Pancreatic trauma: a ten-year multi-institutional experience

Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.     

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An analysis of 100 patients sustaining multiple injury and pancreatic trauma was completed. Sixteen patients with penetrating injury died within the first 24 hours, 14 of whom died intraoperatively from major hepatic and/or retroperitoneal venous injury. Eighty-four patients survived long enough to permit evaluation of treatment. There was no statistically significant relationship between mode (p = 0.3) or anatomic area (p = 0.5) of injury and death. However, death was more common in the presence of duct injury (p less than 0.0001). Thirty-nine patients were determined to have duct injury and 45 did not. These two groups were equivalent, with the exception of a higher incidence of concomitant bowel injury (p less than 0.05) in those with duct violation. Combined sump and Penrose drainage was found to be adequate treatment of both proximal and distal nonductal injury with no significant difference in mortality or morbidity rates (p = 0.5). Resection of distal ductal injuries as opposed to drainage alone resulted in significantly lower morbidity and mortality rates (p less than 0.05), comparable to those of drained nonductal injuries. No conclusions could be made relevant to proximal duct injuries, except that drainage alone is inadequate. Seventeen (20 percent) of the 84 patients evaluated died. Pancreatic related mortality rate was 17 percent (14 patients). Two of 23 patients with blunt injury (9 percent) and 12 of 61 patients with penetrating injury (20 percent died). Gram-negative sepsis (82 percent) was the most common cause of death (p less than 0.01), and sepsis was correlated with the presence of pancreatic duct (p less than 0.0001) and bowel (p less than 0.001) injury.     

Effects of three trans isomers of eicosapentaenoic acid on rat platelet aggregation and arachidonic acid metabolism

PURPOSE: To compare in a randomized, prospective manner infectious complication rates associated with presacral drainage versus no drainage in the presence of penetrating rectal injury. METHODS: During a 45-month period, 48 patients with penetrating rectal injuries were entered into a randomized, prospective study at an urban Level I trauma center. The patients were randomized to a presacral drainage group or a nondrainage group. Randomization was performed after detection of the rectal injury. Forty-four injuries were identified by proctoscopy (92%), with the rest detected intraoperatively or by physical examination. All patients with rectal injuries were included regardless of age, associated injuries, time from injury to operation, blood loss, severity of rectal injury, other abdominal organs injured, or hemodynamic stability. Rectal injuries were defined as those injuries to the large bowel distal to the peritoneal reflection. All rectal injuries underwent fecal diversion, and all drainage was accomplished using closed Jackson-Pratt drainage. RESULTS: Forty-eight patients were studied, of whom 25 were randomized to no drainage and 23 were randomized to presacral drainage. The average age for the nondrainage group was 21.9 years, and the average age for the presacral drainage group 26.0 years. The average Penetrating Abdominal Trauma Index score was 34.3 for the nondrainage group and 32.4 for the presacral drainage group. There were two (8%) septic complications (one perirectal and one perivesical abscess) associated with the rectal injuries in the presacral drainage group. The abscesses in the drainage group resolved after computed tomography-guided drainage. There was one (4%) septic complication (rectocutaneous fistula) in the nondrainage group, which was associated with a retained missile fragment. The fistula resolved after bedside percutaneous removal of the missile fragment. CONCLUSION: We conclude that presacral drainage for penetrating rectal injuries has no effect on infectious complications associated with the rectal injuries.     

Mortality and morbidity of pancreatic injury

Pancreatic trauma, regardless of etiology, has been consistently associated with a mortality of 20 percent and enormous morbidity. Twenty-five pancreatic injuries, including four solitary wounds of the pancreas, were analyzed to determine why pancreatic trauma should have such an adverse prognosis. Eleven patients were victims of blunt trauma and fourteen sustained gunshot wounds. There were no stab wounds. The important determinants of mortality were associated injuries to major vessels, wounds of the head of the gland, and failure to adequately control leaking exocrine secretion. All four deaths were directly related to massive hemorrhage; in two instances leakage of pancreatic juice was also implicated. With the exception of benign solitary blunt wounds of the pancreas to the body of the gland immediately ventral to the spinal column, an injury of the pancreas is evidence that the abdomen has been subjected to severe trauma, which predisposes the patient to a high mortality and morbidity. The pancreatic injury, interacting with other abdominal injuries, is likely to be a cause of significant mortality and to result in complications that will prolong the patient's hospitalization.     

