A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain

Preoperative progressive pneumoperitoneum (PPP) is a safe and effective procedure in the treatment of large incisional hernia (size > 10 cm in width or length) with loss of domain (LIHLD). There is no consensus in the literature on the amount of gas that must be insufflated in a PPP program or even how long it should be maintained. We describe a technique for calculating the hernia sac volume (HSV) and abdominal cavity volume (ACV) based on abdominal computerized tomography (ACT) scanning that eliminates the need for subjective criteria for inclusion in a PPP program and shows the amount of gas that must be insufflated into the abdominal cavity in the PPP program. Our technique is indicated for all patients with large or recurrent incisional hernias evaluated by a senior surgeon with suspected LIHLD. We reviewed our experience from 2001 to 2008 of 23 consecutive hernia surgical procedures of LIHLD undergoing preoperative evaluation with CT scanning and PPP. An ACT was required in all patients with suspected LIHLD in order to determine HSV and ACV. The PPP was performed only if the volume ratio HSV/ACV (VR = HSV/ACV) was >or=25% (VR >or= 25%). We have performed this procedure on 23 patients, with a mean age of 55.6 years (range 31-83). There were 16 women and 7 men with an average age of 55.6 years (range 31-83), and a mean BMI of 38.5 kg/m(2) (range 23-55.2). Almost all patients (21 of 23 patients-91.30%) were overweight; 43.5% (10 patients) were severely obese (obese class III). The mean calculated volumes for ACV and HSV were 9,410 ml (range 6,060-19,230 ml) and 4,500 ml (range 1,850-6,600 ml), respectively. The PPP is performed by permanent catheter placed in a minor surgical procedure. The total amount of CO(2) insufflated ranged from 2,000 to 7,000 ml (mean 4,000 ml). Patients required a mean of 10 PPP sessions (range 4-18) to achieve the desired volume of gas (that is the same volume that was calculated for the hernia sac). Since PPP sessions were performed once a day, 4-18 days were needed for preoperative preparation with PPP. The mean VR was 36% (ranged from 26 to 73%). We conclude that ACT provides objective data for volume calculation of both hernia sac and abdominal cavity and also for estimation of the volume of gas that should be insufflated into the abdominal cavity in PPP.

Blunt gastric injury. A multicentre experience

A multicentre retrospective analysis of blunt gastric injuries from four trauma centres in Brazil was performed. From January 1982 to May 1996, 33 patients were found to have blunt gastric injury: 26 were male and the mean age was 26.2 years. The most frequent mechanism of injury was automobile versus pedestrian (17) followed by motor vehicle accidents (seven). Abdominal pain was the most common finding (29) and peritoneal signs were present in 14. There were 21 grade I, seven grade II, four grade III and one grade IV blunt gastric injuries. Simple suture was the treatment of choice in 24 patients, eight required no treatment, and only one patient underwent gastric resection. The liver and spleen were the most commonly associated injured organs. Two patients had isolated gastric injury. There were two gastric fistulae and both patients died. Overall morbidity and mortality was 12 (36%) and nine (27%), respectively. The ISS was higher in the non-survivor group (P=0.03) and the gastric organ injury score did not reach statistical significance when comparing survivors and non-survivors. We conclude that blunt gastric injury is uncommon and is associated with other injuries of greater magnitude, which generally influence mortality.

Increases in fines and driver licence withdrawal have effectively reduced immediate deaths from trauma on Brazilian roads: first-year report on the new traffic code

Road accidents are a major cause of death in Brazil, with rates increasing steadily for years. Our objective here is to report the impact of the new Brazilian Traffic Code, introduced in 1998. Its main new features include a large increase in fines and a rigid penalty scoring system that leads to driver license withdrawal. Speed limits have actually been raised on many roads, but adherence to the rules has been monitored more closely. We compare the incidence of injured patients and immediate deaths in road accidents and emergency room admissions to a level I trauma centre in downtown São Paulo between January and December 1998 with corresponding data from between January and December 1997. There was an overall 21.3% reduction in the number of accidents and a 24.7% reduction in immediate deaths, saving 5962 lives on Brazilian highways. Tickets issued fell by 49.5% (601977 during 1997 to 304785 during 1998). Motor vehicle accident-related emergency room admissions decreased by 33.2%. We conclude that very costly tickets and threatened driver licences have proved very effective in decreasing immediate deaths from trauma. Further advances in educational programmes associated with road and vehicle safety measures are likely to provide the much needed further reduction in the still high trauma mortality on Brazilian roads and streets.

