Inferior Vena Cava Suture Instrument
Editor.\p=m-\Interruptionof the vena cava (IVC) is an accepted treatment for venous thromboembolic disease when anticoagula-
To the inferior
tion therapy fails or is contraindicated. Complete interruption of the IVC is recommended when there is evidence of a septic component or when microembolic episodes are suspected. In all other cases, partial interruption is usually preferred. Spencer and Quaddlebauer1 described a technique for plication of the IVC that consists of creating channels, 3 mm in diameter, following the longitudinal axis of the IVC, by placing longitudinal mattress sutures through the vein. To facilitate this technique, a new instrument has been devised (manufactured by E. Cottely, Buenos Aires). Use of this instrument avoids both extensive dissection sometimes neces-
Fig 1.—Instrument inferior
for
sary for applying occlusive clamps and occlusive clamping itself, and ensures picking up the posterior wall of the vena cava during the application of the sutures. The instrument consists essentially of two arms, as shown in Fig 1. Minimal dissection of the IVC is required to permit passage of the posterior arm of the instrument underneath the vessel (Fig 2). The anterior arm is applied (Fig 3) and the sutures are placed (Fig 4, top and bottom). Fivemillimeter spacing of the sutures results in compartments 3 mm in diameter. Proper spacing is facilitated by the millimetrical marking en¬ graved on the anterior arm of the instrument. When all sutures are placed, the clamp is removed and the sutures tied. The final result is illus¬ trated in Fig 5. Juan Carlos Parodi, MD Cleveland Fabio Miguel Soffer, MD Buenos Aires 1. Spencer FC, Quaddlebauer J: Plication of the IVC for pulmonary embolism. Ann Surg
155:827, 1962.
clamping
vena cava.
Fig 2.—Clamping position.
inferior vena cava,
initial
Fig 3.—Clamp¬ ing inferior vena cava,
final
Fig 5.—Final
position.
Fig 4.—Suturing
result.
inferior
vena cava.
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
Trauma Care
To the
Study
Editor.\p=m-\Earlyin
their careers,
physicians are taught the responsibility of accuracy and validity. Abuse of a
scientific forum is a serious matter, with wide-ranging implications for individual patient care and medicolegal issues. Drs West, Trunkey, and Lim in the Archives (114:455-460, 1979) described a method and offered conclusions relating to comparisons of the quality of emergency medical care between two geographical areas. The report almost totally avoids the qualifications necessary for a valid scientific presentation. The Society of Neurologic Surgeons of Orange County, Calif, has determined that none of the authors of this report is either a neurosurgeon or a neuropathologist, or has ever consulted with members of either specialty. The authors are thus
unqualified to with injuries
assess care
of
patients
to the CNS. Further-
a committee of the Society of Neurological Surgeons of Orange County has reviewed the available CNS-injury material of their report
more,
and has found that the data did not in any way support their conclusions. Further examination makes this apparent. One hundred apparently consecutive deaths due to acute trau¬ ma in San Francisco and Orange coun¬ ties, Calif, were discussed. The inade¬ quacy of the authors' work is mani¬ fested by, to begin with, using such protean areas as Orange County and San Francisco. Orange County is a sprawling, relatively rural area with a climate and a life-style distinctly different from those of San Francisco. Its 1.6 million inhabitants use freeway transportation heavily, with its inher¬ ent risks and high-speed accidents. San Francisco is more urban, and is characterized by a colder climate and by a population of well under a million people, who travel via the subway and use buses, city taxi cabs, and cable cars to a greater degree than freeway systems. Its population increases ap¬ proximately five times a week during certain hours, when out-of-town work¬ ers enter the city. However, the basic discrepancies between the two areas are apparent and conclusions drawn from any study of patients in Orange County and San Francisco must strongly take this into consideration. The statistics, information, and, eventually, conclusions in this article are drawn from information obtained from coroners' records and autopsies.
Editor.\p=m-\Interruptionof the vena cava (IVC) is an accepted treatment for venous thromboembolic disease when anticoagula-
To the inferior
tion therapy fails or is contraindicated. Complete interruption of the IVC is recommended when there is evidence of a septic component or when microembolic episodes are suspected. In all other cases, partial interruption is usually preferred. Spencer and Quaddlebauer1 described a technique for plication of the IVC that consists of creating channels, 3 mm in diameter, following the longitudinal axis of the IVC, by placing longitudinal mattress sutures through the vein. To facilitate this technique, a new instrument has been devised (manufactured by E. Cottely, Buenos Aires). Use of this instrument avoids both extensive dissection sometimes neces-
Fig 1.—Instrument inferior
for
sary for applying occlusive clamps and occlusive clamping itself, and ensures picking up the posterior wall of the vena cava during the application of the sutures. The instrument consists essentially of two arms, as shown in Fig 1. Minimal dissection of the IVC is required to permit passage of the posterior arm of the instrument underneath the vessel (Fig 2). The anterior arm is applied (Fig 3) and the sutures are placed (Fig 4, top and bottom). Fivemillimeter spacing of the sutures results in compartments 3 mm in diameter. Proper spacing is facilitated by the millimetrical marking en¬ graved on the anterior arm of the instrument. When all sutures are placed, the clamp is removed and the sutures tied. The final result is illus¬ trated in Fig 5. Juan Carlos Parodi, MD Cleveland Fabio Miguel Soffer, MD Buenos Aires 1. Spencer FC, Quaddlebauer J: Plication of the IVC for pulmonary embolism. Ann Surg
155:827, 1962.
clamping
vena cava.
Fig 2.—Clamping position.
inferior vena cava,
initial
Fig 3.—Clamp¬ ing inferior vena cava,
final
Fig 5.—Final
position.
Fig 4.—Suturing
result.
inferior
vena cava.
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/16/2015
Trauma Care
To the
Study
Editor.\p=m-\Earlyin
their careers,
physicians are taught the responsibility of accuracy and validity. Abuse of a
scientific forum is a serious matter, with wide-ranging implications for individual patient care and medicolegal issues. Drs West, Trunkey, and Lim in the Archives (114:455-460, 1979) described a method and offered conclusions relating to comparisons of the quality of emergency medical care between two geographical areas. The report almost totally avoids the qualifications necessary for a valid scientific presentation. The Society of Neurologic Surgeons of Orange County, Calif, has determined that none of the authors of this report is either a neurosurgeon or a neuropathologist, or has ever consulted with members of either specialty. The authors are thus
unqualified to with injuries
assess care
of
patients
to the CNS. Further-
a committee of the Society of Neurological Surgeons of Orange County has reviewed the available CNS-injury material of their report
more,
and has found that the data did not in any way support their conclusions. Further examination makes this apparent. One hundred apparently consecutive deaths due to acute trau¬ ma in San Francisco and Orange coun¬ ties, Calif, were discussed. The inade¬ quacy of the authors' work is mani¬ fested by, to begin with, using such protean areas as Orange County and San Francisco. Orange County is a sprawling, relatively rural area with a climate and a life-style distinctly different from those of San Francisco. Its 1.6 million inhabitants use freeway transportation heavily, with its inher¬ ent risks and high-speed accidents. San Francisco is more urban, and is characterized by a colder climate and by a population of well under a million people, who travel via the subway and use buses, city taxi cabs, and cable cars to a greater degree than freeway systems. Its population increases ap¬ proximately five times a week during certain hours, when out-of-town work¬ ers enter the city. However, the basic discrepancies between the two areas are apparent and conclusions drawn from any study of patients in Orange County and San Francisco must strongly take this into consideration. The statistics, information, and, eventually, conclusions in this article are drawn from information obtained from coroners' records and autopsies.