Biloma and biliary fistula associated with hepatorrhaphy for liver injury

BACKGROUND/AIMS: To review our experience in managing post-hepatorrhaphy complications in liver trauma. MATERIALS AND METHODS: During the period of 1986-1994, 6250 trauma patients were admitted to the Accident & Emergency Unit of the University Hospital Kuala Lumpur. The medical records were reviewed. There were 175 patients with liver trauma requiring hepatorrhaphy. The major post-operative complications (biloma and biliary fistula) were noted. We reviewed and discussed the various management of these biliary complications. RESULTS: Eleven patients developed either a biloma, biliary fistula or both. Patients age ranged from 15 to 40 years with a mean ISS of 23. Seven patients suffered penetrating injury and 4 were victims of blunt trauma. The right lobe was injured in 10 patients, with 1 patient sustaining left lobe injury. All liver injuries were either grade 3 (7 patients) or grade 4 (4 patients). No patient sustained extrahepatic biliary tract injury. Biloma and fistulas were diagnosed 14-30 days post-injury (mean 24 days) by CT or HIDA scans. All were managed by CT-guided percutaneous drainage. One patient also required percutaneous transhepatic cholangiography with biliary stent placement due to bile-stained ascites. Fistulas persisted from 5-120 days (mean 44 days). No patient required further operative intervention all fistula closed spontaneously without complication. CONCLUSION: Uncomplicated biliary fistula post-hepatectomy for liver trauma can be treated with percutaneous drainage.     

Gastric wounds: study of 85 patients

During January 1987 and December 1990 we studied 85 patients (75 males), the age varying between 6 and 47 years (mean 27.6) sustaining penetrating (81 patients) and blunt (4 patients) gastric wounds. The mortality rate was 17.6% (15 patients) with four deaths occurring during the surgical procedure as consequence of critical associated injuries. Only one death happened as consequence of gastric wound; 6 patients died during the first 24 hours of hospitalization because of irreversible shock, 9 deaths came about after the first day of hospitalization (4 sepsis, 3 respiratory failure, 2 head trauma). The morbidity rate among the 81 patients that survived after surgical treatment was 39.5% (32 patients). The main postoperative gastric complication was vomiting in 10 patients (5 presenting vagus nerve injury and 5 sustaining pancreatic and/or another hollow viscus wounds) one patient presented with gastric suture dehiscence. Among the 12 patients sustaining vagus nerve injury the presence of gastric complication was higher in the group that was not submitted to pyloroplasty (6 patients). Analysing the patients presenting gastric and pancreatic injuries we verified that morbidity rate was statistically significantly higher in this group (69.2%) than in overall morbidity (39.5%).     

Human papillomavirus infection in squamous cell carcinoma of the vulva, in various synchronous epithelial changes and in normal vulvar skin

