1. What distinguishes facial from other lacerations?

Show answer
Appearance is clearly of primary importance. Quality of the final result depends on strict adherence to basic principles of wound management and painstaking technique. Copious irrigation, judicious debridement, gentle tissue handling, meticulous hemostasis, and minimization of sutures combined with early stitch removal are critical to an optimal result. Fine suture and sharp instruments should be used; eversion of the wound margin with layered closure, obliteration of dead space, and lack of tension are mandatory.

2. What factors influence treatment for the wound?

Show answer
The mechanism of injury, the clinical assessment of contamination, and the time elapsed since wounding dictate treatment. Clean lacerations, heavily contaminated wounds, crush injuries, and bites are treated very differently.

3. How are clean lacerations repaired?

Show answer
They should be irrigated with normal saline or Ringer’s lactate. Only the surrounding skin should be prepared, and no antiseptic should be introduced into the wound. Regional anesthesia is preferred because of the potential for spread of contamination with direct injection of the wound margin. Epinephrine should be avoided because it devitalizes tissue and potentiates infection. Wounds should be repaired in layers with absorbable suture in deep tissue. The smallest number of sutures necessary to overcome the natural resting wound tension should be used. Sutures should be removed within 3-5 days, and the wound margin should be subsequently supported with Steri-strips.

4. How are dirty lacerations repaired?

Show answer
Heavily contaminated wounds should remain open after irrigation and debridement to undergo delayed closure. Because of cosmetic considerations, however, this approach is unacceptable in the face. For this reason, meticulous debridement of devitalized tissue and removal of all foreign material is essential. The wound should be cultured before copious irrigation, and a broad-spectrum antibiotic should be instituted prophylactically. The patient must be informed of the potential of a postrepair infection.
KEY POINTS: FACIAL LACERATIONS

1. Appearance is of paramount importance.
2. Clean lacerations are treated with minimal, tension-free, fine monofilament suture placement and early suture removal (3-5 days).
3. Heavily contaminated wounds are irrigated, debrided, and repaired with administration of antibiotics.
4. Human and animal bites are highly prone to infection; therefore, antibiotics and delayed closure are necessary.
5. N-butyl-2-cyanoacrylate (Dermabond) is used to repair pediatric facial lacerations.

5. What factors influence suture selection?

Show answer
Any method of suturing provokes tissue damage, impairs host defense, increases scar proliferation, and invites infection. Presence of a single silk suture in a wound lowers the infective threshold by a factor of 10,000. Therefore, fine, monofilament suture, just strong enough to overcome the resting wound tension, should be used. Use as few sutures as possible. Wounds with little or no retraction may be closed with tape alone.

6. Which wounds are suitable for closure with tissue adhesives?

Show answer
N-butyl-2-cyanoacrylate may suffice for cutaneous closure of low-tension lacerations in children (preferred method) and adults. This adhesive effectively closes low-tension lacerations. This method is fast and relatively painless. It has a low complication rate and produces excellent cosmetic outcomes. In many instances, if initial wound orientation is against Langer’s lines, it may, in fact, offer an advantage over conventional manual suturing.

7. Should eyebrows be shaved when facial lacerations are repaired?

Show answer
No. They provide a landmark for realignment of disrupted tissue edges and do not always grow back.
8. How should crush avulsion injuries with associated skin loss be repaired? Show answer
Nonviable elements must be surgically excised because they predispose to infection and lead to excessive scarring. If viability is in doubt, the wound should be irrigated thoroughly and left open with moist dressings. A delayed closure can be accomplished when the questionable areas have declared themselves. It is often prudent to close facial tissue as it lies; this technique often produces a less obtrusive scar than straight-line debridement and closure.

9. How should bites be treated?

Show answer
Both animal and human bite wounds are big-time contaminated and prone to infection. The wound should be left open and closed in a delayed fashion. Antibiotic prophylaxis is indicated. If the wound becomes infected, the sutures must be removed and the wound allowed to drain and heal. The patient should be informed that a scar revision will be necessary.

10. Should skin grafts or flaps be used for primary closure of a wound?

Show answer
Complicated tissue transfer techniques have no place in the acute treatment of facial wounds. Closure should be achieved in the simplest way possible and complex reconstructive efforts should be deferred until the scar has matured (months). When tissue loss prevents closure, it may be necessary to use a thin split-thickness skin graft for coverage.

11. When are antibiotics indicated in the treatment of facial lacerations?

Show answer
Copious irrigation, debridement, and gentle tissue handling are more pertinent to the prevention of infection than the use of antibiotics in clean and clean-contaminated wounds. Antibiotic coverage is indicated, however, in crush avulsion injuries, bites, and heavily contaminated injuries.

12. What determines the quality of the scar?

Show answer
Location of the wound, age of the patient, and type and quality of skin determine it. Lesser determinants are the type and quantity of suture material and wound care. Final appearance depends little on the method of suture. Contusion, infection, retained foreign body, improper orientation of laceration, tension, and beveling of edges predict a poor outcome. Differences among suture materials are negligible; however, the technical factors of suture placement to produce wound eversion and time to removal affect the final result.

13. When should scars be revised?

A scar usually has its worst appearance at 2 weeks to 2 months after suturing. Scar revision should await complete maturation, which may take 4-24 months. A good rule of thumb is to undertake no revisions for at least 6-12 months after initial repair. The maturation of the wound may be assessed by its degree of discomfort, erythema, and induration.

14. What controversies exist regarding the care and repair of facial lacerations?

Show answer
There is little controversy about the care and repair of facial lacerations. Attention to basic principles of wound care usually produces a satisfactory scar. Because of the cosmetic considerations in facial trauma, primary repair in some instances is undertaken for the sake of appearance despite the risk of infection that would be deemed unacceptable in other areas of the body.

