[Endovideosurgical interventions for thoracoabdominal wounds]

The authors presented results of examination and treatment of 1347 patients with different injuries of the chest and abdomen. Medico-diagnostic measures used in treatment of such kind of patients with rational application of endovideosurgical techniques such as thoraco- and laparoscopy are described which proved to be the final kind of operative treatment.

Inhibition of surgical trauma-enhanced peritoneal dissemination of tumor cells by human catalase derivatives in mice

Surgical trauma, which is inevitably associated with the surgical removal of cancer, has been reported to accelerate tumor metastasis. The close association of reactive oxygen species with the trauma and tumor metastasis supports the possibility of using antioxidants for the inhibition of metastasis. To inhibit surgical trauma-enhanced peritoneal dissemination, human catalase (hCAT) derivatives, i.e., hCAT-nona-arginine peptide (hCAT-R9) and hCAT-albumin-binding peptide (hCAT-ABP), were designed to increase the retention time of the antioxidant enzyme in the abdominal cavity after intraperitoneal administration. Both (125)I-labeled derivatives showed significantly prolonged retention in the cavity compared to (125)I-hCAT. Cauterization of the cecum of mice with a hot iron, an experimental model of surgical trauma, induced abdominal adhesions. In addition, cauterization followed by colon26 tumor cell inoculation increased lipid peroxidation in the cecum and mRNA expression of molecules associated with tissue repair/adhesion and inflammation in the peritoneum. hCAT derivatives significantly suppressed the increased mRNA expression. The cauterization also increased the number of tumor cells in the abdominal organs, and the number was significantly reduced by hCAT-R9 or hCAT-ABP. These results indicate that hCAT-R9 and hCAT-ABP, both of which have a long retention time in the peritoneal cavity, can be effective at inhibiting surgery-induced peritoneal metastasis.

[Arterial embolisation for post-traumatic retroperitoneal bleeding]

BACKGROUND

Road traffic accidents resulting in multiple organ trauma are among the leading causes of mortality among people under 45 years of age. Those with pelvic injury are at special risk, because of difficult haemostasis and massive bleeding of mixed origin. Various methods of treatment have been used, including laparotomy, direct clamping and ligation of affected vessels, retroperitoneal packing, and external/internal pelvic stabilisation. In selected cases, angioembolisation of various vessels can be used

CASE REPORTS

A 24-year-old male patient was admitted after a road traffic accident, in which he suffered multiple injuries to the skull, abdomen and pelvis. An emergency laparotomy was performed, revealing ruptures of the spleen, mesentery, right ureter, and bladder, and a giant haematoma in the retroperitoneal space. The spleen was removed, and the traumatised organs temporarily repaired. The pelvis and femoral bones were stabilised externally. After surgery, the patient was transferred to the ITU; he was haemodynamically unstable due to coagulopathy and persistent bleeding from the superior gluteal artery. On the fourth day, angioembolisation of the latter was performed using three occluding coils that resulted in immediate control of the bleeding and haemodynamic stabilisation.

DISCUSSION AND CONCLUSION

In selected cases of severe bleeding from a traumatic pelvic injury, angioembolisation can be used as a lifesaving technique, especially in patients with coagulopathy after ineffective surgical interventions.

Isolated gallbladder perforation following blunt abdominal trauma in a six-year-old child

Isolated perforation of the gallbladder secondary to blunt trauma is rare. Furthermore, only a few cases exist in the infant age group. It has vague symptoms and interpretation of the radiology imaging is challenging. Diagnosis is usually made at operation. We report the case of a six-year-old boy who fell on to the handlebars of his scooter, sustaining an isolated gallbladder perforation. The authors highlight the importance of interpreting the volume of intraperitoneal fluid and early diagnostic laparoscopy.

