Canadian journal of surgery. Journal canadien de chirurgie
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A review of records of 27 patients with duodenal fistulas admitted to St. Joseph's Health Centre in Toronto since 1969, when total parenteral nutrition (TPN) was instituted, showed that in 19 patients the fistula formed after gastric resection, pyloroplasty or transduodenal sphincteroplasty. The remaining fistulas resulted from delayed presentation of perforated duodenal ulcers, trauma suffered in motor vehicle accidents and disease in neighbouring organs. ⋯ It appears that a direct surgical attack on duodenal fistulas is rarely necessary. With appropriate management, the majority will heal spontaneously. Total parenteral nutrition is the cornerstone of therapy and gastrojejunostomy is invaluable in certain cases.
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The authors describe three patients with similar clinical features and patterns of colonic injury following blunt abdominal trauma. Perforation was discovered 7 to 10 days after injury and was indicated by the clinical signs of systemic sepsis. A prominent sign of occult sepsis was post-traumatic pulmonary insufficiency. ⋯ The large number of concomitant injuries and the subsequent sepsis led to a higher morbidity and mortality than in cases of penetrating injuries to the colon. The key to successful management of blunt colonic injuries is early diagnosis. Awareness of the type of injury and the magnitude of the deceleration force combined with the presence of persistent ileus may lead to earlier laparotomy.
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In a review of 101 patients suffering from frostbite who were admitted to hospitals in Saskatoon during 10 winters, it was found that alcohol consumption was a contributing factor in 39 patients and a motor vehicle accident or breakdown in 33 others. Sixty-six patients underwent primary treatment in Saskatoon, the other 35 were referred for management of demarcated gangrene. Two hospitalized patients died, both of causes unrelated to the frostbite. ⋯ The mainstays of treatment remain rapid rewarming and adequate delay before conservative débridement or amputation. The delay allows healing of partial-thickness injuries and demarcation of full-thickness injuries. One third of patients receiving primary care in Saskatoon required amputation.
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Blunt chest trauma continues to be an important cause of death following motor vehicle accidents in Canada. Current methods of diagnosis are presented emphasizing a physiologic approach. The most important physiologic consequence of trauma associated with chest wall instability or ruptured diaphragm is pulmonary contusion. ⋯ Methods for recognizing and treating cardiac tamponade are outlined. The indications for early thoracotomy following cardiac trauma are listed; thoracotomy should be done in a fully equipped operating room rather than the emergency room. Successful management of major chest injuries requires an aggressive physiologic approach to diagnosis and emphasis on maintaining effective ventilation and adequate cardiac output.
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Many pitfalls exist in treating patients with blunt and penetrating wounds of the chest and abdomen. The thoracic and abdominal cavities should not be dissociated in the examiner's mind because apparently trivial lesions of one may be associated with serious lesions of the other. Constellations of injuries should be sought, especially in blunt and seat-belt injuries. ⋯ When splenectomy is unavoidable, decisions about the need for penicillin and pneumococcal vaccine are important and should include dose and frequency. Liver injuries are also treated more conservatively. Lobectomy is seldom necessary as assiduous local hemostasis and débridement (accompanied in about 3% of cases by ligation of the hepatic artery) are effective when good exposure and preliminary measures to achieve temporary hemostasis are obtained.