References
BIBLIOGRAPHY
1. Adame N Jr, Bayless P: Carotid arteriovenous fistula in the neck as a result of a facial laceration. J Emerg Med 16:575-578, 1998. Medline Similar articles Full article
2. Amiel GE, Sukhotnik I, Kawar B, Siplovich l: Use of N-butyl-2-cyanoacrylate in elective surgical incisions: Long-term outcomes. J Am Coll Surg 189:21-25, 1999. Medline Similar articles Full article
3. Farion KJ, Osmond MH, Hartling L, et al: Tissue adhesives for traumatic lacerations: A systematic review of randomized controlled trials. Acad Emerg Med 10:110-118, 2003.
4. Hollander JE, Richman PB, WerBlud M, et al: Irrigation in facial and scalp lacerations: Does it alter outcome? Ann Emerg Med 31:73-77, 1998. Full article
5. Keyes PD, Tallon JM, Rizos J: Topical anesthesia. Can Fam Physicians 44:2152-2156, 1998.
6. Mitchell RB, Nanez G, Wagner JD, Kelly J: Dog bites of the scalp, face, and neck in children. Laryngoscope 113:492-495, 2003.
7. Quinn J, Wells G, Sutcliffe T, et al: A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 277:1527-1530, 1997. Medline Similar articles Full article
8. Simon HK, Zempsky WT, Burns TB, Sullivan KM: Lacerations against Langer’s lines: To glue or suture? J Emerg Med 16:185-189, 1998. Full article

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COLON TRAUMA

1. How do most colon injuries occur?

Show answer
Nearly all (> 95%) colon injuries are caused by penetrating trauma from gunshot, stab, iatrogenic, or sexual injury. Blunt colonic trauma is rare and usually results from seat belts during motor vehicle accidents.

2. How are colon injuries diagnosed?

Show answer
They are usually diagnosed during laparotomy for penetrating trauma. For patients in whom the need for laparotomy has not been established, chest and upright abdominal radiographs assess free air and detect the location of penetrating objects. Triple-contrast computed tomography (CT) or soluble-contrast radiographs (followed by barium, if necessary) can diagnose retroperitoneal colon injuries. White blood cells or fecal material in diagnostic peritoneal lavage (DPL) is highly suggestive of a bowel injury.

3. How are colon injuries graded?

Show answer

* Grade I-contusion hematoma without devascularization; or partial-thickness laceration
* Grade II-laceration < 50% circumference
* Grade III-laceration > 50% circumference
* Grade IV-transection of the colon
* Grade V-transection with segmental tissue loss

4. What are three surgical options for managing a colon injury?

Show answer

1. Primary repair: suturing of simple sidewall perforations or resection and primary anastomosis for more complex injuries
2. Colostomy: injured colon is exteriorized as a loop colostomy or the injured area is resected and an end ileostomy or proximal colostomy is formed
3. Exteriorized repair: a repaired perforation or anastomosis is suspended on the abdominal wall. If the suture line does not leak after 10 days, it can be returned to the abdominal cavity under local anesthesia. If the repair breaks down, it is treated like a loop colostomy.

5. What are the advantages and disadvantages of each of these options?

Show answer

1. Primary repair is desirable because definitive treatment is carried out at the initial operation and the patient is spared the morbidity of a colostomy and its reversal. The disadvantage is that suture lines are created in suboptimal conditions, so leakage may occur.
2. Proximal colostomy avoids an unprotected suture line in the abdomen but requires a second operation to close the colostomy. Stomal complications, including necrosis, stenosis, obstruction, and prolapse, may occur.
3. Exteriorized repair is similar to colostomy formation in that it avoids formation of an intraperitoneal suture line. Unfortunately, many patients require a colostomy closure, and stomal complications similar to those of colostomies may occur.

6. How are most patients with colon injuries surgically managed?

Show answer
Primary repair is safe and effective in essentially all patients with colon trauma. Handsewn and stapled anastomoses have equal complication rates.
KEY POINTS: SURGICAL MANAGEMENT OF COLON INJURIES

1. Primary repair is safe.
2. Handsewn and stapled anastomoses have equal complication rates.
3. A preoperative dose of antibiotic therapy, to be continued for 24 hours, is advantageous.

7. How should the surgical incision and penetrating wound be managed?

Show answer
Wounds should be left open (for delayed primary closure) to decrease the incidence of wound infection and fascial dehiscence.

8. What complications are associated with colonic injury and its treatment?

Show answer

* Wound infection (≤ 65% if the skin incision is closed primarily; do not be tempted to close a dirty incision)
* Intraabdominal abscess (20%)
* Fascial dehiscence (10%)
* Stomal complications (5%)
* Anastomotic leak (5%)
* Mortality (6%)

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11. How are acute liver injuries classified?

Show answer
Liver wounds are generally graded on a scale of I to VI according the depth of parenchymal laceration and involvement of the hepatic veins or retrohepatic portion of the inferior vena cava. Optimal methods of obtaining hemostasis vary with the severity of the injury.

12. Do all patients with a traumatic liver injury require surgery?

Show answer
No. Nonoperative treatment is the standard for victims of blunt trauma who remain hemodynamically stable (approximately 85% of patients). One third of such patients require blood transfusions, but if the volume exceeds 6 units in the first 24 hours, angiography should be done. CT scan should be repeated in 5-7 days for grade IV and V injuries. Complications, including perihepatic infection, biloma, and hemobilia, have been reported in 10% of nonoperative patients.

13. What are the options for temporary control of significant hemorrhage in victims of hepatic trauma?

Show answer
Ongoing hemorrhage leads to the vicious cycle of acidosis, hypothermia, and coagulopathy. Manual compression, perihepatic packing, and the Pringle maneuver are the most effective temporary strategies.

14. What is the Pringle maneuver?

Show answer
The Pringle maneuver is a manual or vascular clamp occlusion of the hepatoduodenal ligament to interrupt blood flow into the liver. Included in the hepatoduodenal ligament are the hepatic artery, portal vein, and common bile duct. Failure of the Pringle maneuver to control liver hemorrhage suggests either (1) injury to the retrohepatic vena cava or hepatic vein or (2) arterial supply from an aberrant right or left hepatic artery (see question 9).

15. What is the finger fracture technique?

Show answer
Finger fracture hepatotomy or tractotomy is the method of exposing bleeding points deep within liver lacerations by blunt dissection. Pushing apart the liver parenchyma enables points to be identified and ligated. This method is most commonly required for penetrating injuries.

16. What is the role of selective hepatic artery ligation in securing hemostasis in patients with a major liver injury?

Show answer

Deep lacerations of the right or left hepatic lobe may result in bleeding that cannot be completely controlled by suture ligation of specific bleeding points within the liver parenchyma. In this situation, either the right or left artery can be ligated for control of the bleeding with little risk of ischemic liver necrosis.

17. Why is retrohepatic vena caval laceration lethal?

Show answer
Exposure requires either extensive hepatotomy, extensive mobilization of the right lobe, or right lobectomy, or transection of the vena cava. The large caliber and high flow of the inferior vena cava results in massive hemorrhage during surgical exposure, whereas clamping of the inferior vena cava often results in hypotension attributable to an abrupt decrease in venous return to the heart.

