2-9 units). Seven patients responded to blood, plasma, and platelet transfusions. The other 4 patients required endoscopic hemostasis.Three patients died within a month of colonoscopy from comorbidities. None had bleeding as a cause of death. Eight surviving patients did not have recurrent bleeding. Conclusion AHRU does exist in the USA and should be considered as an important cause of acute lower GI bleeding in elderly, critically ill, and bedridden patients. AHRU should be recognized and managed correctly.

The Injury Severity Score (ISS) and the New ISS (NISS) underscore injury severity after GSW. This study assesses the Urban ISS (UISS), which incorporates all injuries.Complete trauma program registry (TPR) data and chart analyses were performed on 585 patients (pts) over 28 months. Factors analyzed included age, gender, ISS, NISS, UISS, time of admission, intent of injury, race, number GSW, weapon, and outcome.The 585 patients could be categorized within three groups. The first group included 98 pts with low ISS (1-2), no organ injuries, and early discharge; the second group included 47 patients with severe shock who died during operation; the third group of 442 pts were admitted after operation. All injury scores correlated (p 0.001) with assault, number GSW, death, and length-of-stay (LOS). Death and LOS correlated closely with assault and the resultant number of GSW, best seen with UISS compared to ISS or NISS. Race and admission time did not correlate with death or LOS.UISS correlates better than ISS and NISS in victims of inner-city firearm injuries.

Gastric prophylaxis against stress ulceration with histamine 2 blockers or protein pump inhibitors is a quality standard in septic Surgical Intensive Care Unit (SICU) patients to reduce gastric pH below 3.5. This study assesses the efficacy of gastric prophylaxis with pH monitoring.A total of 100 patients were studied for 481 days. All received histamine 2 blockers or protein pump inhibitors. Daily pH control was judged as poor (1-3), moderate (4-5), or good (5). Patients with poor pH received double-dose or an infusion gastric prophylaxis. Nasogastric tube bile or blood and transfusions for stress ulceration were recorded.Gastric prophylaxis was poor for 37 days, moderate for 83 days, and good for 279 days. NGT blood occurred on 15 days (40%) with poor, 17 days (20%) with moderate, and 17 days (6%) with good control. Transfusions for stress ulceration occurred on 5 days (14%) during poor, 3 days (4%) during moderate, and 1 day (0.3%) during good control (P.05). Enhanced gastric prophylaxis improved pH control and reduced nasogastric tube blood. Transfusion for stress ulceration after enhanced therapy was required on 1 day (8%) with poor control and never for moderate or good control.Gastric prophylaxis against stress ulceration should be monitored by nasogastric tube pH.

Surgeons always like to perform their magic on young adults who are in training in some athletic event for the upcoming Olympics. Unfortunately, our society continues to age so that more and more operations are performed in the elderly. The challenges of surgery in the geriatric population relate to the adverse events that aging has on both physical well-being and mental acumen. The extent of physical derangement is often referred to by the popular term “frailty” whereas the progressive mental deterioration often falls under the name of “Alzheimer’s disease.” Although aging, per se, is not the cause of fragility or reduced acumen, the trend is for both to become progressively worse each year. Clearly, the effect of fragility and decreased cognitive function impair successful surgical treatment. This is true not only for elective surgery but especially for emergency operations after injury.

BACKGROUND Recent data suggest that intraoperative (Phase I) colloid (human serum albumin [HSA]) and a high fresh frozen plasma (FFP)/red blood cell (RBC) resuscitation will reduce postoperative (Phase II) fluid uptake. This study compares a noncolloid (balanced electrolyte solution [BES]) plus low (≤ 0.35) FFP/RBC resuscitation (Group A) with an HSA plus high (>0.35) FFP/RBC resuscitation. METHODS A previous randomized study of 94 patients included 48 BES patients and 46 HSA patients. A Subgroup A of 25 BES patients with low FFP/RBC was compared with a Subgroup D of 21 HSA patients with high FFP/RBC. Parameters monitored included Phase I vital signs and resuscitation needs; Phase II duration, BES needs, weight gain, and hourly urine output; and postoperative plasma volume (PV) by radioiodinated serum albumin (RISA), extracellular fluid (ECF) volume by inulin space, and interstitial volume by ECF-PV. RESULTS Admission pulse (132 for A vs. 133 for D), systolic blood pressure (SBP) (74 for A vs. 74 for D) and Phase I shock time (SBP < 80 Torr; 25 for A vs. 35 for D) were similar. Phase I RBC needs (12.5 ± 1.3 for A vs. 14.9 ± 1.7 for D) and BES needs (8.4 ± 0.6 L for A vs. 8.4 ± 0.6 L for D) were similar. During Phase II, D patients had more RBC, comparable BES, and weight gain, with lower hourly urine output compared with Group A patients. CONCLUSION HSA with high FFP/RBC does not prevent Phase II fluid uptake and causes lower urine output despite increased PV. Colloid reduces glomerular filtration, increases tubular reabsorption, and increases ECF, thus, prolonging Phase II. LEVEL OF EVIDENCE Therapeutic study, level IV.