[Contrast enhanced ultrasound improves detection and quantification of intra-abdominal bleeding]

A 71-year-old man had a coarse needle biopsy performed. After the biopsy symptoms of abdominal bleeding were deteced. An acute ultrasound examination was performed as Focussed Assessment with Sonography in Trauma (FAST). The findings were inconclusive and a Contrast Enhanced Ultrasound (CEUS) was carried out. CEUS immediately demonstrated as well a rim around the liver with clear borders as a large amount of abdominal fluid. Upon these findings immediate surgery was performed. CEUS improves the contrast between areas with and without perfusion, which enhance the presence of haemorrhagic fluid, independently of the fluid's echo-pattern. CEUS seems to be a fast and valuable extension to FAST.

Retrospective review of the costs of routine pelvic X-rays in a trauma setting

Multidetector Computed Tomography (MDCT) technology plays an important role in the evaluation of injured patients. At our institution pelvic X-ray (PXR) is obtained routinely on trauma patients. Many also receive MDCT of the abdomen and pelvis for other indications. We hypothesized that there would be a substantial cost savings in adopting a policy of deferring PXR in a hemodynamically normal patient who will also proceed to MDCT for other indications. We retrospectively reviewed the charts of trauma patients from February 1, 2008 to February 1, 2009. We reviewed whether a PXR was done, the result, whether an MDCT was also done, and the presence or absence of pelvic fractures. We collected billing and cost data from various hospital sources. We identified 1,330 patients with PXR between February 1, 2008 and February 1, 2009. Of those patients, 810 (61%) had MDCT after PXR. Sixty-six patients (8.0%) had pelvic fractures; 39 were correctly identified on PXR (59% of fractures). Twenty-seven were detected only by MDCT (41% of fractures); all pelvic fractures were identified on MDCT. Seven hundred and forty-four patients (92% of patients with both PXR and MDCT) had negative PXR and negative MDCT. Using three methods of cost analysis, the estimated cost savings range is from $77,011 to $331,080. MDCT of the pelvis is more sensitive and more specific than PXR. In patients who are hemodynamically normal and asymptomatic, forgoing routine PXR could result in an estimated savings from $77,011 to $331,080, depending on the method used to calculate costs.

Management of open abdomen with an absorbable mesh closure

PURPOSE

To examine the methods and results of treatment in patients with an open abdomen (OA) at a single institution where an absorbable mesh closure (AMC) is most commonly used.

METHODS

A retrospective study was performed in OA patients from January 2001 to June 2007. Outcomes were analyzed in terms of enteroatmospheric fistula (EAF) formation and survival.

RESULTS

There were 73 OA patients receiving definitive closures (40 trauma and 33 nontrauma). Twenty-four patients were able to undergo a delayed primary fascial closure (DPFC) after initial vacuum pack closure (DPFC rate 33%). The DPFC rate was significantly lower in patients with an associated infection or contamination (9% vs 44%, P = 0.002). The EAF and mortality rates of the DPFC group were 0% and 13%, respectively. Absorbable mesh closure was used in 41 of 49 patients who failed DPFC (84%). There were 9 patients who had EAF (overall EAF rate 12%), 6 of whom were in the AMC group (EAF rate 15%). The overall and AMC group mortality rates were 29% and 37%, respectively.

CONCLUSION

Absorbable mesh closure carries high EAF and mortality rates. Therefore, DPFC should be considered as the primary closure method. Absorbable mesh closure should be reserved for patients who fail DPFC, especially those with peritonitis or contamination.

Biomechanical considerations for abdominal loading by seat belt pretensioners

While seat belts are the most effective safety technology in vehicles today, there are continual efforts in the industry to improve their ability to reduce the risk of injury. In this paper, seat belt pretensioners and current trends towards more powerful systems were reviewed and analyzed. These more powerful systems may be, among other things, systems that develop higher belt forces, systems that remove slack from belt webbing at higher retraction speeds, or both. The analysis started with validation of the Ford Human Body Finite Element Model for use in evaluation of abdominal belt loading by pretensioners. The model was then used to show that those studies, done with lap-only belts, can be used to establish injury metrics for tests done with lap-shoulder belts. Then, previously-performed PMHS studies were used to develop AIS 2+ and AIS 3+ injury risk curves for abdominal interaction with seat belts via logistic regression and reliability analysis with interval censoring. Finally, some considerations were developed for a possible laboratory test to evaluate higher-powered pretensioners.