18. What is the physiologic rationale for use of a shunt in attempted repair of retrohepatic vena caval injuries?

Show answer
Hemorrhage control requires maintenance of venous return to the heart while both antegrade and retrograde bleeding through the laceration is stopped. These requirements are met by shunting blood through a tube spanning the laceration between the right atrium and lower inferior vena cava.

19. What is the intrahepatic balloon tamponading device?

Show answer
For transhepatic penetrating injuries, a 1-inch Penrose drain is sutured around a red rubber catheter. This forms a long balloon that is threaded through the bleeding liver injury and inflated with contrast media through a stopcock in the red rubber catheter. The balloon tamponades liver hemorrhage. The catheter is brought out through the abdominal wall, deflated, and removed 24-48 hours later.

20. What are the indications for perihepatic packing?

Show answer
Liver packing with planned reoperation for definitive treatment of injuries in patients who have hypothermia, acidosis, and coagulopathies is a life-saving maneuver. Laparotomy pads (> 20) are packed around the liver to compress and control hemorrhage. The skin of the abdomen is then closed with towel clips (abbreviated laparotomy), and the patient’s metabolic abnormalities are corrected with planned reoperation within 24 hours.

21. What is the abdominal compartment syndrome?

Show answer
The abdominal compartment syndrome is a potentially lethal complication of perihepatic packing. It may occur when intraabdominal pressure exceeds 20 cmH2O. Intraabdominal pressure increases because of bowel and liver edema secondary to ischemia and reperfusion injury or continued hemorrhage into the abdominal cavity. As pressure increases beyond 20 cmH2O, venous return, cardiac output, and urine output decrease, but ventilatory pressures increase. Patients must return promptly to the operating room for decompression of the abdomen. A manometer attached to the Foley catheter is useful in following intraabdominal pressure.

1. What are the goals of hand repair?

Show answer
Functional considerations override cosmesis in the treatment of hand trauma. There are no minor hand injuries. Initial diagnosis and management determine the final result; expert secondary repair cannot overcome primary errors in diagnosis or decision making.

2. What determines the final outcome of a hand injury?

Show answer
It is determined by minimal sacrifice of tissue and primary healing accomplished by early wound closure. Minimization of scar tissue by control of edema, prevention of infection, early wound closure, and vigorous physical therapy produce the optimal functional outcome.

3. What factors influence treatment of hand trauma?

Show answer
Mechanism, location, and timing of injury; hand dominance; occupation; age; and general health of the patient.

4. How common are occupational hand injuries?

Show answer
Hand injuries result in more days lost from work than any other type of occupational injury.

5. What are the essentials of examination of the hand?

Show answer
Inspection of position, color, and temperature often reveals the injury. Location suggests possible injury to underlying structures. Motor, sensory, and Doppler ultrasonic examination are confirmatory. All injuries must be radiographed, and surgical exploration provides the definitive diagnosis.

6. How and where should hand injuries be explored?

Show answer
Hand wounds should be explored under tourniquet control with adequate analgesia using delicate instruments in a well-lighted surgery suite. Visual magnification is usually mandatory.

7. How is emergency hemostasis of injured hands achieved?

Show answer
In the acute setting (outside the operating suite), no tourniquet should be applied, and there should be no blind clamping of any structures. Hemostasis may be achieved by elevation of the extremity and with direct compression of the wound. This approach prevents injury to delicate underlying structures that are tough to see.

8. How are fingertip injuries treated?

Show answer
If < 1 cm of pulp is disrupted, the wound will heal spontaneously with daily cleansing and dressing with nonadherent, moist gauze. Larger defects may require a skin graft, which can often be provided by defatting the amputated piece. Bone exposure necessitates flap coverage if digital length is to be maintained. Digital nerves cannot be repaired distal to the distal interphalangeal (DIP) joint.

9. What is the classification system for fingertip amputations?

Show answer

Classification for fingertip amputations is based on the amount of remaining sensate volar skin. Although the favorably angulated amputation commonly removes some nail and bone, the volar skin is available for easy coverage. This amputation type is “favorable” for treatment by dressings only, allowing wound repair by contraction and epithelialization. The volarly angulated amputation angle is “unfavorable” for conservative management and usually requires a reconstructive procedure. (Image from Ditmars DM Jr: Fingertip and nail bed injuries. In Kasdan ML (ed): Occupational Hand and Upper Extremity Injuries and Disease. Philadelphia, Hanley & Belfus, 1991, with permission.) (See Figure 34-1.)

Figure 34-1 Fingertip amputations.

10. How are nail bed injuries repaired?

Show answer
Repair of the disruption of the germinal matrix must be meticulously approximated under magnification and the nail bed splinted, preferably with the avulsed part. Subungual hematomas should be evacuated by a hot-tipped paperclip or battery-powered electric cautery. Repair of the disruption of the sterile eponychial fold must be maintained for 3 weeks with Xeroform gauze or with the original nail. Often, nail bed disruption cannot be diagnosed without removal of the nail.

11. What is the initial management of flexor tendon?

Show answer
Flexor tendon laceration is not an emergency, and repair should not be undertaken in the emergency department. If a hand surgeon is unavailable, the wound should be copiously irrigated and sutured and prophylactic antibiotics instituted. This injury can wait for definitive repair.

12. What is the proper management of an open fracture?

Show answer
Open fractures should be cultured and then undergo copious lavage with normal saline or Ringer’s lactate. Broad-spectrum antibiotic coverage should be instituted, and the hand should be splinted in the position of function with a bulky dressing.

13. What is the proper treatment for hand infection?

Show answer
The extremity should be immobilized and elevated, and parenteral antibiotics should be given. The patient should be immediately referred for possible surgical drainage.

14. What is the proper management of human bites?

Show answer
After cleansing of the wound, a radiograph should be taken. The wound should be left open-never closed. Antibiotics should be started, and the wound should be rechecked at 24 and 48 hours. If evidence of infection is present, parenteral antibiotics should be instituted and referred for possible surgical drainage. The so-called fight bite occurs over the metacarpophalangeal (MCP) joint or proximal interphalangeal joint when a clenched fist is impaled on the front teeth of an adversary. This often inoculates the MCP joint with anaerobic streptococci. When infection is diagnosed, immediate arthrotomy and lavage should be performed.

15. How are injection injuries treated?

Show answer
Despite their innocuous appearance, injection injuries may cause profound destruction of hand structures. Any such injury requires immediate hospitalization with prompt and extensive decompression, drainage, and debridement.