Background During the past 50 years many changes have occurred in treating liver injury. Nonoperative therapy (NOT) for blunt penetrating injuries is now common. Study design This report highlights the current therapy of liver injury. Results Complications of NOT include early rebleeding requiring prompt operative intervention; intrahepatic hematoma which becomes infected necessitating drainage; bile peritoneum requiring exploration and drainage; and hemobilia requiring embolization, hepatotomy with ligation, or resection. Operative exposure through a midline incision which can be extended as a median sternotomy is preferred. Prehepatic and intrahepatic packs are helpful. Full mobilization of the right and left triangular ligaments augments exposure. Hemostasis for both blunt and penetrating, usually, is obtained by hepatorrhaphy using the 2’ blunt tipped needle swedged onto a 2-O chromic suture. Through-and-through injuries may require hepatotomy with intrahepatic ligation of cross-linking vessels. Locally destructive wounds may require nonanatomic debridement to the point of healthy liver tissue which is then sutured. Formal segmentectomy, or lobectomy, is seldom needed. Hepatic artery ligation controls deep arterial not involving the portal venous supply. The retrohepatic caval atrial shunt will facilitate hemostasis from central liver injuries involving the hepatic veins or retrohepatic cava. Debridement of emacerated liver tissue should be extended to good liver parenchyma where deep liver sutures help with approximate the edges. Drainage is not used for minor injuries. Closed suctions are best for larger wounds. Common duct drainage should be avoided. Conclusion Most liver injuries are treated by NOT. Operative therapy involves hemostasis, debridement when necessary, and selective drainage. How to cite this article Lucas CE. The Evolution of Liver Injury Diagnosis and Treatment in the Past 50 Years. Panam J Trauma Crit Care Emerg Surg 2014;3(3):124-131.

RESUMEN Antecedentes Las drogas callejeras ilícitas son omnipresentes. Los estereotipos de drogas son la heroína, la clásica ‘depresora’ y la cocaína, la clásica ‘estimulante’. Su mezcla con el alcohol mejora sus efectos. Método de estudio Este estudio evalúa las complicaciones quirúrgicas del uso de la heroína y la cocaína. Resultados Las complicaciones de la heroína se deben a la contaminación de la heroína durante la dilución realizada con fines de lucro. Las inyecciones de ‘droga mixta’ causan abscesos y celulitis. La infección poli-microbiana puede propagarse rápidamente y requerir desbridamiento extenso. La amputación del antebrazo o miembros inferiores puede ser requerida. La inyección intravenosa produce tromboflebitis, miembros post-flebíticos, neumonía y endocarditis. Una inyección intra-arterial errante, ‘meñique’, causa embolias capilares distales con dígitos gangrenosos y pseudoaneurismas debido a la hemorragia del absceso perivascular. Estos requieren excisión. La endocarditis es a menudo refractaria a los antimicrobianos requiriéndose de una valvulectomía. Se requiere de una esplenectomía para un absceso para prevenir la reinfección de las válvulas del corazón. Las complicaciones de la cocaína reflejan sus intensas propiedades vasoconstrictoras. Esto puede causar despolarización cardiaca con arritmias y muerte súbita, accidente cerebrovascular isquémico, y perforación esplácnica debida a isquemia focal dentro del duodeno, intestino delgado o el colon. Perforaciones esplácnicas requieren resección. El infarto esplénico inducido por la cocaína con o sin hemorragia requiere de una esplenectomía. La cocaína puede causar oclusión vascular por vasoespasmo de los vasa vasorum causando isquemia de la íntima y trombosis; esto puede implicar a la aorta. ‘Empacadores Cuerpo’ que se tragan los paquetes de cocaína de contrabando se encuentran en grave peligro si se rompe el paquete antes de ser excretada con la defecación; requieren operación rápida. Conclusión El conocimiento de las complicaciones de drogas de la calle permite un abordaje quirúrgico racional. How to cite this article Lucas CE. Surgical Challenges associated with the use of Illicit Street Drugs. Panam J Trauma Crit Care Emerg Surg 2014;3(3):114-123.

Background This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones. Methods The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES. Results All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval. Conclusions ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.

Background Chronic neurogenic pain after surgery, especially inguinal herniorrhaphy, remains a major cause of morbidity. The traditional treatment of postinguinal herniorrhaphy neurogenic pain has included triple neurectomy with the removal of any mesh. This report describes a directed, minimally invasive surgical neurectomy that provided pain relief in 28 patients with minimal morbidity. Methods After temporary but successful proximal peripheral nerve blockade, the nerve was blocked in the operating room using a small amount of blue dye mixed with the local anesthetic. After confirming pain relief with the dye-anesthetic mixture, the patient was then sedated, and all blue-stained tissue was excised through a small incision, avoiding both the previous surgical scar and mesh. Results All but 1 of the 28 patients had complete relief for a minimum of 12 months when discharged from follow-up. Conclusions This simple directed neurectomy method typically provides long-term relief for patients suffering from chronic postsurgical neurogenic pain.