In patients with inferior vena cava (IVC) injuries, predictors of survival are investigated. From 1987 to 1995, 27 IVC injuries were identified among 514 patients with vascular trauma. The ability of clinical determinants to predict survival were retrospectively assessed. IVC injuries occurred in 7 females and 20 males (mean age, 27.7 +/- 2.5 years) from both blunt (n = 14) and penetrating (n = 13) trauma. The mean revised trauma score was 10.2 +/- 0.6. Injuries were treated by primary repair (n = 22), ligation (n = 4), or prosthetic grafting (n = 1). Thirteen patients died (48%), 10 within 12 hours of admission. Suprahepatic (n = 2), retrohepatic (n = 12), suprarenal (n = 1), and infrarenal (n = 12) injuries were associated with 100, 67, 100, and 20 per cent mortality, respectively. Blood transfusions (16 +/- 4 vs 23 +/- 4 units), coagulation factor replacement (7 +/- 2 vs 7 +/- 2 units), and electrolyte solution use (8.6 +/- 1.4 vs 9.6 +/- 1.4 L) were similar among survivors and nonsurvivors. Four complications [venous hypertension (n = 2), IVC thrombosis (n = 1), and pulmonary embolus (n = 1)] occurred in the 14 survivors (28.6%). Blunt injury, revised trauma score, free perforation, injury location, intraoperative hypotension, and blood loss were predictive of mortality. IVC injuries remain extremely lethal, and improved survival is associated with infrarenal penetrating injuries and a contained hematoma.     

Cervical vascular injuries: a trauma center experience

BACKGROUND: We analyzed 76 patients with cervical vascular injuries from penetrating neck trauma (n = 528) between 1977 and 1990 at a level I trauma center to evaluate the role of angiography in diagnosis and management and to assess the course and outcome of these patients. METHODS: Patients who were hemodynamically unstable underwent immediate surgical exploration. Stable patients were subjected to diagnostic investigation. Angiography was routinely performed to diagnose vascular injury in zones I and III and zone II if the trajectory was in the vicinity of major vessels. Therapeutic embolization was performed when possible at angiography; all other vascular injuries were treated surgically. RESULTS: Thirteen patients (2.5%) died of penetrating neck trauma, in 12 of whom hemorrhage was the contributing factor (12/76; 15.8% of patients with vascular injury). In nine patients who were hemodynamically stable vascular injury was diagnosed by angiography: 5 (6.8%) of 73 in zone I and 3 (5.4%) of 56 in zone III, four of whom underwent therapeutic embolic occlusion of the injured vessel. Injuries to vertebral and subclavian arteries and subclavian and innominate veins were often multiple, causing exsanguination and death (6.8% in zone I). In three patients with no preoperative neurologic deficit, the internal carotid artery was ligated without complication; in all other patients injury to the common carotid or internal carotid artery was repaired, in six of them with polytetrafluoroethylene grafts. CONCLUSIONS: Selective management of penetrating neck trauma should include routine angiography in zones I and III. Injuries to the common and internal carotid arteries should be repaired. The internal carotid artery may be ligated in the absence of preoperative neurologic deficit. Arterial injuries in the neck can be repaired with polytetrafluoroethylene grafts.     

Noniatrogenic esophageal trauma

Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.     

Immediate surgical treatment of major renal trauma

Of the 77 cases of renal trauma treated at Oulu University Central Hospital during the years 1965--1975, 60 injuries were minor and 17 severe. 73 of these injuries were closed and 4 penetrating. The rate of operative treatment in severe renal injuries was 88% minor renal injuries being treated conservatively. Primary exploration was done in 18 of the 77 cases and in all patients with penetrating injuries. Only 7 of the 73 patients with blunt trauma and one of the 4 patients with penetrating injury required nephrectomy, including one patient with renal carcinoma. 6 of the 77 patients died, most as a result of severe associated injuries, giving a mortality of 8%. None of the surviving patients treated for renal trauma suffered from major complications. In 13 of the 18 patients operated upon, renal injury was the main indication for operation. Operation was performed in 5 of the 18 patients after immediate radiological evaluation. The advantages of immediate surgical management in severe renal injuries are early and final treatment, short hospital stay, and low incidence of complications. Qualifications for emergency surgery are access to renal angiography and familiarity with reparative renal procedures.     