KEY POINTS: CARPAL TUNNEL SYNDROME

1. Symptoms: numbness, tingling, pruritus of the palm, thumb, middle, and index fingers.
2. Mechanical cause is compression of median nerve and carpal tendons.
3. Women are affected twice as often as men; the syndrome is more common after 40 years of age.
4. Predilection for people who perform repetitive manual labor.

16. What is carpal tunnel syndrome (CTS)?

Show answer
CTS is the most common peripheral compression neuropathy; it is signaled by numbness and tingling of the hand.

17. Is CTS more common in older or younger people? Men or women?

Show answer
CTS is more common in people older than age 40 years, but an increasing number of young people with CTS have been reported in recent years, usually those whose jobs involve repetitive manual labor. Women are affected approximately twice as often as men.

18. What are the most preventable causes of deformity in hand injuries?

Show answer
Edema and infection lead to increased scarring and restricted function. Prolonged immobilization in a poor position also impairs function, as does delayed skin closure. Failure to obtain a radiograph leads to a missed diagnosis with delay in recognition of an injury.

19. What is the proper emergency department treatment of all hand injuries?

Show answer
The patient should be sedated and the wound cultured and irrigated. A thorough examination must be performed and a sterile compression dressing placed. The upper extremity should be splinted, tetanus prophylaxis should be administered, and broad-spectrum antibiotic coverage should be instituted for crush avulsion or heavily contaminated wounds. Radiographs of the hand should always be obtained.

20. What are the guidelines for replantation of an amputated finger?

Show answer
There are no absolute guidelines. A microsurgeon who is a member of a replantation team should be consulted. If replantation is planned, parts should not be immersed directly in water or put directly on ice or dry ice. The part should be copiously irrigated, wrapped in a moist sponge, and placed in a sterile plastic container; the plastic container should be placed in an ice-water slurry for transport.

References
WEB SITE

* http://www.ninds.nih.gov
o Search: carpal tunnel

BIBLIOGRAPHY
1. Dunn R, Watson S: Suturing versus conservative management of hand lacerations. Hand lacerations should be explored before conservative treatment. Comment on Br Med J 325(7359):299, 2002. Br Med J 325(7372):1113, 2002.

2. Hansen TB, Carstensen O: Hand injuries in agricultural accidents. J Hand Surg 24B:190-192, 1999.
3. Irvine AJ: Suturing versus conservative management of hand lacerations. Incisions are not lacerations. Comment on Br Med J 325(7359):299, 2002. Br Med J 325(7372):1113, 2002; author reply 325(7372):1113, 2002.
4. Lee SJ, Montgomery K: Athletic hand injuries. Orthop Clin North Am 33:547-554, 2002. Medline Similar articles Full article
5. McAuliffe JA: Hand care in the new millennium: Surgeons’ perspective. J Hand Ther 12:178-181, 1999. Medline Similar articles
6. Riaz M, Hill C, Khan K, Small JO: Long-term outcome of early active mobilization following flexor tendon repair in zone 2. J Hand Surg 24B:157-160, 1999.
7. Taras JS, Lamb MJ: Treatment of flexor tendon injuries: Surgeons’ perspective. J Hand Ther 12:141-148, 1999. Medline Similar articles
8. Van der Molen AB, Matloub HS, Dzwierzynski W, Sanger JR: The hand injury severity scoring system and workers’ compensation cases in Wisconsin, USA. J Hand Surg 24B:184-186, 1999.

1. What is the differential diagnosis of a mass located in front of the ear in a patient of any age?

Show answer
If the mass is painless, discrete, nontender, and located just anterior or just beneath the ear lobe, a parotid tumor is the first choice. The differential diagnosis for other isolated masses include parotitis, primary salivary neoplasm, upper jugular chain node enlargement, tumor of the tail of the submandibular gland, enlarged preauricular or parotid lymph node, branchial cleft cyst, epithelial inclusion cyst, or any mesenchymal neoplasm. Diffuse unilateral enlargement of the parotid gland indicates parotid duct obstruction that can either be persistent or intermittent because of calculi in the main duct. Bilateral diffuse enlargement may be caused by systemic conditions such as mumps, starch-eaters disease, and fatty infiltration.

2. What is the most likely diagnosis of a mass found high in the gland in front of the tragus of the ear?

Show answer
An enlarged lymph node is the most likely diagnosis, although parotid tumors are occasionally found in this location. In older patients who exhibit solar irradiated facial skin and numerous skin keratoses or have a history of skin cancer around the upper face, metastatic skin cancer in the node must be ruled out.

3. What is the likelihood that a parotid mass is malignant?

Show answer
Sixty percent of all salivary gland tumors are benign, and 40% are variably malignant. The most common benign tumor (80%) is the mixed salivary gland tumor, or pleomorphic adenoma. Although “benign,” this mixed salivary gland tumor can recur locally and behave in a locally malignant manner.

4. List the types of benign parotid tumors and their frequency.

Show answer

* Mixed tumor (pleomorphic adenoma) is most common (80%) and, although benign, has some local malignant potential.
* Warthin’s tumor: 14%
* Benign lymphoepithelial lesion: 1%
* Oxyphil adenoma, oncocytoma, and other rare lesions: < 1% each

5. In addition to the parotid, name two other locations for salivary gland tumors. What is the frequency of malignant tumors in these locations?

Show answer

* Submandibular glands: 50% malignant
* Minor salivary glands (oral cavity): 75% malignant

6. Do mixed tumors spread systemically?

Show answer
Very rarely. There have been 43 reported cases. Typically, these rare metastatic events are found in cervical lymph nodes. The lung and brain were the most common distant sites of metastatic disease, all with classical microscopic findings of mixed tumor.

7. Describe the types of malignant tumors and list their frequency.

Show answer
In the parotid region, the presence of pain, rapid enlargement of a nodule, skin involvement, or facial nerve paralysis is highly suggestive of a malignancy.

* Mucoepidermoid carcinoma: 44% (the low-grade variety of this tumor is “almost benign”)
* Malignant mixed tumor: 17%
* Acinic cell carcinoma: 17%
* Adenocarcinoma: 10%
* Adenoid cystic carcinoma: 9%
* Epidermoid carcinoma: 7%

8. Describe the characteristic behavior of adenoid cystic carcinoma.

Show answer
It is uncommon in the parotid but does recur locally with perineural invasion. It may recur 15 years or more after treatment.