Recent trends of splenic injury management in the 21st century emphasizes nonoperative treatment in children and adults. The clinician must base his treatment on clinical criteria on hemodynamic stability and associated injuries. The risk of overwhelming post-splenectomy sepsis is very low and should not influence the decision to operate, if the clinical condition demands it. How to cite this article Lucas CE. 21st Century Approach to Splenic Injury. J Trauma Critical Care Emerg Surg 2013;2(3): 116-125.

To review the history of the innovation of damage control (DC) for management of trauma patients.DC is an important development in trauma care that provides a valuable case study in surgical innovation.We searched bibliographic databases (1950-2015), conference abstracts (2009-2013), Web sites, textbooks, and bibliographies for articles relating to trauma DC. The innovation of DC was then classified according to the Innovation, Development, Exploration, Assessment, and Long-term study model of surgical innovation.The "innovation" of DC originated from the use of therapeutic liver packing, a practice that had previously been abandoned after World War II because of adverse events. It then "developed" into abbreviated laparotomy using "rapid conservative operative techniques." Subsequent "exploration" resulted in the application of DC to increasingly complex abdominal injuries and thoracic, peripheral vascular, and orthopedic injuries. Increasing use of DC laparotomy was followed by growing reports of postinjury abdominal compartment syndrome and prophylactic use of the open abdomen to prevent intra-abdominal hypertension after DC laparotomy. By the year 2000, DC surgery had been widely adopted and was recommended for use in surgical journals, textbooks, and teaching courses ("assessment" stage of innovation). "Long-term study" of DC is raising questions about whether the procedure should be used more selectively in the context of improving resuscitation practices.The history of the innovation of DC illustrates how a previously abandoned surgical technique was adapted and readopted in response to an increased understanding of trauma patient physiology and changing injury patterns and trauma resuscitation practices.

BACKGROUND: Controversy exists about the ideal fresh frozen plasma/red blood cell (FFP/RBC) ratio for resuscitation of patients requiring massive transfusion (MT). This study correlates the FFP/RBC with clotting time (CT), prothrombin time (PT), partial thromboplastin time (PTT), and thrombin time (TT); with procoagulants (fibrinogen [FI], factor 5 [FV], and factor 8 [FVIII]); and with adult respiratory distress syndrome (pO2/FIO2). METHODS: The 32 patients studied in operating room (OR) were in shock for 47 minutes and received an average of 17.6 units RBC, 4.2 units FFP, and 14.2 L balanced electrolyte solution. The 53 patients (including 22 of the OR patients), studied an average of 9.5 hours after operation, had an average shock time of 42 minutes, and received 17.4 units RBC, 4.6 units FFP, and 12.3 L balanced electrolyte solution in OR. RESULTS: The FFP/RBC in OR averaged 0.3:1 (range: 0.1:1 to 0.9:1). The OR study, done after a minimum of 10 RBC units at 3.8 hours, showed a PT of 3.5 seconds off normal (international normalized ratio < 1.3), a PTT of 34 seconds, and TT of 7.9 seconds off normal. FI, FV, and FVIII were restored to 148 mg/dL, 54%, and 81%. The pO2/FIO2 was 282. The early post-OR study showed a PT of 2.3 seconds off normal (international normalized ratio = 1.2), a PTT of 32 seconds, a TT of 7.2 seconds off normal, an FI of 207 mg/dL, an FV of 64%, an FVIII of 102%, and a pO2/FIO2 of 332. Both OR and early post-OR CTs and procoagulant levels are associated with adequate coagulation. All patients with a 0.31:1 or higher FFP/RBC had sufficient restoration of CTs and procoagulants. CONCLUSION: These data show that an FFP/RBC ratio above 0.31:1 in injured patients requiring MT restores CTs and procoagulant to clinically effective levels while not causing adult respiratory distress syndrome. Future studies on defining the ideal FFP/RBC ratio for MT should monitor CTs, procoagulants, and organ function.