The role of pancreatogastrostomy following pancreatoduodenectomy for trauma

The records of all patients undergoing pancreatogastrostomy after pancreatoduodenal resection at the University of Kansas Medical Center were reviewed. Five patients with a mean age of 26 years (range, 20-32 years) and severe penetrating (n = 3) or blunt (n = 2) traumatic injuries have required pancreatoduodenectomy followed by pancreatogastrostomy (n = 4) or pancreatogastrostomy alone (n = 1) since 1975. Their mean Trauma Score was 12 (range, 9-16). All five patients had soft, previously normal pancreatic glands without induration or ductal dilatation. The mean duration of surgery was 6 hours (range, 5-7 hours), mean blood loss was 7200 mL (range, 1,000-17,500 mL), mean transfusion requirements were 14 units of blood (range, 2-32 units), and mean hospital stay was 37 days (range, 11-90 days). Two patients developed right upper quadrant abscesses that required a second procedure. There were no pancreatic anastomotic leaks, fistulas, or other complications related to the pancreatogastrostomy. At last examination, all five patients were alive and well and had not developed endocrine or exocrine pancreatic insufficiency after a mean follow-up of 4 years (range, 1-9 months). Pancreatogastrostomy following pancreatoduodenectomy for trauma has not been previously reported. Our experience demonstrates that pancreatogastrostomy is a safe and expeditious method for handling the pancreatic remnant following pancreatoduodenectomy. Furthermore, the results of this study suggest that pancreatogastrostomy has several advantages over pancreatojejunostomy for restoring pancreato-intestinal continuity in trauma patients.     

A comparison of artificially-depleted, lyophilized coumarin and fresh coumarin plasmas in thromboplastin calibration. European Concerted Action on Anticoagulation

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.     

Penetrating ocular injuries: an epidemiologic and retrospective study

Penetrating injuries of the eye are an important cause of unilateral visual loss. We studied a series of 82 cases of penetrating injuries treated here from 1987 through 1993. The injuries were caused by sharp objects in 66% and blunt trauma in 6%. The prognosis after a penetrating injury is greatly influenced by the nature of the injury and the extent of the initial drainage. Among factors associated with an unfavorable visual outcome were diminished preoperative visual acuity and scleral wounds with dense vitreous hemorrhage.     

Acute epitrochlear lymphadenitis

Blunt trauma accounted for 1/3 of the 32 patients operated upon for injuries of the large intestine and penetrating wounds for 2/3. Most of the blunt injuries (9/10) were caused by traffic accidents, and more than half of the penetrating ones (12/22) were stab wounds. The transverse colon was most commonly affected, followed by the ascending, descending and sigmoid colon, rectum and mesentery. Perforation of the small intestine was the most frequent associated intra-abdominal injury, occurring in 11 patients (34%). Most patients (22/32) underwent simple suture, 6 patients suture with proximal colostomy, 3 primary resection and one exteriorization, combined in all cases with broad-spectrum antibiotic coverage and drainage of the abdominal cavity. Injuries to the right and transverse colon were managed mainly with simple suture, and those to the left colon and rectum with suture and proximal colostomy. 50% of the patients had complications, most frequently wound infection and intra-abdominal abscess. The patients with simple suture had fewer complications than the others. In the absence of complicating factors injuries to the colon are best managed with simple suture, whereas in the presence of complicating factors and in injuries of the rectum, suture or resection with proximal colostomy, especially in cases of severe tissue destruction, remains the treatment of choice.     

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A small number of trauma patients with penetrating thoracic trauma will require formal pulmonary resections to repair severe injuries or control massive haemorrhage. Although previous reports on this subject have addressed the management of these injuries in battle conditions, civilian experience with this type of chest injury is limited. In a 3-year period, 259 patients underwent urgent thoracotomies for penetrating thoracic trauma. We retrospectively reviewed 43 patients who underwent lobectomies or pneumonectomies to control bleeding (93%) or bronchial injuries (7%). Handguns were the aetiologic agent in 41 patients (95%). The most common complication, pneumonia, was seen in 21 patients (87%). Fifteen patients (62%) developed respiratory failure. The complications of wound infection, post-operative haemorrhage and empyema were seen in equal frequency in four patients (16%). Two patients (8%) developed bronchopleural fistulas. Nine pneumonectomies and 34 lobectomies were performed with mortality rates of 66% and 38%, respectively (overall mortality, 44%). Ten (53%) deaths occurred in the operating room, late deaths (2-15 days) were secondary to sepsis and multiple organ dysfunction syndrome (MODS). Currently, the management of patients with devastating thoracic injuries to the thoracic cavity is divided into two stages. First, initial resuscitation with rapid surgery to control major bleeding, cardiac tamponade, tracheal disruptions and potentially lethal air embolism is indicated. Once the life-threatening conditions have been resolved, definitive surgical procedures are performed to repair injuries to any of the thoracic structures.     

