Carlos H. Timaran

Prognostic factors and management of civilian penetrating duodenal trauma

OBJECTIVEnThis study was designed to investigate risk factors in the final outcome of patients with civilian penetrating abdominal trauma and duodenal injuries, the value of the different surgical approaches used, and to define when more complex procedures are indicated, instead of the simple primary repair.nnnMETHODSnThe study design was a retrospective review of prospectively collected data of a 4-year period (July 1992 to June 1996).nnnRESULTSnA total of 167 patients were admitted with penetrating abdominal trauma and duodenal injuries at San Juan de Dios Hospital in Santafé de Bogotá, Colombia.nnnCONCLUSIONnThe independent and significant risk factors that determine the severity of duodenal injury and need for complex procedures, as identified in this series, are preoperative or intraoperative shock; Abdominal Trauma Index higher than 25; and associated injuries to the pancreas, superior mesentric vessels, and colon. These factors are associated with an increased incidence of septic complications, duodenal fistula, and late mortality.

Role of duodenography in the diagnosis of blunt duodenal injuries

BACKGROUNDnThe differentiation of duodenal perforation from duodenal hematoma is not always possible with computed tomography (CT). Our diagnostic guideline has included duodenography to investigate CT findings of periduodenal fluid or wall thickening. However, the utility of duodenography as a diagnostic study in blunt abdominal trauma is not defined. We evaluated duodenography as a diagnostic test in patients with suspected blunt duodenal injuries (BDIs).nnnMETHODSnDuring a 10-year period, 96 patients out of 25,608 trauma admissions had CT findings of possible BDI and underwent duodenography. Demographic and clinical data, diagnostic methods, and management were derived from prospectively collected data. CT and duodenography studies were reviewed and correlated with surgical findings and outcome. All CT scans were obtained with intravenous contrast; oral contrast was used in 32 patients. Duodenography was analyzed using the 2 x 2 method and Bayes theorem.nnnRESULTSnIndications for duodenography included periduodenal fluid without extravasation (76%), abnormal duodenal wall thickening (16%), and retroperitoneal extraluminal gas (5%). Eighty-six duodenography studies were reported as normal, six were consistent with hematoma, one was indeterminate, and only three revealed extravasation. Two of these three patients with duodenal perforation had retroperitoneal extraluminal air. Only one patient underwent exploration on the basis of duodenography. No blunt duodenal perforation was diagnosed by CT. Overall, duodenography had sensitivity of 54% and specificity of 98%. For BDIs requiring repair, duodenography sensitivity was only 25%; the false-negative rate was also 25%. Retroperitoneal extraluminal air was a useful sign of duodenal perforation, occurring in two of three patients with BDI and only in one without BDI (p < 0.001).nnnCONCLUSIONnDuodenography has a low sensitivity in patients with suspected BDI by CT findings and is of minimal utility in diagnostic evaluation. Retroperitoneal extraluminal air seen on CT is an important sign of BDI requiring surgical repair.

Infrainguinal bypass grafting using lyophilized saphenous vein allografts for limb salvage

Critical ischemia in patients with extensive femoropopliteal occlusive disease often ends in amputation in the absence of a suitable autologous vein for reconstruction. Cryopreserved vascular allografts have been used as an alternative conduit with poor results. Antigenicity and rejection are assumed to account for graft failure. Lyophilized vessels have demonstrated patency and structural integrity in the vascular system in our previous experimental studies. We report four patients that underwent femorodistal bypass grafting with lyophilized saphenous veins who lacked usable autologous vein for arterial reconstruction. Early graft thrombosis occurred in three patients who required major amputations. Duplex scans for graft surveillance did not reveal previous significant abnormalities. These cases demonstrate that the clinical use of lyophilized venous allografts for infrainguinal arterial reconstructions failed to yield satisfactory patency and limb salvage. Lyophilized veins therefore are not useful alternative conduits in patients with critical ischemia and no suitable autologous vein grafts.