Background Many changes regarding the use of blood and blood products for resuscitation of severely injured patients have occurred in the past 50 years. This study presents these changes. Study design A review of resuscitation regimens over 50 years is presented. Results During the 1960s, hemorrhage shock (HS) was treated with whole blood (WB) and balanced electrolyte solution (BES); fresh WB restored the labile factors (FV and FVIII) during massive transfusion (MT). When component therapy with red cells (RBC) was started, plasma (FFP) had to be added; patients with MT received a 2/5 RBC/FFP ratio. Platelets were reserved for oozing or counts below 50,000. During the Vietnam conflict, many recommended supplemental albumin therapy. A large prospective randomized study showed that albumin therapy caused many adverse effects including coagulopathy. During the 1980s, the National Institute of Health (NIH) responded to a shortage of FFP by initiating a consensus development conference (CDC) which concluded that FFP was not indicated without an established coagulopathic bleeding; animal HS models showed FFP was beneficial. During the 1990s, military surgeons recommended a 1/1 FFP/RBC ratio. Studies, herein, demonstrated that a 0.3/1 FFP/RBC ratio effectively restored procoagulants; whereas, ratios above 0.45/1 FFP/RBC caused increased BES needs and longer stays. Conclusion Initial therapy for HS should be BES followed by RBC to maintain hemoglobin, perfusion and urine output. FFP should be supplemented after 5 units RBC using a 0.5 FFP/ RBC until hemostasis is obtained. Platelets should be added for ‘medical’ oozing and thrombocytopenia. How to cite this article Lucas CE. A Panoramic View of Blood and Blood Product: Use in the Past Half Century. Panam J Trauma Critical Care Emerg Surg 2012;1(3):139-145.

Run time variability of parallel applications continues to present significant challenges to their performance and energy efficiency in high-performance computing (HPC) systems. When run times are extended and unpredictable, application developers perceive this as a degradation of system (or subsystem) performance. Extended run times directly contribute to proportionally higher energy consumption, potentially negating efforts by applications, or the HPC system, to optimize energy consumption using low-level control techniques, such as dynamic voltage and frequency scaling (DVFS). Therefore, successful systemic management of application run time performance can result in less wasted energy, or even energy savings. We have been studying run time variability in terms of communication time, from the perspective of the application, focusing on the interconnection network. More recently, our focus has shifted to developing a more complete understanding of the effects of HPC subsystem interactions on parallel applications. In this context, the set of executing applications on the HPC system is treated as a subsystem, along with more traditional subsystems like the communication subsystem, storage subsystem, etc. To gain insight into the run time variability problem, our earlier work developed a framework to emulate parallel applications (PACE) that stresses the communication subsystem. Evaluation of run time sensitivity to network performance of real applications is performed with a tool called PARSE, which uses PACE. In this paper, we propose a model defining application-level behavioral attributes, that collectively describes how applications behave in terms of their run time performance, as functions of their process distribution on the system (spacial locality), and subsystem interactions (communication subsystem degradation). These subsystem interactions are produced when multiple applications execute concurrently on the same HPC system. We also revisit our evaluation framework and tools to demonstrate the flexibility of our application characterization techniques, and the ease with which attributes can be quantified. The validity of the model is demonstrated using our tools with several parallel benchmarks and application fragments. Results suggest that it is possible to articulate application-level behavioral attributes as a tuple of numeric values that describe course-grained performance behavior.

Adult trauma centers (TCs) in the United States may be verified with an on-call operating room team if the performance improvement program shows no adverse outcome. Using queuing and simulation methodology, this study attempts to add a volume guideline for injured children.Data from 63 verified TCs identified demographic factors including specific information regarding the first pediatric trauma-related operation done between 11 pm and 7 am each month for 1 year.The annual pediatric admits correlated with the number of operations (383) done from 11 pm to 7 am (P.001). The probability of operation within 30 minutes of arrival varies with the number of admits and the percent of penetrating vs blunt injuries. This likely number of operations from 11 pm to 7 am beginning within 30 minutes of patient arrival would be 3.45, 4.21, and 4.95 for TCs admitting 150, 250, and 350 injured children per year, respectively. The probability that 2 rooms would be occupied simultaneously is 0.074 and 0.109 for centers with 160 and 260 pediatric trauma admissions, respectively.Trauma centers performing less than 6 pediatric trauma operations per year from 11 pm to 7 am could conserve resources by using an on-call operating room team.

This study highlights the inherent challenges of achieving psychomotor skills in an era of nonoperative therapy for solid organ injuries. Technical procedures on the liver, the most frequent intra-abdominal solid organ injured, were assessed in five decades.Guided by prospective assessment and registry data, all patients with liver injury seen during 24 months in five consecutive decades were reviewed. Initially (1960s), all injuries were explored; currently (2000s), most injuries are observed. The number of patients was 235 (1960s), 228 (1970s), 79 (1980s), 116 (1990s), and 64 (2000s). The greater number in the 1990s reflects the diagnosis of minor, clinically insignificant, blunt injuries after abdominal CAT scan became available. Each injury was categorized by cause, severity (Abbreviated Injury Scale), associated shock, and primary therapy (observe [OBS], operation alone [OR], hepatorrhaphy [SUT], tractotomy [TRACT] with intraparenchymal hemostasis, hepatic dearterialization [HAL], and resection [RESECT]). Packing, used in each decade, was placed in one of the above primary treatment groups.The primary techniques for hemostasis are shown in the text table.Shock and Abbreviated Injury Scale correlated with mortality averaged 16%; 40 of 116 deaths (34%) exsanguinated from hepatic injury. During training, a resident performed an average of 12.0, 12.0, 2.4, 4.0, and 1.3 procedures for hemostasis.Reduced incidence and decreased therapeutic laparotomies for liver injury have created a training vacuum for future trauma surgeons. Surgical residents will need to supplement their clinical experience with solid organ hemostasis by practice on appropriate animal models of injury and cadaver dissections.