9. How should a parotid mass be evaluated and treated? Should a biopsy be performed?

Show answer
A moveable, rubbery-feeling mass should not be biopsied preoperatively. A parotid lobectomy is normally carried out with dissection of the facial nerve (cranial nerve [CN] VII), followed by frozen section of the tumor. If a tumor is found to be malignant preoperatively by needle aspiration biopsy (which is obtained secondary to nerve involvement), a complete lobectomy should be performed, keeping in mind that cancer may involve one or more nerve branches. The decision about nerve branch resection can only be determined surgically with actual evidence of neural invasion. Most authorities also advocate removal of adjacent upper neck nodes. With histologic evidence of node involvement, a modified neck dissection is indicated.

10. What is the surgical treatment of a deep lobe parotid tumor?

Show answer
These are quite uncommon because the lobe is only one fifth of the size of the entire gland and lies completely beneath the facial nerve (CN VII). Typically, a superficial parotidectomy is performed first followed by dissection and preservation of the facial nerve. Then the tumor in the deep lobe is removed along with any residual deep lobe tissue.

11. What does a partial or temporary facial nerve (CN VII) paralysis in the presence of an untreated parotid mass suggest?

Show answer
With gradual paralysis, cancer is the likely diagnosis (> 95%). Sudden onset of unilateral CN VII weakness suggests Bell’s palsy, which is typically the result of an inflammatory process and thus may be reversible. Mixed tumors rarely present with nerve paralysis. Facial nerve paralysis has an ominous prognosis. Radical surgery plus radiotherapy may help control cancer in rare cases.

12. What is the best imaging modality that can be used to identify parotid lesions?

Show answer
Deep lobe tumors occasionally extend into the oral pharynx and oral cavity, and the margins of infiltration as well as the extent of tumor are best delineated by magnetic resonance imaging (MRI). This, however, cannot differentiate between malignant and benign lesions. Routine MRI is not necessary when treating a freely moveable superficial parotid tumor.

13. Can children develop parotid tumors?

Show answer
Parotid tumors are uncommon in children, and a greater proportion of their tumors are malignant (50%).

14. What is the cause of parotid tumors?

Show answer
The cause is not clear. Inflammatory disease or stones in the parotid duct have been incriminated, and smoking may play a part in the production of Warthin’s tumors.

15. What is the recommended treatment of benign-appearing parotid tumors?

Show answer
As a rule, it is safer to remove all parotid masses. The only exceptions are long-standing parotid lesions of apparently benign type in older or infirm patients. Aspiration biopsies can be useful here to confirm the diagnosis of mixed tumors or other benign lesions in situations in which surgery would be high risk.

16. What is the most likely diagnosis of a recently enlarging parotid mass in a patient who is HIV positive?

Show answer
A benign lymphoepithelial lesion is most likely. If needle biopsy confirms this diagnosis, surgery is not necessary because of the benign nature of the process in the face of eventual AIDS development. If a cyst is present, fluid aspiration can decrease or temporarily eliminate the swelling.

17. If a malignancy is identified on a frozen section of the superficial lobe of the gland, is further surgery necessary?

Show answer
Removal of the remaining salivary tissue, including the deep lobe, is usually advocated. Low-grade mucoepidermoid carcinoma does not require radical removal. Careful histologic study, of course, is absolutely essential in determining the type of malignant neoplasm. If cancer is confirmed, a limited upper neck dissection is advised. A classical neck dissection is not performed in patients with parotid cancer unless there is evidence of nodal disease.

18. Is further surgery necessary when a mixed tumor is identified in the superficial lobe?

Show answer
Few, if any, cases recur if the resection margins are grossly clean, there is no spillage at surgery, and there is no microscopic penetration of the capsule.

19. When is the appropriate time for nerve grafting after parotid cancer resection?

Show answer
Interposition grafting can be performed after noncancerous frozen sections of the nerve ends have been confirmed. A nerve graft from the contralateral greater auricular nerve is usually preferred.

20. Is it necessary to dissect the facial nerve (CN VII) when performing a parotid tumor resection?

Show answer
Yes. For a Warthin’s tumor, which usually develops in the lower part of the parotid, careful local excision (without identifying the nerve) is permissable because local recurrence is uncommon. Mixed tumors arising in rare anterior locations may also be excised locally without nerve dissection.

KEY POINTS: PAROTID TUMORS

1. The most common benign tumor is a mixed tumor or pleomorphic adenoma.
2. The most common malignant tumor is mucoepidermoid carcinoma.
3. The facial nerve branch most commonly injured during a parotidectomy is the ramus marginalis mandibularis.

21. Which facial nerve branch is most commonly injured during a parotidectomy?

Show answer
Most commonly injured is the ramus marginalis mandibularis, the lowest branch of the nerve that innervates the depressor muscles of the lower lip. This nerve must be preserved. If weakness of the lower lip does occur because of neuropraxia (a common complication even of careful surgery), it will with resolve within 8 weeks.

22. What are the most common causes of postparotidectomy facial nerve paresis?

Show answer
Postoperative palsy is rare. Neuropraxia is typically caused by rough handling of the facial nerve and branches. Coagulation of bleeding vessels, which leads to temporary thermal injury of the nerve; careless suctioning around the nerve itself; and excessive traction of the nerve may result in several weeks of distressing palsy. Despite the greatest care, some patients may still develop temporary paralysis, but most should resolve in weeks.

23. Why do some patients complain of anesthesia of the ear lobe after surgery?

Show answer
They have temporary or permanent injury to the posterior branch of the greater auricular nerve. This nerve can be preserved if it is not involved with tumor and not adherent to the tumor itself.

24. When is a lymph node dissection indicated?

Show answer
Only for clinically positive (palpable) nodes and high-grade cancers.

25. When should postoperative radiation therapy be used after parotidectomy?

Show answer
In all except very low-grade cancers. A radical neck dissection is not performed without evidence of nodal involvement.

26. What are the cure rates with surgery for parotid cancer?

Show answer
In low-grade cancers, cure rates may approach 90%. In one large series of all types of cancers, survival rates at 5, 10, and 15 years were approximately 62%, 54%, and 47%, respectively.

27. Is the stage or histologic grade of the tumor more important in determining the prognosis of adenoid cystic carcinoma?

Show answer
Multivariate analysis shows that tumor stage is more prognostic than tumor grade. Early-stage tumors, even in the face of high-grade histology, enjoy a good prognosis.

28. How common is a salivary fistula after superficial parotidectomy?

Show answer
Rare. If all except a few fragments of the superficial lobe are removed cleanly, fistulas should not occur. The deep lobe itself is rarely, if ever, the source of salivary leak after removal of the superficial lobe.