Posttraumatic empyema thoracis: a 24-year experience at a major trauma center

The purpose of this paper is to review the outcome of patients with posttraumatic empyema thoracis. Between April 1972 and March 1996, the Division of Cardiothoracic Surgery at the King-Drew Medical Center managed or was consulted on 5,474 trauma patients (4,584 patients with penetrating injuries and 890 with blunt injuries) who were admitted emergently for thoracic and thoracoabdominal injuries and who underwent tube thoracostomy. Patients were not given routine prophylactic antibiotics merely because they had a chest tube placed. Based on our previous reports on thoracic trauma, our criteria for empiric antibiotic administration included (1) emergent or urgent thoracotomy, (2) soft-tissue destruction of the chest wall by shotgun injuries, (3) lung contusion with hemoptysis, (4) associated abdominal trauma requiring exploratory laparotomy, or (5) associated open long-bone fractures. Eighty-seven of these 5,474 patients developed posttraumatic empyema thoracis, for an incidence of 1.6%. These 87 patients were treated with tube thoracostomy, image-guided catheter drainage, or open thoracotomy with decortication. Seventy-nine of 87 patients (91%) were cured without conversion to open thoracostomy. Four patients required conversion to open thoracostomy, and there were three deaths. Even though a majority of our patients required decortication, successful management of posttraumatic empyema thoracis also was achieved with closed-tube thoracostomy or image-guided catheter drainage based on clinical and radiographic findings with appropriate patient selection. When thoracic empyema did occur in our group, Staphylococcus aureus was the most common microbe isolated, followed by anaerobic bacteria. In correlating microbiologic data with outcomes, S. aureus, especially methicillin-resistant S. aureus, was the most frequent cause of antibiotic failure. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo closed-tube thoracostomy. A review of the role of tube thoracostomy, intrapleural fibrinolytic therapy, image-guided catheter drainage, video-assisted thoracoscopy, and open thoracotomy for the management of thoracic empyema is provided.     

Pancreatic trauma: a rare but severe event

INTRODUCTION: High-speed motor vehicle accidents have contributed to an increasing incidence of pancreatic trauma. Early mortality is generally due to associated vascular and other intra-abdominal injury. MATERIALS AND METHODS: The authors report their experience on pancreatic trauma. Six cases were treated during the last five years. Isolated pancreatic injury was observed only in one case. Two patients received simple external drainage. Two patients required distal pancreatectomy. One patient was mistreated with ligature of distal pancreatic duct and, postoperatively, developed pseudocyst. One patient, with associated duodenal injury, died. COMMENTS: Serum amylase is often unreliable, whereas abdominal CT scans have the best sensitivity and specificity in detecting pancreatic injury. Abdominal exploration is always recommended in retroperitoneal trauma evaluation; complete pancreas mobilisation is needed to determine the integrity of the major pancreatic duct. Treatment protocols are based on severity of injury: they range from simple drainage to distal pancreatectomy (in presence of distal transection or parenchymal injury with duct injury) and to pancreaticoduodenectomy (in presence of massive injury, devascularisation, destruction of ampulla). Complications are seen in 20 to 35% of patients and the overall mortality secondary to complications ranges from 10 to 20%. Fistulas and pseudocysts are the most common complications.     