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were $2,861,526 and total costs were $938,311. All patients had Medicare or Medicaid on admission. Hospital loss ($432,561) was incurred in those patients admitted more than 4 days whereas a profit ($33,285) was realized in patients admitted less than 4 days. These deaths and financial loss could be reduced by better testing and more precise guidelines as to which patients can safely receive home oxygen. Patients can have their saliva tested for the nicotine breakdown product of cotinine; the test takes 10 minutes. The American Burn Association, in conjunction with the American College of Chest Physicians, should address this issue and develop guidelines for physicians who order home oxygen therapy and for state departments of public health who should regulate the companies that deliver home oxygen.

Background The current emphasis on pain assessment as the fifth vital sign and the use of unscientific pain scales is causing serious injury and death from overmedication. Study Design This premise was tested by reviewing the case reports of all trauma center site surveys performed by the authors for the American College of Surgeons Committee on Trauma verification program during 2 separate time periods: 1994 through 1998 and 2000 through 2004. A total of 2,907 and 2,282 reports summarized by one of the authors, plus a total of 53 and 50 other reviewers, respectively, were analyzed from the records of 120 and 94 trauma centers. Most patients were men (71% and 66%) and had sustained blunt injury (83% and 79%). Average age was 35 years for both periods, with a range of 3 weeks to 97 years and 3 days to 98 years, respectively. The most common injuries involved head (33% and 34%), chest (13% and 13%), abdominal (22% and 21%), orthopaedic (18% and 18%), or multiple (9% and 14%). There were 1,459 and 867 deaths, respectively; all had a multidisciplinary peer review. Results Overmedication with sedatives/narcotics, during the two periods, clearly contributed to deaths in 13 and 32 patients and probably contributed to deaths in 5 and 14 patients, respectively. This occurred in 17 and 43 patients, respectively, after blunt injury and in 1 and 3 patients, respectively, after penetrating injury. Two clinical scenarios predominated, ie, overmedication in preparation for an imaging study and overmedication after discharge from ICU to the floor. The sequel of hypotension and compromised airway requiring intubation initiated a cascade of negative events that led to death. One patient in each period died as a result of prehospital overmedication. Conclusions The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.

Glucocorticoids (GC) attenuate the post-insult inflammatory response and have been observed to confer end-organ protection following a variety of ischemic insults. We aim to assess this benefit on renal perfusion and function in injured patients requiring massive transfusion. The effect of pharmacologic methylprednisolone (MP) therapy was studied in 118 patients (pts), of whom 60, by random, received 1 g MP intraoperatively and 15 mg/kg for an additional 3 days. Postoperative measurements were made of effective renal plasma flow (ERPF), glomerular filtration by inulin (CIn), creatinine clearance (CCr) and clearances of osmoles (CCosm), sodium (CNa), and free water ( $${\text{C}}_{{{\text{H}}_{ 2} {\text{O}}}}$$ ). Continuous variables were compared between the two groups using the student’s t test. Enrolled pts on average received 13.5 units of PRBCs with no differences in the resuscitation regimen. There were no statistically significant differences in the postoperative renal function as measured by ERPF (p = 0.57), CIn (p = 0.84), CCr (p = 0.99), CNa (p = 0.07), COsm (p = 0.95), and $${\text{C}}_{{{\text{H}}_{ 2} {\text{O}}}}$$ (p = 0.33). The incidence of renal compromise, as determined by an inulin clearance of

BACKGROUND Respiratory complications are a major cause of morbidity and mortality in patients with cervical spinal cord injury (CSCI). We hypothesized that patients with CSCI had esophageal dysfunction, predisposing them to aspiration. The purpose of this study was to characterize esophageal function in these patients. METHODS CSCI and similarly injured control (spinal cord injury below T1) subjects were prospectively enrolled from two trauma centers. All underwent esophageal manometry to measure lower (LES) and upper esophageal sphincter (UES) pressures. A subset of patients had detailed manometry and 24-hour pH studies performed to evaluate dynamic esophageal function. RESULTS Eighteen CSCI and five control subjects were enrolled. The groups were similar with regards to age, sex, injury mechanism, Injury Severity Score, and hospital stay. Resting LES and UES pressures were similar in CSCI and control patients and did not differ from established norms. Five CSCI and two control patients underwent detailed manometric assessment. Defective UES relaxation was observed in all CSCI patients but not controls. CSCI patients had increased UES relaxation pressures (18.4 +/- 5.3 versus 3.9 +/- 0.7 mm Hg; p = 0.01) and UES bolus pressures (23.8 +/- 2.2 versus 10.2 +/- 6.9 mm Hg; p = 0.006) compared with controls. Esophageal body and LES function were normal. Two of five CSCI patients had abnormal 24-hour pH studies. CONCLUSION Patients with CSCI demonstrate significantly disturbed dynamic function of the pharynx and UES while resting parameters remain normal. Because adequate UES relaxation is critical to the clearance of secretions and coordination of swallowing, this is an important potential mechanism of aspiration in patients with CSCI.