29. What is Frey’s syndrome?

Show answer
Gustatory sweating, also known as auriculotemporal nerve syndrome, is a well-known sequela after parotidectomy. Patients become socially debilitated by episodes of unilateral hyperhidrosis, pain, and flushing in the cutaneous distribution of the auriculotemporal nerve when they eat. The most widely accepted theory of the pathophysiology is the aberrant regeneration theory. In this theory, autonomic fibers from the parotid gland, when damaged by surgery or trauma, regrow into the sheath of the severed auriculotemporal nerve, causing the syndrome. Nonsurgical treatment includes medications such as topical anticholinergics and systemic atropine. Surgical treatments include neurectomy with or without the insertion of a graft to provide a barrier to reinnervation.

30. When is chemotherapy used after parotidectomy in the face of malignancy?

Show answer
Total gross excision of parotid cancer, sparing facial nerve if possible and followed by regional radiotherapy, provides excellent rates of control and survival with only moderate toxicity. Patients presenting postoperatively with gross residual tumor or recurrence after surgery should be considered for trials of more aggressive treatment with combined chemotherapy or altered fractionation schemes of irradiation.

31. Can a mixed tumor metamorphose into a true malignancy?

Show answer
Possibly, but it is rare.

32. Can facial nerve (CN VII) function be preserved despite the sacrifice of facial branches?

Show answer
Occasionally, lip elevator function can be maintained by preserved branches from the zygomatic or buccal branches of the facial nerve that cross over and accomplish similar function as the cut nerve branch.

33. Which tumor suppressor gene is most often associated with parotid cancer?

Show answer
p53 has been found in some parotid cancers. These lesions are usually advanced and larger than those without p53.

References
WEB SITE
http://www.acssurgery.com
BIBLIOGRAPHY
1. Blevins NH, Jackler RK, Kaplan MJ, Boles R: Facial paralysis due to benign parotid tumors. Arch Otol Head Neck Surg 118:427-430, 1992.
2. Christensen NR, Jacobsen SD: Parotidectomy: Preserving the posterior branch of the great auricular nerve. J Laryngol Otol 111:556-559, 1997. Medline Similar articles
3. Goldwyn RM, Cohen MN: The Unfavorable Result in Plastic Surgery. Philadelphia, Lippincott Williams & Wilkins, 2001.
4. Ismail Y, McLean NR, Chippindale AJ: MRI and malignant melanoma of the parotid gland. Br J Plast Surg 54:636-637, 2001. Medline Similar articles <a href=”http://dx.doi.org/10.1054/bjps.2001.3674″>Full article
5. Kelley DJ, Spiro RH: Management of the neck in parotid carcinoma. Am J Surg 172:695-697, 1996. Medline Similar articles Full article
6. Malata CM, Camilleri IG, McLean NR, et al: Malignant tumors of the parotid gland: A 12-year review. Br J Plast Surg 50:600-608, 1997. Full article
7. Ogata H, Ebihara S, Mukai K: Salivary gland neoplasms in children. Jpn J Clin Oncol 24:88-93, 1994. Medline Similar articles
8. Spiro RH, Huvos AG: Stage means more than grade in adenoid cystic carcinoma. Am J Surg 164:623-638, 1992. Medline Similar articles
9. Teymoortash A, Werner JA: Value of neck dissection in patients with cancer of the parotid gland and a clinical NO neck. Onkologie 25:122-126, 2002. Medline Similar articles Full article
10. Toonkel LM, Guha S, Foster P, Dembow V: Radiotherapy for parotid cancer. Ann Surg Oncol 1:468-472, 1994. Medline Similar articles
11. Tullio A, Marchetti C, Sesenna E, et al: Treatment of carcinoma of the parotid gland: The result of a multicenter study. J Oral Maxillofac Surg 59:263-270, 2001. Medline Similar articles Full article
12. Yugueros P, Loellner JR, Petty PM: Treating recurrence of benign parotid pleomorphic adenomas. Ann Plast Surg 40:573-576, 1998.

1. Is health care reform an oxymoron?

Show answer
Yes.

2. What is fee for service?

Show answer
The doctor establishes the price, and the patient agrees to pay it. This traditional system of exchange has great merit if both parties understand the value of the service provided. If either party (usually the patient) cannot estimate the service value, it is possible (even likely) that the doctor will honestly escalate the service value in a fashion unchecked by the patient’s perceptions. Thus, in a fee-for-service system, medical prices tend to increase.

3. What is discounted fee for service?

Show answer
The patient gets together with a group of friends, and they come to the doctor with the following proposition: “Hey, Doc, you can dazzle us with your fancy medical talk, but we still think that your prices are too high. How about my pals and me will pay you 80% of what you charge us?”

4. Is there a difference between hospital costs and hospital charges?

Show answer
Absolutely. Hospital cost is the sum of the expenses (e.g., sutures, nurses’ salaries, electricity, instrumentation sterilization, Band-Aids) that are expended in suturing a laceration, for example. The hospital typically charges about twice the cost (100% markup) for repairing a cut finger. This markup is highly industry specific. Thus, whereas intensely competitive food chains may make a profit of only 1 penny on a loaf of bread, hospitals and liquor stores usually charge twice the cost.

5. What are fixed costs?

Show answer
After accounting for light, heat, and staff (nurses, housekeepers, administrators) at a hospital but before seeing a single patient, doctors and the hospital have already spent a huge amount of money. Doctors and hospitals must pay fixed costs whether or not they provide any medical services at all.

6. What are actual costs?

Show answer
These are the incremental costs of actually providing a service in a hospital (in addition to the fixed costs of light and heat). For example, a patient shows up in the emergency department at midnight complaining of a lump on the tip of his nose. The doctor, with characteristic erudition, says, “Yep, you have a wart on your nose,” and sends the patient home with a bill for $500. The actual cost of this encounter is obviously negligible. The patient is really paying for the fixed costs of nurses and emergency resuscitative equipment should he have a cardiac arrest.

7. Is hospital accounting a precisely scientific and objective analysis of financial data?

Show answer
No.

8. What is health insurance?

Show answer
Traditionally, people can purchase insurance that may pay either all or a portion of their hospital and physician charges if they become ill. Insurance companies make a profit, therefore, only if the patient stays healthy. Insurance companies have elaborate tables to predict who will get sick, and they prefer to sell policies exclusively to young, healthy individuals. This practice is termed “skimming.” The insurance company takes all of the risk-and they like to keep it low. Conversely, hospitals must cover fixed costs-and the more expensive (and more frequent) the health care that physicians provide, the better it is for the hospitals.