The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures

In order to identify the prognostic factors and to evaluate the impact of associated injuries in the outcome of patients with pelvic fractures, a retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. Demographic data, the mechanism of injury, the physiologic status on admission, associated injuries, pelvic fracture classification, complications and mortality were analysed. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to "shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. No correlation between pelvic fracture classification or fracture stability with mortality was observed. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture.

[Esophagogastric acute injury caused by a chemical agent]

Treatment of chemical agent ingestion remain controversial. The incidence of these episodes has increased over the several last decades due to a variety reasons.

PURPOSE

To analyze the occurrence, complications and results of the treatment of chemically induced esophagogastric injury.

METHODS

Twenty-one adult patients with chemically induced esophagogastric injury were retrospectively studied. The patients were admitted up to 23 days after ingestion of a chemical agent to the Emergency Department of Santa Casa of Sao Paulo University Hospital from August, in a 12-year period. The mean age was 32.1 years. Eleven patients were of the female gender, which attempted suicide. Soda was the most ingested agent (76.2%), muriatic acid was present in three cases (14.3%) followed by one case of sulfur acid and another one of ammonia (4.8% each).

RESULTS

Injuries of the Larynx and Pharynx were frequently associated with those of the esophagus, accounting for 18 cases (85.7%). Esophageal, gastric and duodenal injuries were assessed and classified according to endoscopic features. Five cases each of severe esophageal or gastric lesions were present.

CONCLUSION

Treatment and outcome varied and suggested placement of esophageal tube to be harmful. Global mortality rate was 28.6% with the highest rate related to esophageal injuries of the third degree.

Trauma in pregnant women: analysis of maternal and fetal mortality

Twenty-seven traumatised pregnant women were analysed retrospectively over a period of 9 years. Mean age was 23.7 years (16-42 years). Gestational age ranged from 10 to 40 weeks (mean, 21.5 weeks), with most victims (46.1%) being in the second trimester. The predominant mechanism (65.3%) was blunt abdominal injury due to an automobile accident (the patient being run over or collision). At admission, 8 (30.7%) patients had haemodynamic alterations. 6 patients (23.0%) presented vaginal bleeding and 4 of these were haemodynamically normal. We analysed maternal mortality, fetal mortality and their causes. We also compared the median RTS and TRISS values for the groups with maternal-fetal survival and the group with maternal-fetal death. Fetal death occurred in all pregnant women admitted with vaginal bleeding. Maternal mortality due to haemorrhagic shock was 11.5%. Fetal mortality was 30.7%, with 37.5% of these deaths being caused by maternal death. The major cause of fetal mortality was a detached placenta (50.0%). The trauma indices, RTS and TRISS, were significantly lower (p = 0.0025 and p < 0.0001) in the group of maternal-fetal death but they were not of prognostic value in terms of fetal mortality.

Severely injured patients in the intensive care unit: a critical analysis of outcome and unexpected deaths identified by the TRISS methodology

An analysis of the factors related to the morbidity and mortality of 64 patients sustaining abdominal trauma requiring intensive care during the postoperative period, and an evaluation of the unexpected deaths based on trauma indices was carried out to identify factors that could have contributed to the observed outcome. Head and chest injuries occurred in approximately 40% of all patients. Pneumonia was the most common complication. ISS (p = 0.03), but not TS was statistically significant as predictor of outcome. Probability of survival (TRISS) was 62.4 +/- 4.2%, while observed overall survival rate was 54.7%. Multivariate analysis identified age greater than 45 years (p = 0.02; RR = 2.5) and ISS greater than 20 (p = 0.03; RR = 4.0) as the most predictive factors for systemic complications. Mortality was directly influenced by age greater than 45 years (p = 0.05; RR = 2.4) and by the presence of a systemic complication (p = 0.003; RR = 5.5). Eleven patients were classified as "unexpected death"; 5 were considered preventable, 3 non preventable, 1 potentially preventable, and 2 cases had incomplete data and could not be classified. Changes in the care of the severely injured due to a review of complications and deaths may ultimately lead to a reduction in errors and a better quality of care.

