Gary J. Merlotti

Colostomy in penetrating colon injury: is it necessary?

OBJECTIVE To compare in a randomized prospective manner the complication rates associated with colostomy versus primary repair in penetrating colon injuries. METHODS During a 38-month period, 114 patients with penetrating wounds of the colon were entered into a randomized prospective study at an urban Level I trauma center. The patients were randomized to a primary repair group or a diversion group. Randomization was completely independent of any risk factors, including number of abdominal organ systems injured, extent of fecal contamination, blood loss, presence of shock (systolic blood pressure < 80), time from injury to operation, and severity of colon injury. Five patients initially entered in the study died in the immediate postoperative period (< 24 hours) and were removed from the study because their deaths were unrelated to their colon injuries. RESULTS A total of 109 patients were studied, of which 56 were randomized to primary repair and 53 to diversion (39 colostomies, 14 ileostomies). The average age for the primary repair group was 28.5 years and for the diversion group it was 26.8 years. The average Penetrating Abdominal Trauma Index for the primary repair group was 24.3 and for the diversion group it was 22.8. There were 11 (20%) septic-related complications in the primary group versus 13 (25%) in the diversion group. Complication rates in the presence of significant fecal contamination, shock, significant blood loss (> 1000 mL), more than two organ systems injured and extent of colon injury were all higher in the diversion group. There was one mortality in the diversion group and two in the primary repair group. CONCLUSIONS The authors conclude that all penetrating colon injuries in the civilian population should be primarily repaired.

Peritoneal lavage in penetrating thoraco-abdominal trauma.

Forty-five consecutive patients with penetrating thoraco-abdominal trauma underwent surgical exploration to evaluate the ability of peritoneal lavage to detect peritoneal penetration. Eight patients fulfilled standard criteria for operation and did not undergo lavage. The remaining 37 patients underwent diagnostic peritoneal lavage using a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3 as our previously established criterion for peritoneal penetration, there were seven true positive, one false positive, 28 true negative, and one false negative lavage for an overall accuracy of 94.6% with 87.5% sensitivity and 96.6% specificity as determined by subsequent laparotomy. While 33% of this patient cohort were found to have significant injuries (four had isolated diaphragmatic injuries, all detected by peritoneal lavage), 67% were subjected to negative surgical exploration, as accurately predicted by peritoneal lavage. Negative laparotomy carried a 10.7% operative morbidity. Based on these data we advocate diagnostic peritoneal lavage in patients with thoraco-abdominal penetrating trauma who otherwise lack operative indications.

The use of absorbable mesh in splenic trauma

Previous reports from this hospital documented a splenic preservation rate of 50% (18/36) in adults after blunt and penetrating trauma. Recently (January through December 1984), use of an absorbable mesh helped to attain a 67% (22/33) salvage rate. The mesh is applied in such a fashion that it acts by tamponade. It proved useful in patients with bleeding from a large surface area or from deep parenchymal injuries, even those extending into the hilum. No deaths occurred in the splenic salvage patients. There was no difference in postoperative complications among the splenectomy, conventional splenorraphy, or mesh wrap splenorraphy groups. However, workup of persistent postoperative fevers in two splenic wrap patients revealed perisplenic fluid collections on CT scan. Aspiration yielded sterile fluid. Possible cause and effect relationship is being studied in the dog lab. We conclude that splenic wrapping is both a safe and efficacious method of splenic preservation.

Use of peritoneal lavage to evaluate abdominal penetration

A retrospective study was undertaken to evaluate peritoneal lavage in detecting abdominal penetration. Two hundred thirty-five patients with thoracoabdominal, flank, or tangential abdominal gunshot wounds were lavaged. Of these patients, 44 (18.7%) had positive lavages, defined as red blood cell counts greater than 10,000 cells/mm3, white blood cell counts greater than 500 cells/mm3, or the presence of bile, feces, or vegetable matter. There were 13.6% false positives and 1.0% false negatives, with an overall accuracy of 96.6%. The results were unaffected by mechanism or site of injury. If the criteria were changed to include red blood cell counts greater than 100,000 cells/mm3, there would have been no false positives, but an unacceptably high 11.1% false negative rate. Therefore we conclude that peritoneal lavage can be a reliable indicator of abdominal penetration provided sufficiently sensitive criteria are used. These criteria should include red blood cell counts greater than 10,000 cells/mm3 instead of 100,000 cells/mm3.

