Biomedical subjects
J Pillgram-Larsen
Publications and source records attributed to J Pillgram-Larsen.
[Bronchial ruptures are rare and should be surgically treated].
Bronchial rupture in blunt trauma is caused by sudden compression of the chest with dislocation of the lungs. The less pliant bronchi may thus rupture. Bronchial rupture is rare in patients admitted alive. Bronchial rupture has been diagnosed in two of the last 275 severe chest traumas admitted to Ullevål hospital since 1993 (0.7%). A 19-year-old male had total atelectasis of the lung 19 days after the trauma. A four-year-old boy experienced total collapse of the lung and became critically ill the fourth day after initial normalisation of the chest X-ray. Both patients were successfully operated on, with reconstruction of the left main bronchus in both cases, after 29 and seven days, respectively. In the child an upper lobectomy was necessary. These patients illustrate that with expectative treatment in bronchial rupture, serious complications may be experienced.
Complement activation in injured patients occurs immediately and is dependent on the severity of the trauma.
In order to study the factors related to complement activation, the complement activation products C3bc and TCC were measured in plasma at admittance and during the stay in the intensive care unit in 108 consecutive patients with multiple injuries. These patients were admitted to the surgical department during a 4-month period. Complement activation occurred immediately after the trauma and correlated strongly with the Injury Severity Score and was inversely correlated to the Base Excess. Complement activation also correlated with the number of transfusions. Sepsis caused complement activation later during the stay in hospital. All seven patients developing the adult respiratory distress syndrome (ARDS) had increased complement activation, either on admission or later during the stay in the intensive care unit. Complement activation is known to contribute to organ damage following ischemia and reperfusion. Clinical studies have demonstrated the importance of early restoration of adequate circulation and the present demonstration of a strong negative correlation between complement activation and Base Excess indicates that early restoration of aerobic metabolism may reduce complement activation and the risk for organ dysfunction.
[Military medicine on the battlefield--in reality].
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[Air bags influence the pattern of injury in severe thoracic trauma].
Severe intrathoracic cardiovascular injuries were found in three patients who were drivers of cars involved in head on collisions causing air bags to be released. A 32 year old male had not worn a seat belt, while a 39 year old female was restrained by a seat belt. The male patient suffered an intimal lesion of the brachiocephalic artery. Extensive soft tissue haematomas were seen subcutaneously and retrosternally. The female suffered a rupture of the aortic isthmus and a dislocated pelvic fracture. Vascular repair was performed in both patients. The female died after two months without having regained consciousness. The third patient, a 47 year old male, had not worn a seat belt. He lost his pulse within minutes. Midline emergency thoracotomy showed a complete rupture of the right atrium. An air bag protects against injuries caused by hitting internal parts of the vehicle. It does not necessarily protect against deceleration trauma in high speed collisions.
Diaphragmatic injuries.
A 6-year series of 26 patients with diaphragmatic injury is presented, 15 with rupture from blunt injuries and 11 after penetrating injuries. All had associated injuries and seven died because of these. The diagnosis may be difficult and was consequently delayed in two patients. Eleven ruptured diaphragms were diagnosed before operation, 14 on the operating table and one at autopsy (dead on arrival). Herniation of abdominal organs was seen in nine of 15 patients after blunt injuries. In most patients repair was via laparotomy using absorbable sutures. It is still essential that the surgeon should be aware of the possibility of the diagnosis and the associated severe injuries.
Long-term prevalence of impairments and disabilities after multiple trauma.
The prevalence of impairments and disabilities in activities of daily living (ADL), nonwork activities, and work were registered in a consecutive series (n = 69) of subjects with severe injuries. At follow-up 3 years after trauma, residual impairments prevailed in 80%. Only a few (6%) were ADL-dependent. Seventy-six percent had lost at least one nonwork activity, while vocational disability caused by the trauma occurred in 19%. Cognitive impairment was significantly associated with vocational disability, while physical impairment and pain were significantly associated with nonwork disability. Other parameters that influenced vocational disability negatively were age and blue-collar employment status. Although overall changes in social network quantity and quality were small, significantly more subjects with cognitive impairment or vocational disability experienced a decline in the quality and quantity of their social network after trauma. Furthermore, 25% of the subjects reported an increase in feelings of loneliness after trauma. We recommend the design of individualized, multidisciplinary rehabilitation plans before discharge from departments of surgery.
[Avoid blood transfusion in elective surgery].
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[Aortoiliac arteriosclerosis treated with bypass surgery].
After introduction of the crimped Dacron bifurcation prosthesis, bypass surgery has been the preferred surgical treatment for arteriosclerosis in the aortoiliacal segment. During the years 1979-88 we performed 152 aortoiliacal/femoral bypass operations. Perioperative mortality was 2%, while 96% of patients experienced improvement from operation. Primary and secondary five-year graft patency rates were 84 and 88%. Considering the high risk in this patient group, we regard the operational mortality to be acceptable, and the long term results satisfactory. However, surgical treatment should be reserved for patients with serious occlusive disease in the aortoiliac segment. For patients with more limited lesions, endovascular procedures are a relevant alternative to surgery.
[Femoropopliteal bypass in arteriosclerosis].