Handlebar hernia: a rare type of abdominal wall hernia

Traumatic abdominal wall hernias are a type of acquired hernia secondary to blunt trauma Caused, by direct trauma from handlebar like objects. This rare hernia is named 'Handlebar hernia'. We report a case of such hernia without any significant intra-abdominal injury. The abdominal wall defect was repaired in layers by Jones technique. Postoperative course was uneventful. The authors recommend clinical suspicion for traumatic hernia in all patients with traumatic abdominal wall injury. Definitive treatment includes surgical exploration with primary repair of all tissue layers of the abdominal wall.

FAST scan: is it worth doing in hemodynamically stable blunt trauma patients?

BACKGROUND

During the last decade, focused assessment with sonography for trauma increasingly has become the initial diagnostic modality of choice in trauma patients. It is still questionable, however, whether its use results in the underdiagnosis of intra-abdominal injury. It also remains doubtful whether a positive focused assessment with sonography for trauma affects clinical decision making in hemodynamically stable blunt trauma patients as evidenced through abdominal computerized tomography use. The aim of this study was to evaluate the results of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients and to determine its role in the diagnostic evaluation of these patients.

METHODS

We reviewed our prospectively maintained trauma database. In trauma patients at our institute, focused assessment with sonography for trauma examinations are performed by surgery residents and are considered positive when free intra-abdominal fluid is visualized. Abdominal computerized tomography, diagnostic peritoneal lavage, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury.

RESULTS

In our 7-year study period, 2,980 trauma patients were evaluated at our institute, of which 2,130 patients underwent a focused assessment with sonography for trauma. In all, 18 patients had an inconclusive focused assessment with sonography for trauma, whereas 7 patients died on arrival, leaving 2,105 patients for our analysis. A total 88 true positive focused assessment with sonography for trauma were conducted. All hemodynamically stable blunt trauma patients who had a positive focused assessment with sonography for trauma (70/88) were confirmed by computerized tomography. Patients who underwent exploratory laparotomy directly (17/88) or diagnostic peritoneal lavage (1/88) as confirmation either had penetrating trauma or became hemodynamically unstable. A total of 1,894 true negative focused assessments with sonography for trauma scans were conducted, with 1,201 confirmed by computerized tomography and the rest by observation. In all, 118 false negative focused assessment with sonography for trauma were performed, of which 44 (37.3%) subsequently required exploratory laparotomy. Five patients had false positive focused assessment with sonography for trauma scans. Focused assessment with sonography for trauma scan had an overall sensitivity of 43%, a specificity of 99%, and positive and negative predictive values of 95% and 94%, respectively. Accuracy was 94.1%. In the hemodynamically stable blunt trauma group, there were 60 patients with true positive focused assessment with sonography for trauma examinations and 87 patients with false negative focused assessment with sonography for trauma examinations. In this group of patients, focused assessment with sonography for trauma had a sensitivity of 41%, specificity of 99%, and positive and negative predictive values of 94% and 95%, respectively. The overall accuracy was 95%.

CONCLUSION

Given the low sensitivity, a negative focused assessment with sonography for trauma without confirmation by computerized tomography may result in missed intra-abdominal injuries. It is also observed in all focused assessment with sonography for trauma positive hemodynamically stable blunt trauma patients, confirmation is preferred through the use of a computerized tomography for better understanding of the intra-abdominal injuries and to decide on operative versus no-operative management. Thus, the use of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients seems not worthwhile. It should be reserved for hemodynamically unstable patients with blunt trauma.

Effects of seat belts worn by pregnant drivers during low-impact collisions

OBJECTIVE

The aim of this study was to understand the injury mechanisms of pregnant drivers and associated fetal outcomes.

STUDY DESIGN

Frontal and rear impact tests using a dummy representing the anthropometry of a pregnant woman were conducted.

RESULTS

In frontal impact tests without a seat belt, abdominal pressure peaked at the point where the dummy contacted the steering wheel. Rear impact tests without a seat belt showed that the dummy moved forward because of rebound and contacted the steering wheel, which was avoided when a seat belt was worn.