Cervicothoracic vascular injuries

Arterial and venous trauma of the cervicothoracic region continues to present challenging problems for the surgeon, despite advances in vascular diagnostics and surgical technique. Whether due to penetrating or blunt mechanisms, overall incidence of these injuries is low, whereas morbidity and mortality remain high. Despite collective experience from busy trauma centers, there still remain controversies regarding diagnostic evaluation, operative approach, and surgical treatment of these potentially devastating injuries. Therefore, this article compares and contrasts recent literature and controversies surrounding the treatment of cervicothoracic trauma. Pros and cons of duplex ultrasonography and angiography in the diagnosis of carotid and vertebral artery injury are highlighted, and selective versus mandatory neck exploration for zone II penetrating injuries are discussed. Increasing awareness of blunt carotid artery injury is emphasized, including management dilemmas that frequently accompany this type of injury. In addition, we review interventional radiological techniques for the management of vertebral artery injury and surgical approaches for aortic arch branch vessel or major cervicothoracic vein injury.     

Epidemiology of immediate and early trauma deaths at an urban Level I trauma center

The objective of this study is to identify and differentiate the injury patterns and causes of death among patients who died within the 1st hour and those in the period between 1 and 48 hours after hospital admission. Information was collected from the 1994 to 1996 trauma data base at an urban Level I trauma center. The records of 155 trauma patients who died within the 1st hour (immediate trauma death, ITD) and between 1 and 48 hours (early trauma death, ETD) were examined retrospectively. Total and constituent Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Score were analyzed. ITDs constituted 49 per cent of all deaths within 48 hours. Blunt mechanisms accounted for 37 per cent of ITDs and 40 per cent of ETDs (not significant), whereas penetrating trauma accounted for 59 per cent of ITDs and 56 per cent of ETDs (not significant). Exsanguination most commonly caused death among ITDs (54%) and head injury (51%) among ETDs (P < 0.01). Patients who died within the 1st hour had higher ISS (42.6 +/- 23.2, P < 0.03), lower TS (1.7 +/- 1.9, P < 0.0001), and lower Glasgow Coma Score (3.1 +/- 1.1, P < 0.0001) than those who died after the 1st hour. Patients with ITD had a significantly worse chest ISS than those with ETD (47.4 +/- 28.6 vs 19.0 +/- 19.1, P < 0.0001). We conclude that 1) ITD is caused primarily by exsanguination, whereas ETD is largely due to the sequelae of severe neurologic injury; 2) ITD has a significantly lower TS and higher ISS than ETD; and 3) thoracic injuries are more severe among patients with ITDs than among those with ETDs. The severity of thoracic injury among ITDs suggests that rapid surgical intervention is critical during the resuscitation of these severely injured patients.     

Neuroendocrine effect of a short-term treatment with DHEA in postmenopausal women

BACKGROUND: Most publications during the past decade have condemned the use of anatomic resection for liver trauma and advocated a conservative surgical approach when operative intervention was required. This policy has been supported by the high mortality rate reported by most authorities. The purpose of this study was to assess the results of anatomic hepatic resection for liver trauma in an institution in which the hepatobiliary surgeons are responsible for the management of severe liver injuries. METHODS: During the period 1983 to 1996, 287 patients with liver injuries were admitted to the hospital and 37 patients with severe liver trauma underwent anatomic resection. Demographic, clinical, operative, and postoperative data were collected and analyzed. The resections performed included right hemihepatectomy (n = 27), left hemihepatectomy (n = 1), left lateral segment resection (n = 5), and segmental resection (n = 4). RESULTS: There were three postoperative deaths after right hemihepatectomy (11.1%) and an overall mortality rate of 8.1%. There were no intraoperative deaths. Postoperative complications occurred in 22 patients (60%) and were most frequent in patients with concomitant injuries to other systems. Liver-related morbidity occurred in seven patients (19%). The median postoperative stay was 20 days. CONCLUSIONS: Anatomic hepatic resection for trauma is associated with low mortality and liver-related morbidity rates when performed by experienced hepatobiliary surgeons, and its role in the management of severe hepatic trauma should be reevaluated.