Marisol Badiel

Safety of Performing a Delayed Anastomosis During Damage Control Laparotomy in Patients with Destructive Colon Injuries

BACKGROUND Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL. METHODS We performed a retrospective chart review of patients with penetrating DCI during 2003 to 2009. Severity of injury, surgical management, and clinical outcome were assessed. RESULTS Sixty patients with severe gunshot wounds and three patients with stab wounds were included in the analysis. DCL was required in 30 patients, all with gunshot wounds. Three patients died within the first 48 hours, three underwent colostomy, and 24 were managed with DA. Thirty-three patients were managed with standard laparotomy: 26 patients with primary anastomosis and 7 with colostomy. Overall mortality rate was 9.5%. Three late deaths occurred in the DCL group, and only one death was associated with an anastomotic leak. CONCLUSIONS Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.

Experiencia en dos hospitales de tercer nivel de atención del suroccidente de Colombia en la aplicación del Registro Internacional de Trauma de la Sociedad Panamericana de Trauma

OBJECTIVE: To describes the experience in the implementation of a TRS in two hospitals in Cali, Colombia. METHODS: The TRS includes prehospitalary, during hospitalization and discharging status information of each patient. Each hospital has an electronic data capture strategy. A three month Pilot-period descriptive analysis is presented. RESULTS: 3293 patients has been registered, 1626 (49.4%) from the Public hospital and 1613 (50.6%) from the Private one. 67.2% were men; the mean age ±SD was 30.5±20 years; 30.5% were less than 18 years. The overall mortality rate was 3.5%. The most frequent consulting cause were falls (33.7%); 11.6% of injuries are secondary to fire gunshot, and this group where mortality rate was 62%. CONCLUSION: It was determined the needing for the TRS implementation and the mechanisms to provide continuity. The registry becomes an information source for the investigation developing. It was identified the causes of consult, morbidity and death due to trauma that will allow a better planning of the emergency services and of the regional trauma system in order to optimize and reduce the attention costs. Based on optimal information system it will be able to present the necessary adjusts to redesign the Trauma and Emergencies Attention System in the Colombian South-West.

Complex penetrating duodenal injuries: Less is better

BACKGROUND The traditional management of complex penetrating duodenal trauma (PDT) has been the use of elaborate temporizing and complex procedures such as the pyloric exclusion and duodenal diverticulization. We sought to determine whether a simplified surgical approach to the management of complex PDT injuries improves clinical outcome. METHODS A retrospective review of all consecutive PDT from 2003 to 2012 was conducted. Patients were divided into three groups according to a simplified surgical algorithm devised following the local experience at a regional Level I trauma center. Postoperative duodenal leaks were drained externally either via traditional anterior drainage or via posterior “retroperitoneal laparostomy” as an alternate option. RESULTS There were 44 consecutive patients with PDT, and 41 of them (93.2%) were from gunshot wounds. Seven patients were excluded owing to early intraoperative death secondary to associated devastating traumatic injuries. Of the remaining 36 patients, 7 (19.4%) were managed with single-stage primary duodenal repair with definitive abdominal wall fascial closure (PDR + NoDC group). Damage-control laparotomy was performed in 29 patients, (80.5%) in which primary repair was performed in 15 (51.7%) (PDR + DC group), and the duodenum was over sewn and left in discontinuity in 14 (48.3%). Duodenal reconstruction was performed after primary repair in 2 of 15 cases and after left in discontinuity in 13 of 14 cases (DR + DC group). The most common complication was the development of a duodenal fistula in 12 (33%) of 36 cases. These leaks were managed by traditional anterior drainage in 9 (75%) of 12 cases and posterior drainage by retroperitoneal laparostomy in 3 (25%) of 12 cases. The duodenal fistula closed spontaneously in 7 (58.3%) of 12 cases. The duodenum-related mortality rate was 2.8%, and the overall mortality rate was 11.1%. CONCLUSION An application of basic damage-control techniques for PDT leads to improved survival and an acceptable incidence of complications. LEVEL OF EVIDENCE Therapeutic study, level IV.

Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients.

BACKGROUND Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia. METHODS During a 2-year period (2012–2013), blunt and penetrating trauma patients (≥15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality. RESULTS We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. CONCLUSION There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT. LEVEL OF EVIDENCE Therapy/care management study, level IV.