CONCLUSION

Wearing a seat belt reduces abdominal pressure or prevents contact with the steering wheel during collisions.

Early fascial closure of the damage control abdomen in children

Traditional staged closure of the damage control abdomen frequently results in a ventral hernia, need for delayed abdominal wall reconstruction, and risk of multiple complications. We examined the potential benefits in children of early fascial closure of the damage control abdomen using human acellular dermal matrix (HADM). We reviewed our experience with five consecutive children sustaining intra-abdominal catastrophe and managed with damage control celiotomy. To accomplish early definitive abdominal closure, HADM was sewn in place as a fascial substitute; the skin and subcutaneous layers were approximated over silicone drains. The five patients ranged in age from 1 month to 19 years at the time of presentation. Intra-abdominal catastrophes included complex bowel injuries after blunt trauma in two children, necrotizing pancreatitis and gastric perforation in one teenager, necrotizing enterocolitis in one premature infant, and perforated typhlitis in one adolescent. All damage control wounds were dirty. Time range from initial celiotomy to definitive abdominal closure was 6 to 9 days. After definitive closure, one child developed a superficial wound infection. No patient developed a ventral hernia. After damage control celiotomy in children, early abdominal wall closure using HADM may minimize comq plications associated with delayed closure techniques and the need for additional procedures.

[Post traumatic entero-mesenteric venous infarct]

The paper presents a case of entero-mesenteric venous infarct, occurred in a man of 34 years, discovered intraoperator, when to intervene surgically in emergency surgery for acute abdomen of peritonitic type. The etiology of this venous infarct was posttraumatic, the patient underwent an abdominal aggression with seven days prior to onset of symptoms. In literature, the posttraumatic etiology is found in a small number compared to the large number of abdominal contusion, intimal lesional factor beeing associated with blood thickness. Paraclinical investigations were not significant in terms of preoperator diagnosis, surgical intervention (backward and forward thrombectomy of superior mesenteric vein with Fogarty probe and venosuture) having a favorable evolution. This intervention is practiced as an exception on the basis of the idea that venous thrombosis spreads to mezenteric vein and its collaterals followed by extensive arterial thrombosis and total compromise of intestinal viability.

The prognostic significance of thoracic and abdominal trauma in severe trauma patients (Injury severity score > 15)

The aim of the present study was to assess the prognostic significance of thoracic and abdominal trauma in severely injured patients. A retrospective analysis was performed based on data from the period from March 1 2006 to December 31 2007, taken from the Trauma Registry of the University Hospital "SantAndrea" in Rome. A total of 844 trauma patients were entered in a database created for this purpose, and only patients with an Injury Severity Score (ISS) > 15, (163 patients, 19.3%), were selected for the present study. These patients were divided into 2 groups: Group A (103 patients, 63.2%), consisting of patients with at least one thoracic injury, and Group B (46 patients, 28.2%) consisting of patients with concomitant thoracic and abdominal injuries. The impact of thoracic and abdominal trauma was studied by analyzing mortality and morbidity, in relation to patient age, cause and dynamics of trauma, length of hospital stay, and both ISS and New ISS (NISS). In a vast majority of cases, the cause of trauma was a road accident (126 patients, 77.3%). The mean age of patients with ISS > 15 was 45.2 +/- 19.3 years. The mean ISS and NISS were 25.7 +/- 10.5 and of 31.4 +/- 13.1 respectively. The overall morbidity and mortality rates were 18.4% (30 patients) and 28.8% (47 patients) respectively. In Group A the mortality rate was 23.3% (24 patients) and the morbidity rate was 33.9% (35 patients). In Group B mortality and morbidity rates were 369% (17 patients) and 43.5% (20 patients) respectively. It was shown that the presence of both thoracic and abdominal injuries significantly increases the risk of mortality and morbidity. In patients with predominantly thoracic injuries, NISS proved to be the more reliable score, while ISS appeared to be more accurate in evaluating patients with injuries affecting more than one region of the body.

[Sports and genitourinary traumas]

INTRODUCTION

Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas.