9. What are health maintenance organizations (HMOs)?

Show answer
HMOs are complex systems composed, in their most comprehensive form, of hospitals, doctors plus offices, and an insurance company. HMOs contract with large groups of people (potential patients) to maintain their health. Enrollees pay a monthly fee (just like health insurance) so that all hospital and physician charges are covered if the enrollees become ill. Unlike health insurance, however, in the HMO model, hospitals and physicians get paid whether or not the enrollee gets sick. So, it is better for everyone if enrollees stay healthy-and out of the hospital.

10. Initially, a lot of physicians did not like HMOs. Why?

Show answer
Because physicians are fiercely independent. They did not want a bunch of business managers telling them how to manage patients.

11. Why are physicians fiercely independent?

Show answer
We were probably born that way.

12. Is that good?

Show answer
Probably not. Eventually, everyone will need to work together and not hit each other when they are mad.

13. Do HMO administrators really dictate how physicians manage their patients?

Show answer
Yes and no. Physicians have developed medically effective and optimally efficient strategies-termed clinical pathways-for caring for many common illnesses. Although physicians must treat each patient individually, when we adhere to predetermined treatment guidelines (as encouraged by HMO administrators), patients usually get better faster and cheaper.

14. Do physicians follow these clinical pathways?

Show answer
Traditionally, no.

15. What do HMO managers do?

Show answer
They evaluate each physician’s utilization of expensive resources (within the predetermined clinical pathways) relative to the health of the physician’s patients.

16. Do physicians welcome this kind of scrutiny?

Show answer
No.

17. What is a preferred provider organization (PPO)?

Show answer
A PPO is a group of doctors who have elected to remain legally independent of a hospital and insurance company (if they joined together, they would be an HMO) and, most of all, patients. But PPOs maintain their independence as physicians, even though most PPOs require administrators to coordinate programs, keep the books, and keep the doctors from hitting each other. PPOs have the perception of independence, however.

18. Is health care expensive?

Show answer
Unfortunately, yes. Physicians argue that patients pay a lot but also get a lot. In the United States, patients expect unlimited access to liver transplantation and magnetic resonance imaging (MRI) for every headache. Americans believe that fancy, expensive health care is not just a privilege-it is a right.

19. So what is the problem?

Show answer
The chief executive officers (CEOs) of big American corporations argue that the obligatory expense of health care is driving up the cost of U.S. products and making American companies less competitive in the global market-there is more health care than steel in a new Chevrolet.

20. Does big business have a solution?

Show answer
They think so. The CEOs still want unlimited access to the most modern health care for themselves and their families. Without sounding cynical, the CEOs want to save health care dollars spent on their employees and “other people’s families.” They want to limit access to health care, but they do not want to wield the ax personally. So they developed the idea of capitation.

21. What is capitation?

Show answer
The CEOs of large businesses come to hospitals, HMOs, or PPOs and say: “Why don’t you provide all health care for all my employees at a fixed price, say, $180 per month per head?” (hence, capitation). In this model, physicians make the decisions about who gets how much medical care (satisfying their urge for independence), but they also promise to provide all necessary medical care for a prearranged price. Thus, they take all of the risk. CEOs like this model because they can still offer health care as an employee benefit and budget the cost in advance.

22. Why do physicians not like capitation?

Show answer
All of a sudden physicians may have acquired a little more independence than they bargained for. Now they are paid in advance so that all costs of patients’ health care are subtracted from the money they negotiated up front. Now they must advise against an MRI for every headache and break the news to Granny that she will not think better if they dialyze her blood urea nitrogen down to 50. This is the reverse of the good old days when physicians were rewarded if their patients got sick and stayed sick. Physicians could ply them with a smorgasbord of drugs and technologies. Now physicians are trying to control health care costs.

23. Is all this change good?

Show answer
Absolutely. Medicine has always changed-and the faster, the better. Physicians were initially attracted to medicine as an intellectually stimulating discipline because medicine and surgery evolve rapidly.

24. Can physicians keep up with all this change?

Show answer
Absolutely.

25. Despite all of the medical Chicken Littles who sonorously declare that the sky is falling, is medicine (and even more clearly, surgery) still the most gratifying, stimulating, and rewarding profession?

Show answer
Absolutely.

References
BIBLIOGRAPHY
1. Blumenthal D: Controlling health care expenditures. N Engl J Med 344:766-769, 2001. Medline Similar articles Full article
2. Dudley RA, Luft HS: Managed care in transition. N Engl J Med 344:1087-1092, 2001. Medline Similar articles Full article
3. Fuchs VR: What’s ahead for health insurance in the United States? N Engl J Med 346:1822-1824, 2002.
4. Iglehart JK: Changing health insurance trends. N Engl J Med 347:956-962, 2002.
5. Schroeder SA: Prospects for expanding health insurance coverage. N Engl J Med 344:847-852, 2001. Medline Similar articles Full article
6. Wilensky GR: Medicare reform-now is the time. N Engl J Med 345:458-462, 2001. Medline Similar articles Full article
7. Wood AJ: When increased therapeutic benefit comes at increased cost. N Engl J Med 346:1819-1821, 2002. Medline Similar articles Full article
8. Wright JG: Hidden barriers to improvement in the quality of health care. N Engl J Med 346:1096, 2002. Medline Similar articles

1. What is the physiologic role of the spleen?

Show answer
In fetal development, the spleen serves as a major site for hematopoiesis. In early childhood the spleen produces immunoglobulin M (IgM) and tuftsin. The spleen also functions as a filter, allowing resident macrophages to remove abnormal red blood cells (RBCs), cellular debris, and encapsulated and poorly opsonized bacteria.

2. What injury patterns are associated with splenic trauma?

Show answer
Direct blunt force, deceleration, and compression to the left torso. Think spleen after a motor vehicle accident or fall: lower rib fractures, left side-only rib fractures, and high-energy transfer (big hits) increase the probability of splenic injury.

3. What are the signs and symptoms of splenic injury?

Show answer
The main sign is pain in the left upper quadrant. This is produced by stretching the splenic capsule. Peritoneal irritation (rebound tenderness) is caused by extravasated blood (blood is very irritating). Vital signs vary depending on associated blood loss and are not specific for injuries to the spleen. Unfortunately, a large number of patients with a significant splenic injury exhibit no signs or symptoms at all.