Damage control resuscitation: early decision strategies in abdominal gunshot wounds using an easy "ABCD" mnemonic.

BACKGROUND Early damage-control resuscitation (DCR) indicators have not been clearly discerned in patients with penetrating abdominal trauma. Our objective was to identify these clinical indicators that could standardize a DCR initiation policy in this subset of patients. METHODS Prospective data collection from January 2003 to October 2010 at a Level I trauma center in Cali, Colombia. All adult (>15 years) patients with abdominal gunshot wounds (GSWs) were included. They were divided into two groups: those who underwent DCR and those who did not. Both groups were compared by demographics, clinical variables, severity scores, and overall mortality. Other scores were compared with our newly devised model using the area under the receiver operating characteristic curve (AUROC). RESULTS There was a total of 331 abdominal GSWs. Of these, a total of 162 (49%) underwent DCR. The overall mortality was 11.2%. Multivariate analysis identified (A) acidosis (base deficit ≥ 8); (B) blood loss (hemoperitoneum > 1,500 mL); (C) cold (temperature < 35°C); (D) damage (New Injury Severity Score > 35) as significant clinical indicators that aided in the decision process of early implementation of DCR. The Trauma-Associated Severe Hemorrhage (AUROC, 0.8333), McLaughlin (AUROC, 0.8148), ABC (AUROC, 0.7372) scores and our ABCD mnemonic (AUROC, 0.8745) were all good predictors of DCR, and the difference between them was statistically significant (p < 0.001). CONCLUSION We have identified (A) acidosis (base deficit ≥ 8); (B) blood loss (hemoperitoneum > 1,500 mL); (C) cold (temperature < 35°C); (D) damage (New Injury Severity Score > 35) as significant clinical indicators that aided in the decision process of early implementation of DCR for patients with abdominal GSWs. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

A comprehensive five-step surgical management approach to penetrating liver injuries that require complex repair

BACKGROUND The objective of this study was to describe a comprehensive five-step surgical management approach for patients with penetrating liver trauma based on our collective institutional experience. METHODS A prospective consecutive study of all penetrating liver traumas from January 2003 to December 2011 at a regional Level I trauma center in Cali, Colombia, was conducted. RESULTS A total of 538 patients with penetrating thoracoabdominal trauma were operated on at our institution. Of these, 146 had penetrating liver injuries that satisfied the inclusion criteria for surgical intervention to manage their hepatic and/or associated injuries. Eighty-eight patients (60%) had an American Association for the Surgery of Trauma–Organ Injury Scale (AAST-OIS) of Grade III (54 patients, 37%), Grade IV (24 patients, 16%), and Grade V (10 patients, 7%). This group of patients required advanced “complex” techniques of hemostasis such as the Pringle maneuver (PM), perihepatic liver packing (PHLP), and/or hepatotomy with selective vessel ligation (SVL). The focus of our study was this subgroup of patients, which we further divided into two as follows: those who required only PM + PHLP (55 patients, 63%) to obtain control of their liver hemorrhage and those who required PM + PHLP + SVL (33 patients, 37%). Of the patients who required PM + PHLP + SVL, 10 (27%) required ligation of major intrahepatic branches, which included suprahepatic veins (n = 4), portal vein (n = 4), retrohepatic vena cava (n = 1), and hepatic artery (n = 1). The remaining 23 patients (73%) required direct vessel ligation of smaller intraparenchymal vessels. The overall mortality was 15.9% (14 of 88), with 71.4% (10 of 14) related to coagulopathy. Mortality rates for Grade III was 3.7% (2 of 54), for Grade IV was 20.8% (5 of 24), and for Grade V was 70% (7 of 10). The mortality in the PM + PHLP + SVL group was higher compared with the PM + PHLP group (12 [36.4%] vs. 2 [3.6%], p = 0.001]. CONCLUSION For those patients who fail to respond to PM + PHLP and/or those who have AAST-OIS penetrating liver injuries, Grades IV and V would benefit from immediate intraparenchymal exploration and SVL. LEVEL OF EVIDENCE Therapeutic study, level V.