METHODS

Literature review of peer-reviewed articles published by May 2009.

RESULTS

Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade I-II lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma.

CONCLUSIONS

Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.

Impact of abdominal complications on outcome after mechanical circulatory support

BACKGROUND

Mechanical circulatory support (MCS) is life sustaining for patients with end-stage heart failure. Most devices require abdominal wall transgression, creating a potential for abdominal complications. The incidence and impact of these relatively underreported complications are unknown.

METHODS

A retrospective review was performed on 179 patients who received MCS therapy from 1999 to 2008. Abdominal complications were grouped as abdominal wall, gastrointestinal tract, and solid organ.

RESULTS

Ninety-eight patients (55%) experienced 157 abdominal complications. These involved the abdominal wall in 69 (44%), the gastrointestinal tract in 52 (33%), and the solid organs in 36 (23%). Surgical intervention was required in 36% of patients with abdominal wall complications, 19% of patients with gastrointestinal tract complications, and 14% of patients with solid organ complications. Multivariate analysis identified diabetes mellitus (p < 0.001), emergent device placement (p = 0.019), and preimplant mechanical ventilation (p = 0.045) as independent risk factors for developing an abdominal complication. Kaplan-Meier survival while receiving MCS was significantly reduced for patients with abdominal complications versus those without (p = 0.0142). Multivariate analysis identified only solid organ abdominal complications (p = 0.001) as an independent risk factor for death while receiving device support.

CONCLUSIONS

Abdominal complications are common in patients supported with MCS devices and significantly reduce survival. Surgical intervention is more frequently required for complications related to the abdominal wall compared with other complications. Patients with significant comorbidities (diabetes mellitus, respiratory failure) requiring urgent or emergent device placement are at higher risk for the development of abdominal complications with an attendant reduction in device-related survival.

[Seat-belt syndrome in a pre-school child]

The authors report on a pre-school child with a typical presentation of the trauma caused by a car safety belt and termed the seat-belt syndrome. The deceleration mechanism which throws the upper body forward in the presence of a rigid belt over the abdominal region results in large contusions of the abdominal wall and trauma to the spine, retroperitoneum, and intra-abdominal organs, or even the chest. In making the diagnosis a thorough examination of the spine is necessary as well as a repeated surgical examination of the abdomen, because seat-belt syndrome is often associated with small intestine rupture, a symptom which can remain unrecognised at the early stage. In the case of a four-year-old boy described here, two loops of the small intestine were resected for perforation; stabilization of the vertebral column was indicated on the 5th post-injury day because of decompensated diabetes and deteriorated health state following intra-abdominal surgery. In this boy, poor compensation of juvenile diabetes resulted in infectious complications requiring repeated drainage of an abscess of the abdominal wall injured by the seat belt.The abdominal wall healed within 2 months, diabetes was managed with insulin therapy and good spondylodesis was achieved at 9 months after the injury.

[Gunshot wound to gravid uterus: a case report]

The authors report the case of a 24-years old pregnant woman gravida 2 para 1 who sustained a gunshot injury at 23 weeks gestation. The bullet injured the rectosigmoid jonction, the jejunum and traversed the uterine cavity with resultant of fatal injury of the fetus. Laparotomy was required for treatment of the maternal injuries. Although a fetus demise was delivered by caesarian section a review of literature indicated that operative delivery should be avoided when the fetus has died already and the gravid uterus don't impaired the surgeon's ability to repair other visceral injuries. But the patient should be followed closely for signs of coagulopathy and intra uterine infection.

[A seatbelt sign following a car accident: look for internal abdominal injury]

We present three patients, a 55-year-old man, a 69-year-old woman and a 25-year-old man, with a seatbelt sign following a car accident. All 3 patients exhibited various injuries that may occur in the case of a blunt trauma, for example rib fractures. In one patient, however, symptoms of internal abdominal injury occurred several days after the accident. The presence of a seatbelt sign is associated with an increased risk of internal abdominal injury. We therefore advise a CT scan of the abdomen in patients who present with a seatbelt sign, even if abdominal ultrasound does not reveal signs of injury.