Ostomy or intestinal anastomosis in cases of peritonitis

Twenty-six patients showing peritonitis due to nontraumatic acute abdomen were submitted to ostomy. Mean age was 51 years (range 25-83), being 13 males and 13 females. Bowel obstruction (BO) was the most frequent cause of peritonitis (11 cases), followed by intestinal perforation (IP) (8 cases), acute mesenteric infarction (AMI) (5 cases), and acute abdomen of inflammatory/infectious origin (AAIO) (2 cases). Brook's ileostomy was performed on 65% of the patients. Jejunostomy was performed only in 4 patients, leading to a bad evolution. Overall mortality was 54%. Primary ostomy or anastomosis in cases of peritonitis constitute a highly controversial theme. Indications and problems involving the intestinal exteriorization in emergency surgery urgency are herein discussed.

[Esophageal injury due to pill ingestion]

In recent years, many case reports concerning esophageal injuries caused by drugs have been published. The primary cause has apparently been the delay in passage and the adherence of the caustic drugs on the esophageal mucosa. The authors report a case of esophageal ulceration caused by an analgesic in a 26-year-old male with no esophageal symptoms. A review of the literature shows that a variety of medications have been implicated; size, shape and improper ingestion of pills affect esophageal transit.

Factors related to the occurrence of postoperative complications following penetrating gastric injuries

The aim of this study was to determine the relationship between diaphragmatic injury and gross contamination of the peritoneal cavity caused by gastric injuries and the occurrence of postoperative complications, especially those related to the pleural cavity. Charts of 73 patients sustaining gastric injuries due to penetrating trauma were retrospectively reviewed. There were 66 males and mean age was 28 years. Stab wounds were the most frequent mechanism of injury, occurring in 46 cases. Most of the injuries were treated using simple suture and minor debridement. Postoperative morbidity rate was 30 per cent and thoracic complications occurred in 11 patients. Twenty-six patients had diaphragmatic injuries; 54 per cent of them developed postoperative complications. Of the remaining 47 patients without diaphragmatic injuries, only eight developed complications. Of the 26 patients with diaphragmatic injuries, seven developed pleuropulmonary complications compared with 4 of 47 without diaphragmatic injury. Of sixteen patients who had gross contamination secondary to gastric injury, characterized by the presence of food or great amounts of gastric contents in the peritoneal cavity, 10 developed postoperative complications compared with 12 of 57 without gross contamination. Overall mortality rate was 11 per cent mostly due to sepsis. In conclusion, the presence of a diaphragmatic injury as well as gross contamination of the abdominal cavity are important factors related to the development of postoperative infections particularly in the pleural space.

Penetrating cardiac wounds: predictive value of trauma indices and the necessity of terminology standardization

The authors evaluated the usefulness of different trauma indices in the prediction of outcome following penetrating cardiac wounds. Sixty-three patients were retrospectively reviewed. Age, mechanism of injury, Physiologic Index (PI) on admission, site of injury, associated injuries, ISS, RTS, Penetrating Cardiac Trauma Index (PCTI), Penetrating Thoracic Trauma Index (PTTI), Penetrating Trauma Index (PTI), TRISS and mortality rate were reviewed. There were 34 patients with a gunshot wound (GSW) and 29 with a stab wound (SW). Shock was present on admission in 88.9 per cent. Mortality was 83 per cent for GSW, 44 per cent for SW, and 39 per cent for patients arriving the hospital with measurable blood pressure. RTS, PI, PCTI, PTTI, PTI, and ISS reached statistical significance when comparing survivors and nonsurvivors. The probability of survival (PS) based on the TRISS methodology was 37.84 +/- 5.14. The observed survival rate was 38 per cent. Fourteen patients were considered "fatal" on admission and underwent an emergency thoracothomy. Mortality rate for this selected group was 100 per cent. We conclude that physiologic impairment, shock, and GSW are variables with high significance on mortality. Trauma indices such as PI, RTS, PCTI, PTTI, PTI, and ISS are good predictors of outcome. Trauma indices are an important tool to objectively compare results among different institutions.

Colonic (splenic flexure) necrosis due to thrombosis of the middle colic artery following blunt abdominal trauma

We report an unusual case of a 28-year-old man who developed a colonic necrosis due to thrombosis of the middle colic artery 18 hours following blunt abdominal trauma. Although rare, this condition can occur in those patients whom non surgical treatment was initially performed.

Emergency department thoracotomy

The emergency department thoracotomy as a ressuscitative measure is a controversial subject in trauma surgery. Indiscriminate indication has occurred due to unclearness upon the real value of this procedure, but further critical evaluation has reduced initial enthusiasm rather emphasizing a more rational approach by systematization of criteria for selective indication. Clinical outcome is related to injury mechanism and patients conditions upon admission. According to vital signs the patients conditions are classified as fatal, agonic and shock; survival rates oscillate between 0 to 40%. This study presents a review of the literature discussing indications, technical aspects, complications and clinical outcome of emergency department thoracotomy in trauma patients.