Comparison of nonoperative management with renorrhaphy and nephrectomy in penetrating renal injuries.

BACKGROUND We reviewed our experience with penetrating renal injuries to compare nonoperative management of penetrating renal injuries with renorrhaphy and nephrectomy in light of concerns for unnecessary explorations and increased nephrectomy rates. METHODS In this retrospective study, we reviewed the records of 98 penetrating renal injuries from 2003 to 2008. Renal injuries were classified according to the American Association for the Surgery of Trauma and analyzed based on nephrectomy, renorrhaphy, and nonoperative management. Patient characteristics and outcomes measured were compared between management types. Continuous variables were summarized by means and compared using t test. Categorical variables were compared using χ² test. RESULTS Nonoperative management was performed in 40% of renal injuries, followed by renorrhaphy (38%) and nephrectomy (22%). Of renal gunshot wounds (n = 79), 26%, 42%, and 32% required nephrectomy, renorrhaphy, and were managed nonoperatively, respectively. No renal stab wound (n = 16) resulted in a nephrectomy and 81% were managed conservatively. Renal injuries managed nonoperatively had a lower incidence of transfusion (34 vs. 95%, p < 0.001), shorter mean intensive care unit (ICU) (3.0 vs. 9.0 days, p = 0.028) and mean hospital length of stay (7.9 vs. 18.1 days, p = 0.006), and lower mortality rate (0 vs. 20%, p = 0.005) compared with nephrectomy but similar to renorrhaphy (transfusion: 34 vs. 36%, p = 0.864; mean ICU: 3.0 vs. 2.8 days, p = 0.931; mean hospital length of stay: 7.9 vs. 11.2 days, p = 0.197; mortality: 0 vs. 6%, p = 0.141). The complication rate of nonoperative management was favorable compared with operative management. CONCLUSIONS Selective nonoperative management of penetrating renal injuries resulted in a lower mortality rate, lower incidence of blood transfusion, and shorter mean ICU and hospital stay compared with patients managed by nephrectomy but similar to renorrhaphy. Complication rates were low and similar to operative management.

Chest computed tomography for penetrating thoracic trauma after normal screening chest roentgenogram.

BACKGROUND Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention. METHODS A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed. RESULTS In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period. CONCLUSIONS The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality.

A method for management of extraperitoneal pelvic bleeding secondary to penetrating trauma.

Several techniques for the management of bleeding from extraperitoneal pelvic bullet tracks have been described in the literature. Some methods described include packing followed by direct control of the bleeding and use of thumbtacks. These methods often incur significant blood loss and prolonged operative times. We present our experience with an alternative method, which involves tamponade of the bleeding using a Foley catheter. This method has been used on 11 consecutive patients with successful control of life-threatening hemorrhage.

Fibronectin Depletion and Microaggregate Clearance following Trauma

Ninety-seven traumatized patients had blood samples taken immediately upon admission before any resuscitation. Microaggregate (MA) formation was measured by the screen filtration pressure (SFP) technique. Plasma fibronectin levels (Fn) were measured by immunoturbimetric assay. An Injury Severity Score (ISS) was calculated for each patient. The results show a highly significant correlation between severity of trauma, amount of MA formation, and amount of Fn depletion. We conclude that the highly significant correlation between MA formation and Fn depletion following trauma suggests a role for the reticuloendothelial system (RES) in the clearance of MA that form following trauma. Further, enhancement of RES clearance of MA may be possible by purified Fn or cryoprecipitate administration early in the treatment of trauma patients, thereby preventing the adverse sequelae of end organ MA deposition.