Since Kunlin's report on femoropopliteal bypass operations, this procedure, with homologous vein or various prosthesis has been the principal treatment for serious arteriosclerosis in this anatomical area. During the years 1979-88 we performed 235 femoropopliteal bypasses. Reversed autologous vein was used in 60% and the distal anastomosis placed below the knee in 75%. Perioperative, 30 days mortality was 2.1%. 93% of the operations were successful. The overall five year patency rate was 50.6%, but with significantly better results with the distal anastomosis above the knee. There was no significant difference, however, between reversed homologous vein and human umbilical vein grafts in the below knee position. At present, the indications for femoropopliteal bypass are critical ischemia and seriously incapacitating claudication.
Serum cardio-specific troponin T after open heart surgery in patients with and without perioperative myocardial infarction.
One hundred and sixteen consecutive patients undergoing open heart surgery were studied to evaluate the diagnostic use of cardiac specific troponin T in serum (S-TnT) measured preoperatively, at day 1 and day 4 postoperatively. The results were related to perioperative myocardial infarction (POMI), diagnostically based on ECG-changes, as well as to other perioperative variables. Cardiac surgery resulted in increased levels of S-TnT day 1 in all patients, and the level of this increase was dependent on the type of surgical procedure performed and the duration of cardiac perioperative ischaemia. Similar results were observed for serum creatine kinase isoenzyme (mass determination) (S-CKMB), but differences were generally less well correlated with other perioperative variables. At day 1, patients with POMI had higher levels of S-TnT as well as S-CKMB when compared to patients without POMI. At day 4, most patients still had elevated levels of S-TnT, but the difference in S-TnT levels between patients with POMI and patients without POMI was more pronounced. In contrast, the levels of S-CKMB were essentially normalized in both groups. Measurements of S-TnT at day 4 appears to be of significant value in diagnosing POMI. However, most of the patients without POMI had increased levels of S-TnT at day 4, suggesting that some irreversible operatively induced myocardial damage had occurred. Thus, even at a late postoperative stage the perioperative duration of ischaemia and type and extent of the surgical procedure should be taken into consideration.
[Autologous vein vs. human umbilical vein for femoropopliteal bypass].
Below knee femoropopliteal bypass was performed with reversed saphenous vein in 81 cases and with modified human umbilical vein in 74. The two groups were comparable as regards indications, coexisting disease and distal run-off. The cumulated patency rates were almost identical in the two groups, but early mortality and wound complications were higher in the saphenous vein group. Aneurysm formation in the umbilical veins was not a problem in this series. It is concluded that human umbilical vein is a very satisfactory bypass alternative when the saphenous vein is not available. In selected cases it may also be justifiable to use it in order to keep operation time and trauma at a minimum.
[Rupture of the thoracic aorta and multiple injuries].
Traumatic rupture of the thoracic aorta is an extremely severe injury, and is usually fatal. The injury is most often seen in forceful deceleration trauma. This complicates the priority of diagnosis and treatment in relation to other severe injuries in the same patient. During the period 1984-1991, nine patients underwent operation for this injury at the Department of Thoracic Surgery. Two patients succumbed, because of free rupture in the operating theatre. The others survived. Three of these were treated by directly suturing the rupture, and four by introducing a prosthesis. The prognosis in operated traumatic rupture of the thoracic aorta is good if the haematoma is contained. Relevant history of deceleration and suspicion of mediastinal widening should lead to arcography and prompt operation if the diagnosis is confirmed. Only significant intraabdominal or intracranial hemorrhage supersede aortic rupture in the initial priorities for treatment.
[Anti-shock trousers--over and out? From fighters and Vietnam to civilians].
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Initial axial computerized tomography examination in chest injuries.
A total of 41 injured patients examined by both chest radiography and axial computerized tomography (CT) of the chest within the first 24 h after the accident were reviewed. In all, 10 patients died, eight from cerebral or cervical injuries, two from haemorrhage. Of the 27 cases with a haemothorax, 13 were seen on a chest radiograph. In only one case was a haemothorax seen on CT large enough to warrant intervention. CT revealed one minor pneumothorax. Nine patients already treated with a chest drain had some residual air demonstrated by CT, two being significant pneumothoraces. CT showed 28 cases of lung contusion as opposed to 23 on a chest radiograph. Of five cases with a mediastinal haematoma, three were seen on a chest radiograph, including the only patient with aortic rupture. Clinically important pathology was revealed in ordinary chest radiographs. Contusions, small pneumothoraces and minor effusions were sometimes overlooked. CT scan of the chest alone is rarely warranted in the injured patient, given a liberal indication for chest drainage and ready access to arch aortography.
[Acute thoracotomy--the life-threatening cases take precedence].
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[Quality assurance in a surgical department].
The quality of a given service in a surgical department depends on many factors. Most important are adequate resources, training of the surgeons and nurses and time for follow-up and clinical research. Quality standards should be defined in accordance with the international literature and results should be continuously surveyed to ensure that the agreed goals are met. This article describes various general rules and routines which have been established in our department, as well as the specific systems used to measure the quality of our surgical service in three special fields: Care of patients with tumour mammae, care of patients with gallstone disease, and prospective registration of complications for all gastroenterological patients in our surgical department.