The use of illicit drugs, specifically heroin and cocaine, complicates trauma patient management and consumes extensive hospital resources. This paper focuses on heroin- and cocaine-related injuries observed by physicians at Detroit Receiving Hospital, a large urban Level I trauma center. The pharmaceutical effects, mode of administration, and the manner in which these drugs affect diagnosis and treatment of injuries are documented and discussed. Specific drug-related complications associated with overdose, soft-tissue infections, bacterial endocarditis (therapy resistant), vascular thromboses, vascular aneurysms, vasoconstriction, stroke, cardiac arrhythmias, muscle ischemia, and solid-organ abscesses are also analyzed. Illicit drug use significantly complicates initial diagnosis and trauma management and is associated with severe adverse pathophysiologic effects. Currently, prevention efforts, such as interventions in trauma centers, should be considered as the most efficient and feasible way to prevent injury recidivism in this patient population. We also conclude that legislative change may be the answer in reducing or preventing the horrendous problems caused by illicit drugs.

Background Tertiary hyperparathyroidism typically occurs in patients who have recovered from renal failure after renal transplantation. This report describes a syndrome of tertiary hyperparathyroidism after recovery from multiple organ failure (MOF) with acute oliguric renal failure (AORF). Methods Six patients with MOF including AORF are presented. Increased parathyroid hormone (PTH) levels were documented as early as 3 weeks after injury or septic insult and remained increased in some patients for several weeks. Results The resultant increase in calcium levels led to recurrent bouts of bradycardia, often leading to asystole requiring cardiopulmonary resuscitation. Hypercalcemic-induced bradycardia was refractory to hydration, loop diuresis, atropine, and external pacing. Definitive treatment requires bisphosphonate therapy, which must be repeated until organ function has returned to normal. Conclusions A new syndrome of life-threatening tertiary hyperparathyroidism is described in patients with critical illness. This syndrome probably is being overlooked frequently in critical care units. Early diagnosis and prophylactic treatment with bisphosphonate may preclude the life-threatening cardiac arrhythmias.

BACKGROUND: Massive localized lymphedema (MLL) is a rare entity first described in 1998 in patients with morbid obesity; the incidence is rising with the increased prevalence of morbid obesity. This report defines the clinical presentation and surgical challenges in 6 patients with MLL. METHODS: The MLL in 6 patients with morbid obesity (weight range 270 to 585 lbs) involved the thigh in 3 patients, the calf in 1 patient, and the abdomen in 2 patients. The time from onset to presentation averaged 3 years (range 1 to 8 years). Two thigh lesions precluded ambulation because both legs could not be on the ground simultaneously; the 2 abdominal lesions were too heavy to permit ambulation. RESULTS: The surgical excision required the use of pulleys to elevate the MLL tissues, which, on excision, weighed between 24 and 78 lbs. A long oval horizontal incision and a long transverse incision were used for the 2 abdominal lesions. Long horizontal oval limb incisions with multiple perpendicular cross incisions had to be used to excise MLL in the 4 limb lesions. In 2 cases, the vessel-sealing device was employed successfully for dissecting subcutaneous edematous tissue. Loose wound closure permitted postoperative lymph leakage, which continued for 3 to 8 weeks. The histology demonstrated fibrotic lymphatic tissue with vascular and lymphatic proliferation and edema; all patients did well. CONCLUSIONS: MLL is rare and is best treated by surgical excision facilitated by pulleys and imaginative incisions to obtain primary closure. Long-term follow-up is necessary to assess for subsequent liposarcoma or angiosarcoma.

The liver is the largest organ in the body and the organ most frequently injured. This is true for both blunt and penetrating wounds. The morbidity and mortality associated with liver injury vary with the associated hemorrhagic shock insult, the severity of liver injury as judged by the Abbreviated Injury Score (AIS), and the presence or absence of bleeding at the time of operative intervention. The severity of injury related to missile wounds correlates directly with the amount of energy that is dissipated as the missile traverses the liver, with the energy being calculated by the classic formula of energy = mass × volume 2 ÷ 2. Thus, high velocity missiles have the greatest potential for creating the worst injuries. When a patient with a liver injury presents with severe hemorrhagic shock that is not rapidly reversible with preoperative resuscitation, the mortality is very high; when the hemorrhagic shock insult is corrected while in transit to the operating room, the mortality is low; when there is no associated hemorrhagic shock, the mortality is negligible.

