ObjectiveTo evaluate the authors' experience with periduodenal perforations to define a systematic management approach. Summary Background DataTraditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines.

The management of parotid sialoceles and fistulae have been unsatisfactory in the past, and numerous methods of treatment with varying success and morbidity have been described. The present prospective study reports results of conservative therapy in 51 patients over a 3-year period. In 50 patients, the injury healed upon conservative management. During the early phase of the study, a limited conservative regimen through which the patients received nothing orally for 5 days only was used. During the latter part of the study, patients were administered nothing orally until complete healing of the injury. In terms of the time it took for healing of the injury, the differences of the two regimens (24 +/- 4 vs. 9.4 +/- 0.9 days) was highly significant (p less than 0.001). The response to conservative management depended on the severity of injury as demonstrated by sialography. Injury to minor intraparotid ducts (G1) healed in significantly less time compared with that to a major intraparotid duct (G2) or ductal injuries (p less than 0.001). There was no difference between the healing of G2 injury (10.3 +/- 1.8 days) and partial ductal transections (10.5 +/- 2.2 days) (p greater than 0.05). There was a significantly greater delay in healing with complete duct transections (21.5 +/- 3.7 days) compared with partial duct transections and G2 injuries (10.2 +/- 2.1 days) (p less than 0.01). There was no difference in the mean period for healing between salivary fistulae and sialoceles (p greater than 0.05). It is concluded that a new classification of parotid fistulae based on sialographic findings has prognostic and therapeutic value. Furthermore, the excellent results achieved with conservative therapy in this study suggest that it may be the initial treatment of choice for parotid fistulae.

This study involved 163 patients with penetrating injuries of the diaphragm (knife, 139; bullet, 24). Intra-abdominal injuries were present in 122 patients (75 per cent) and this resulted in early diagnosis and treatment of the associated diaphragmatic injury (mortality 3.2 per cent). In the remaining 41 patients (25 per cent) the injury was confined to the diaphragm, and the diagnosis was missed during the initial admission in 10 patients who returned at a later stage with diaphragmatic hernia. A diaphragmatic hernia was found in 24 cases (14.7 per cent). Fourteen of these were diagnosed during the initial admission (mortality 7.1 per cent) and the remaining ten were diagnosed during a subsequent admission (mortality 30 per cent). The initial chest radiograph was diagnostic of diaphragmatic injury in 13 per cent, abnormal but not diagnostic in 76 per cent, and completely normal in 11 per cent. The importance of early diagnosis in reducing mortality, morbidity and hospital stay is emphasized. A high index of suspicion, careful clinical examination, and serial chest radiographs remain the best way of making the diagnosis.