4. What studies can help in diagnosing splenic trauma?

Show answer
Ultrasound (US) can be performed in the emergency department and can rapidly identify as little as 200 mL fluid/blood. When US is not available, diagnostic peritoneal lavage (DPL) is an accurate and sensitive measure of intraabdominal bleeding.
Hemodynamically stable patients permit more thorough evaluations. Although US is extremely sensitive for detecting intraabdominal bleeding, computed tomography (CT) not only can detect and quantify intraabdominal blood but also can characterize specific intraabdominal injuries.

5. How are splenic injuries classified, and why is that important?

Show answer
Management is governed by the hemodynamic status of the patient, but therapy is also influenced by the CT grade of splenic injury. Nonoperative management is most successful in grades I-III, whereas operative intervention is often required for grade IV injuries. Grade V injuries demand prompt operative intervention. (See Table 26-1.)

6. Do splenic injuries require laparotomy?

Show answer
No. Nonoperative management is successful in approximately 95% of patients with grades I-III. Hemodynamically stable patients with evidence of ongoing bleeding (requiring transfusion) may be treated by selective arterial embolization if a bleeding site is identified on angiography.

7. What are contraindications to nonoperative management of splenic injuries?

Show answer

* Hemodynamic instability
* Persistent coagulopathy
* Additional intraabdominal injury requiring operative intervention
. GRADES OF SPLENIC INJURY

8. What is the failure rate of nonoperative management of splenic injury?

Show answer
Any patient with signs of hemodynamic instability, persistent bleeding, worsening pain or tenderness, or progressive injury by CT scanning has failed nonoperative management. Approximately 60% of all splenic injuries can be managed nonoperatively with a failure rate of 12%. Factors that predict nonoperative failure include multiple injuries, grade III-V spleen injuries, age > 55 years, and blood traunsfusion.
KEY POINTS: EXPECTANT MANAGEMENT OF SPLENIC INJURIES

1. Nonoperative management is successful in 95% of grades I-III injuries.
2. 60% of all splenic injuries are managed nonoperatively, with a 12% failure/conversion rate.
3. Factors that predict failure/conversion to operative treatment include injury > grade III, age > 55 years, and blood transfusion requirements.
4. Patients with evidence of ongoing bleeding (e.g., contrast “blush” on CT or ongoing transfusion requirements) may be managed with selective arterial embolization.

9. What is delayed rupture of the spleen?

Show answer
This is a rare complication that occurs in < 1% of patients with a splenic injury. Delayed splenic rupture should be distinguished from a delay in diagnosis of splenic injury and rupture of a known splenic injury. True delayed splenic rupture occurs > 48 hours in a patient with a history of abdominal trauma and no overt clinical evidence of intraabdominal injury on initial presentation.

10. What are the general principles of operative management of the injured spleen?

Show answer
The first priority is to control bleeding. This can usually be accomplished by packing and manual compression of the spleen. If successful, the abdomen is then thoroughly explored for other injuries. Complete mobilization of the spleen by division of the splenocolic, splenorenal, phrenosplenic, and gastrosplenic ligaments is required for complete assessment of the spleen. The short gastric vessels can be ligated with division of the gastrosplenic ligament. Repair of the spleen can be accomplished by application of hemostatic agents, direct pledgeted suture repair of the splenic parenchyma, partial splenectomy, and construction of a “splenic wrap” using absorbable mesh. If splenectomy is required, the splenic artery and vein should be ligated individually prior to removing the spleen.

11. What early complications arise after splenectomy?

Show answer
Bleeding, acute gastric dilatation, gastric perforation, pancreatitis (the splenic artery courses along the top of the pancreas), and subphrenic abscess.

12. What is splenic autotransplantation?

Show answer
Autotransplantation is accomplished by implanting splenic tissue parenchymal slices into pouches created in the gastrocolic omentum.

13. Does splenic autotransplantation preserve splenic function?

Show answer
Autotransplantion after splenectomy is controversial. At least 30% of the original splenic mass is needed to provide normal function. After autotransplantation, IgG and IgM levels are increased in response to pneumococcal vaccine compared with patients after splenectomy alone.

14. Does postsplenectomy leukocytosis predict infection?

Show answer
Elevations in white blood cell (WBC) count and platelet count (PC) after splenectomy are a common physiologic event. After the fourth postoperative day, however, a WBC > 15 x 103 and a PC/WBC < 20 are highly associated with sepsis and should not be confused with the physiologic response to splenectomy.

15. Should a follow-up CT scan be performed after nonoperative management of splenic injuries before patient discharge?

Show answer
No. Most patients who fail nonoperative management do so within 5 days and will exhibit hemodynamic evidence of ongoing hemorrhage. However, follow-up CT should be performed for grade III and IV injuries at 4-6 weeks before getting back to vigorous physical activity.

16. What is OPSS, and how is it prevented?

Show answer
Overwhelming post splenectomy sepsis (OPSS) is a devastating bacteremia (typically encapsulated bacteria) that occurs in 2% of patients after splenectomy. The risk of OPSS is greatest when splenectomy is performed during infancy. The most common organisms are pneumococcus (50%), meningococcus, Escherichia coli, Haemophilus influenzae, staphylococcus, and streptococcus. Although rare, OPSS carries a mortality rate of 75% and has spurred interest in splenic preservation. OPSS is primarily prevented by postoperative vaccination. Pneumococcal, meningococcal, and Haemophilus flu vaccines should be given 2 weeks after splenectomy and are recommended every 5 years. Sepsis can occur despite vaccination; consequently, long-term prophylaxis with oral penicillin is recommended for children.

References
WEB SITES

1. http://www.east.org/tpg/bluntabd.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0506.htm

BIBLIOGRAPHY
1. Cocanour CS, Moore FA, Ware DN, et al: Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg 133:619-624, 1998. Medline Similar articles Full article
2. Leemans R, Manson W, Snijder JA, et al: Immune response capacity after human splenic autotransplantation: Restoration of response to individual pneumococcal vaccine subtypes. Ann Surg 229:279-285, 1999. Medline Similar articles Full article
3. Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver (1994 revision). J Trauma 38:323-324, 1995.
4. Shatz DV: Vaccination practices among North American trauma surgeons in splenectomy for trauma. J Trauma 53:950-956, 2002. Medline Similar articles Full article
5. Toutouzas KG, Velmahos GC, Kaminski A, et al: Leukocytosis after posttraumatic splenectomy: A physiologic event or sign of sepsis? Arch Surg 137:924-928, 2002. Full article
6. Uecker J, Pickett C, Dunn E: The role of follow-up radiographic studies in nonoperative management of spleen trauma. Am Surg 67:22-25, 2001. Medline Similar articles