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This Month in
June 2002

This Month in Archives of Surgery

Arch Surg. 2002;137(6):638. doi:10.1001/archsurg.137.6.638
Oldies but Goodies

Remember the criteria that John Ranson promulgated back in 1974? Interestingly, Eachempati et alArticle, using all the technical advances of the modern era, affirmed that for prognostication in severe acute pancreatitis the Ranson score was still valid, as good as more fanciful data from the APACHE III score.

There was a time when everyone performing parathyroid surgery opened the neck bilaterally, found the abnormality, and effected a cure in more than 95% of cases. Now that minimally invasive techniques have taken hold, it is important to localize the offending gland or glands, usually with sestamibi scanning and gamma probes, and follow excision with a quick determination of parathyroid hormone levels. It is important to note that (1) it is difficult for any technique to beat more than 95% effectiveness, regardless of noninvasiveness, and (2) Jaskowiak et alArticle should be commended for pointing out some of the potential pitfalls of modern technical advances.

How does one handle indeterminate colitis—that is, colitis that neither the surgeon nor the pathologist can classify as ulcerative colitis or Crohn disease of the colon? Dayton et alArticle reviewed the records of 79 patients in this category who underwent ileal pouch–anal anastomosis and compared them with patients receiving the same procedure for ulcerative colitis. Overall, they found that the incidence of pouch complications after ileal pouch–anal anastomosis was only slightly higher in the indeterminate group. The functional results were the same. Their conclusion was that the overwhelming majority of patients with indeterminate colitis could undergo this operation confident that the outcome would equal that of patients with ulcerative colitis.

A Prospective, Randomized Trial of PTFE Patch Repair vs Simple Cruroplasty for Large Hiatal Hernia

Because of experience with reherniation when large hiatal hernias were repaired with simple cruroplasty, Frantzides et alArticle performed a prospective, randomized controlled trial involving 72 individuals undergoing laparoscopic Nissen fundoplication with a hernia defect 8 cm or longer in diameter. Thirty-six patients underwent Nissen fundoplication with posterior cruroplasty, and 36 underwent Nissen fundoplication with posterior cruroplasty and circumferential onlay of PTFE mesh. Aside from a slightly longer operative time and an additional cost of $1000 in the prosthetic group, both clusters had similar hospital experiences, with a mean follow-up of 3 years (range, 6 months to 6 years). There was a recurrence rate of 22% in the cruroplasty-only group, as opposed to 0% in the PTFE-reinforced group. Thus, the use of mesh reinforcement is recommended.

Prospective Evaluation of the Safety of Enoxaparin Prophylaxis for Venous Thromboembolism in Patients With Intracranial Hemorrhagic Injuries

One of the vexing problems in trauma surgery is that of prophylaxis for venous thromboembolic disease in patients with intracranial hemorrhagic lesions. In this high-risk group, should pneumatic pressure devices be the standard, or is a more active program better? To help solve this problem, Norwood et alArticle treated 150 patients with blunt intracranial hemorrhagic injuries with enoxaparin sodium (low-molecular-weight heparin; 30-mg subcutaneous dose every 12 hours) beginning approximately 24 hours after admission to the emergency department. Only 6 patients had computed tomographic scans showing worsening with heparin therapy, and no difference was noted between operatively treated and nonoperatively treated individuals. All 6 patients who developed progression of intracranial hemorrhagic injuries after initiation of enoxaparin therapy survived hospitalization, demonstrating that low-molecular-weight heparin can be used safely for venous thromboembolism prophylaxis in these trauma patients if started 24 hours after admission or craniotomy.

Devastating and Fatal Complications Associated With Combined Vascular and Bile Duct Injuries During Cholecystectomy

We commend to you this sobering article pointing out that bile duct injuries after cholecystectomy can be both morbid and lethal, especially when they are associated with vascular trauma. The authors point out that rapid identification of combined injuries is important to patient outcomes.