Sphincter of Oddi dysfunction (SOD) is one of the causes of post-cholecystectomy syndrome and biliary pain and is a challenge from both the diagnostic and therapeutic points of view. Sphincter of Oddi dysfunction is typically diagnosed months to years after cholecystectomy. Continued biliary type pain after cholecystectomy may occur in as many as 10–20% of patients. Ten percent or more of these patients may eventually be shown to have SOD. The syndrome is often associated with a variety of other gastrointestinal disorders thought to be caused by dysmotility. According to the Milwaukee classification, patients with biliary pain can be divided into three types. Type I patients show all the objective signs suggestive of a disturbed bile outflow (i.e. elevated liver function tests, dilated common bile duct and delayed contrast drainage during endoscopic retrograde cholangiopancreatography). Type II patients have biliary type pain along with one or two of the criteria from type I. Type III patients have biliary pain only, with no other abnormalities. The present paper will focus primarily on SOD syn-drome, papillary stenosis and the diagnostic and therapeutic approaches, in particular endoscopic sphincterotomy.

Sphincter of Oddi dysfunction (SOD) is one of the causes of postcholecytectomy syndrome and biliary pain. Endoscopic sphincterotomy (EST) is recommended in some cases for patients refractory to conservative treatment. By the Milwaukee classification, patients with biliary pain can be divided into three groups. Group I patients show all the objective signs suggestive of a disturbed bile outflow-i.e., elevated liver function tests, dilated common bile duct (CBD), and delayed contrast drainage during endoscopic retrograde cholangio pancreatography (ERCP). Group II patients have biliary-type pain along with one or two of the criteria from group I. Group III patients have only biliary pain, with no other abnormalities. This study confirms the effectiveness of EST for the relief of symptoms in group I patients (papillary stenosis).Between 1989 and 1999, we treated eight patients clinically diagnosed as having group I papillary stenosis by EST. Their ages ranged from 52 to 73 years. In addition to biliary pain, all patients were found to have dilated CBD, elevated enzyme levels, and delayed contrast drainage at ERCP. None of the patients had CBD stones or other causes of obstruction. Sphincter of Oddi manometry was not performed.EST was successfully performed in eight patients. Each patient had a very large papilla. A false orifice was found in one patient. In five patients, endoscopic cannulation of the bile duct was very difficult. The use of a long, tapered catheter and guidewire papillotomy was necessary in four patients. A precut papillotomy was performed in one patient. All patients achieved resolution of their symptoms after EST. There were no complications. The average length of the follow-up period was 26 months.SOD is a real entity that continues to pose a diagnostic dilemma. EST is an effective and safe modality for the treatment of papillary stenosis (group I patients). SOD manometry is not necessary before EST in group I patients.

Level II trauma centers may be verified (1999, American College of Surgeons Committee on Trauma) with an on-call operating room team if the performance-improvement program shows no adverse outcomes. Using queuing and simulation methodology, this study attempted to add a volume guideline.Data from 72 previously verified trauma centers identified multiple demographic factors, including specific information about the first trauma-related operation that was done between 11:00 PM and 7:00 AM each month for 12 consecutive months.The annual admissions averaged 1,477 for 37 Level I trauma centers, 802 for 28 Level II trauma centers, 481 for 4 Level III trauma centers, and 731 for 3 pediatric trauma centers. The annual admissions correlated with the number of operations done between 11:00 PM and 7:00 AM (p0.001). These 946 operations were performed by general surgery (39%), neurosurgery (8%), orthopaedic surgery (33%), another specialty (9%), or multiple services (10%). Admission to operation time was within 30 minutes for 12.1% of patients (2.6% for blunt and 24.1% for penetrating injuries). The probability of operation within 30 minutes of arrival varied with the number of admissions and with the percentage of penetrating versus blunt injuries. The likely number of operations from 11:00 PM to 7:00 AM would be 19 for 500 annual admissions, 26 for 750 annual admissions, and 34 for 1,000 annual admissions, with 5.83, 7.98, and 10.13 patients, respectively, going to operation within 30 min. The probability that two rooms would be occupied simultaneously was 0.14 and 0.24 for centers admitting 500 and 1,000 patients, respectively.Trauma centers performing fewer than six operations between 11:00 PM and 7:00 AM per year could conserve resources by using an immediately available on-call team, with responses monitored by the performance-improvement program.