[Inferior vena cava trauma: analysis of 36 cases]

The authors analysed 36 trauma patients with inferior vena cava injuries to evaluate different surgical approaches, as well as, important aspects related to morbidity and mortality. Gunshot wounds were the most frequent cause of inferior vena cava injuries and 55% of the patients had circulatory instability on admission. Retrohepatic inferior vena cava was frequently injured in association with liver injury. From those 20 unstable patients on admission, there were 17 deaths, and injury was in the retrohepatic portion of the inferior vena cava in 9, and in the supradiaphragmatic portion in 3. These data support the concept that site of injury and hemodynamic status on admission are the principal factors related to morbidity and mortality in inferior vena cava injuries.

[Effects of food restriction on the protein and electrolyte composition in the liver and muscles of rats]

Protein and electrolyte disturbances in hepatic and muscle tissues are related to trauma, sepsis, or short term starvation or semistarvation. The consequences of a prolonged semistarvation are poorly understood. For five weeks, male adult rats were offered 50% of the diet until they had a weight loss of 40%, after which protein and electrolyte (Ca++, Mg++, Zn++, Na+, K+) changes in the liver and soleus and extensorum digitorum longus muscles were analyzed. There was a significant weight loss after 5 weeks of semistarvation. Hepatic protein and serum albumin were not changed, but the authors observed a significant muscle protein depletion. A fall in Zn++ levels in the blood was accompanied by a rise in muscle and liver concentrations. The rise in Ca++ and Mg++ concentration in blood and in the muscles might be related to the enhanced proteolysis. Results suggest that the early changes of protein and electrolyte metabolism at tissue level with semistarvation impair muscular and hepatic functions as they delay adequate response to trauma and infection.

[Gastrin changes in the gastric antrum G-cells and in serum gastrin levels after 80% jejunoileal resection in rats]

A study was made of the changes in the cell population producing gastrin of the gastric antrum in rats submitted to resection of 80% of jejunum-ileum. Ninety days after surgery, the animals were killed after a 12 hour nightly fast and the gastric antrum was removed with the objective of specific histological preparations (PAP method) in order to count the G-cells and the blood was taken for serum doses of gastrin. An optical microscope was used to count the cells using a histometric integraded ocular of 42 points and the counting of 10 fields of each histological cut, and the radioimmunoassay method of double antibody was used for the seric dosing of gastrin. Histometry showed a significant drop in the G-cell population of the antrum of enterectomized animals when compared to the control group. Average percentage of G-cells found were 17.55% in the control group and 7.99% in the enterectomized ones. Blood dosing of hormone showed a significant increase of gastrin in the enterectomized animals when compared to controls. Average value of gastrin dosing the control group was 110 Pg/ml and 170 Pg/ml in enterectomized animals. Therefore, the present study permits to conclude that after resection of 80% of jejunum-ileum, there was a decrease in the G-cell population with gastrin in the gastric antrum even in the presence of increased serum gastrin.

[Severe acute pancreatitis, laparotomies, and planned reoperation]

Of 111 cases of acute pancreatitis studied, 13 (11.7%) patients had severe pancreatitis with infection and were submitted to planned reoperation or to open peritoneal drainage. Twelve patients were male, ages ranging from 20 to 56. The etiology was biliary in 4 patients, traumatic in 1 patient, and alcoholic in 8 patients. Early treatment included clinical support at the intensive care unit and surgical intervention was performed after the first week based on clinical signs and on ultrasound and CT scan findings. A total of 42 surgeries was performed (mean of 3.23 operations per patient). Mortality rate was 46% due to systemic complications and to multiple organ failure.

[Use of transhepatic drainage in repair of the main bile duct]

The transhepatic intubation to treat and minimize recurrent stricture after hepaticojejunostomy is analysed. This method was used in seven patients. Three of them had a malignant biliary stricture and four had bile duct injury during cholecystectomy. In four occasions the reconstruction of right and left hepatic ducts were done separately. In two the anastomosis with the jejunum was performed with the left hepatic duct and ducts of medial and lateral segments of right hepatic lobe and in two hepaticojejunostomy was performed. The transhepatic tube was maintained for three to ten months. The patients with malignant disease died after ten days, 35 days and nine months. In the four patients with benign disease, two had an excellent response. One did not and in one the follow up is short to assess the final result. The advantages and disadvantages of transhepatic intubation are discussed.