Utilization of Cardiothoracic Surgeons for Operative Penetrating Thoracic Trauma and Its Impact on Clinical Outcomes

BACKGROUND Large series reporting outcomes for penetrating thoracic trauma have identified injury pattern and injury severity scoring as predictors of poor outcome. However, the impact of surgical expertise on patient outcomes has not been previously investigated. We sought to determine how often board-certified cardiothoracic surgeons are utilized for operative thoracic trauma and whether this has an effect on patient outcomes. METHODS A level I trauma center registry was queried between 2003 and 2011. Records of patients undergoing surgery as a result of penetrating thoracic trauma were retrospectively reviewed. Patient demographics, injuries, injury severity, utilization of a cardiothoracic surgical operative consult and outcomes were recorded. Patients operated on by cardiothoracic surgeons were compared with patients operated on by trauma surgeons using stepwise multivariate analyses to determine the factors associated with utilization of cardiothoracic surgeons for operative thoracic trauma and survival. RESULTS Cardiothoracic surgeons were used in 73.0% of cases (162 of 222) over the study period. The use of cardiothoracic surgeons increased incrementally both overall (38.5% to 73.9%), and for emergent/urgent cases (31.8% to 73.3%). When comparing patients undergoing operation on an emergent/urgent basis by cardiothoracic versus trauma surgeons, there was no significant difference with regard to demographics, mechanism of injury, injury severity scoring, or surgical morbidity. Stepwise logistic regression showed the presence of a cardiothoracic surgeon to be independently associated with survival (odds ratio 4.70; p = 0.019). CONCLUSIONS Use of cardiothoracic surgeons for operative thoracic trauma increased over the study period. Outcomes for severely injured patients with elevated chest injury scores or decreased revised trauma scores may be improved with appropriate operative consultation with a board-certified cardiothoracic surgeon.

Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations

BACKGROUND Studies reporting on penetrating thoracic trauma in the pediatric population have been limited by small numbers and implied differences with the adult population. Our objectives were to report on a large cohort of pediatric patients presenting with penetrating thoracic trauma and to determine age-related impacts on management and outcome through comparison with an adult cohort. METHODS A Level I trauma center registry was queried between 2006 and 2012. All patients presenting with penetrating thoracic trauma were identified. Patient demographics, injury mechanism, injury severity, admission physiology, and outcome were recorded. Patients were compared, and outcomes were analyzed based on age at presentation, with patients 17 years or younger defining our pediatric cohort. RESULTS A total of 1,423 patients with penetrating thoracic trauma were admitted during the study period. Two hundred twenty patients (15.5%) were pediatric, with 205 being adolescents (13–17 years) and 15 being children (⩽12 years). In terms of management for the pediatric population, tube thoracostomy alone was needed in 32.7% (72 of 220), whereas operative thoracic exploration was performed in 20.0% (44 of 220). Overall mortality was 13.6% (30 of 220). There was no significant difference between the pediatric and adult population with regard to injury mechanism or severity, need for therapeutic intervention, operative approach, use of emergency department thoracotomy, or outcome. Stepwise logistic regression failed to identify age as a predictor for the need for either therapeutic intervention or mortality between the two age groups as a whole. However, subgroup analysis revealed that being 12 years or younger (odds ratio, 3.84; 95% confidence interval, 1.29–11.4) was an independent predictor of mortality. CONCLUSION Management of traumatic penetrating thoracic injuries in terms of the need for therapeutic intervention and operative approach was similar between the adult and pediatric populations. Mortality from penetrating thoracic trauma can be predicted based on injury severity, the use of emergency department thoracotomy, and admission physiology for adolescents and adults. Children may be at increased risk for poor outcome independent of injury severity. LEVEL OF EVIDENCE Epidemiologic study, level III.