Excessive postoperative adhesion formation is a major result of surgery. The adhesion reduction effects of a chitosan membrane and poloxamer gel barrier were measured in a rat peritoneal model. Forty-four male Sprague-Dawley rats were divided into four groups (control, poloxamer, chitosan, and poloxamer+chitosan sandwich). Two cm2 of cecal serosa and the adjacent abdominal wall were abraded. The denuded cecum was covered with either a chitosan membrane, a poloxamer gel, chitosan in a sandwich configuration with poloxamer on both sides, or neither (control group) and apposed to the abdominal wall. Fourteen days after surgery adhesions were graded using a whole-number scoring system of zero to five. Adhesion strength was determined using a whole-number system of one to four. Adhesion area was measured on a continuous scale of adhesion severity. Adhesion grades were highest in the control group (5.00 ± 0.00) and were significantly ( P < 0.05) lower in the poloxamer group (3.50 ± 1.35), the chitosan group (1.64 ± 1.63), and the poloxamer+chitosan group (1.18 ± 1.25). The two chitosan-containing groups also had significantly ( P < 0.05) reduced adhesion grades in comparison with the poloxamer group. Adhesion area in both chitosan-containing groups was reduced in comparison with control and adhesion strength was reduced significantly ( P < 0.05) in all groups compared with control. The poloxamer+chitosan group had significantly ( P < 0.05) reduced adhesion strength versus poloxamer only. There was a significant ( P < 0.05) linear correlation ( r = 0.931, P < 0.001) between adhesion grade and adhesion strength. We conclude that chitosan and the combination of poloxamer+chitosan were shown to effectively reduce adhesion area, grade, and strength.

Each morning I give thanks for growing up in America, being a Fellow of the American College of Surgeons (ACS), and serving on the faculty at Wayne State University, the only school to be honored with three Scudder Orators who spent their entire careers at one institution. Their backgrounds say something about all three entities: Dr Alexander Walt, an immigrant who left his homeland because of apartheid to become my chairman and our president; Dr Anna Ledgerwood, a daughter of tenant farmers from the state of Washington, who became my longterm partner; and now, myself, the son of immigrant farmers—no kings or queens, just working bees. Most Scudder Orations have dealt with philosophical, societal, or trauma system issues. Because my political acumen is lacking and my philosophical leanings are so far off the main stream that I believe that Adam and Eve came to earth on a spaceship, I have decided to discuss my favorite topic, namely, the pathophysiology of hemophagic shock and the resultant protein fluxes. The Lucas clan emigrated from the West Coast of Ireland, where the “water of life” is known by the Gaelic term “uisce beatha.” As one traveled across the Irish Sea to the East Coast of England, the “water of life” took on a new meaning one century ago when the great English physiologist, Ernest Starling, published his famous equation now known as the Law of the Capillary

Background: Recurrent acute pancreatitis often leads to chronic obstructive ductal disease requiring operative decompression. Methods: From 1983 through 1998, 124 patients with ductal obstruction underwent lateral pancreaticojejunostomy (78 patients), distal pancreatectomy with end-to-side pancreaticojejunostomy (27 patients), distal pancreatectomy with placement of a pancreas with a filleted duct within a jejunal limb (15 patients), or pancreaticoduodenectomy (4 patients). Preoperative symptoms included abdominal and back pain (99%), nausea with vomiting (99%), and diarrhea with weight loss (11%). Associated conditions included hypertension (20%) and diabetes mellitus (12%). Endoscopy in 106 patients demonstrated distal stricture (37%), proximal stricture (36%), pseudocyst (30%), chain of lakes (15%), calcification and debris (19%), and bile duct stricture (8%). Results: Two patients died, one of an unrecognized esophageal perforation during intubation and the other of leakage of a 1-layer pancreaticojejunostomy. Thirty-six patients developed 53 complications including intra-abdominal abscess (7 patients) and bleeding requiring reoperation in 1 patient. Pain relief was complete in 61 patients, substantial in 39 patients, moderate in 11 patients, minimal in 8 patients, and nonexistent in 3 patients with multiple stones and narrow duct. Ten patients died, with 6 deaths as a result of pancreatic cancer. Two other patients may have died of pancreatic cancer. Conclusions: Lateral pancreaticojejunostomy is the procedure of choice in most patients. Recurrent pancreatitis usually follows alcoholic binges. Long-term follow-up must assess for pancreatic cancer. (Surgery 1999;126:790-7.)

Objective: This study assesses the effects of antimicrobials on wound healing in an in vitro model of chicken flexor tendons in a collagen gel matrix. Two equidistant tendons were bathed in a culture medium for 28 days as fibroblasts (fb) grew from the tendon ends into the collagen gel and migrated toward each other until gap closure. Five groups of 10 paired tendons each included the control and the study groups, which received oxacillin (Ox), clindamycin (Cl), chloramphenicol (Chl), or tetracycline (Tet) in the culture medium to assess their effects on gap closure rate, fb migration, and myofibroblast alpha-smooth muscle (α-SM) actin expression. Results: Gap closure, by day 27, was 98.5% in the controls compared with 97%, 92%, 89.5%, 21.75% in the Tet, Cl, Ox, and Chl groups. Chl retarded gap closure (p < 0.05). Fb migration was similar for all groups. In the control and Ox groups, myofibroblast expressed actin at day 5. By day 7, fb cells were clearly visible in the control, Ox, and Cl groups, whereas, only light actin was present in the Chl and Tet groups. Actin band densities for the Cl, Ox, Tet, and Chl groups were 78.4%, 62.5%, 61.7% and 26.1%, respectively, of the control group. Conclusion: These studies suggest that one reason certain antimicrobials impair wound healing, is due to myofibroblast inhibition of α-SM actin.