Three of the articles in this month's issue deal with areas of trauma care that deserve consideration. In light of the fact that nearly 50% of patients admitted to trauma centers are intoxicated, alcohol problems are an important area of concern. Thus, the first of these articles, "Intoxicated Motor Vehicle Passengers: An Overlooked At-Risk Population" by Schermer et al, informs us that intoxicated passengers injured in motor vehicle crashes are similar to intoxicated drivers in recurrent hospitalizations and emergency department visits, and have a higher than expected mortality rate in the 5 years following their initial injury.
In a second article, "Effects of 2 Patterns of Prehospital Care on the Outcome of Patients With Severe Head Injury," the authors point out that there was no increased benefit of the combined helicopter-physician–advanced life support system over a simpler plan of basic life support, nurse staffing, and ground transport in this grouping. Specific categories of trauma patients may require different types of prehospital care. Careful consideration must be given to verifying each modality of trauma care.
A third article, "Computed Tomography in the Evaluation of Penetrating Neck Trauma: A Preliminary Study" by Gracias et al, suggests a technique that has the potential to alter patient management in a significant way in selected individuals. The authors illustrate that computed tomography in stable patients with penetrating neck trauma is safe and can often demonstrate the trajectory of injury, particularly the remoteness from vital structures, which eliminates the need for invasive studies and promotes early discharge. This early study should lead to further prospective trials of computed tomography after penetrating neck traumas of all types.
Intraductal papillary mucinous tumors are being diagnosed more frequently and deserve special consideration. The series presented is representative and important in that pain was present in 11 of 13 patients (in contradistinction to the painless presence of adenocarcinoma of the pancreas), and the tumors were located in the head of the pancreas in 77% of cases. Emphasis is placed on an accurate determination of ductal disease extent and clear margins at operation (frozen sections). The use of intraoperative ultrasound and wirsungoscopic biopsies was helpful. The 5-year actuarial survival rate of patients in this series was 57%.
Using newer technology (better imaging techniques, the ultrasonic aspirator, intraoperative ultrasound, the argon beam coagulator, and autotransfusion) the authors were able to reduce patient mortality and morbidity after major hepatic resection (mortality, 1%; morbidity, 19%), noting a recent trend toward a change of operative strategy in a significant percentage of cases in which intraoperative ultrasound was used. Further, the new technology has been useful in reducing hospital stay (by 50%), making hepatic resection more cost-effective.
According to this extensive survey, the rate of common bile duct injury is significantly lower when intraoperative cholangiography is used. Should this be a routine? Issues of cost-benefit ratio, efficacy, resource utilization, and reimbursement must all be considered.
This Month in Archives of Surgery. Arch Surg. 2001;136(11):1229. doi:10.1001/archsurg.136.11.1229