R. Saadia

Changing profiles in spinal cord injuries and risk factors influencing recovery after penetrating injuries.

OBJECTIVE The changing profiles of spinal cord injuries in South Africa are addressed in this study. DESIGN A retrospective analysis of 551 patients with spinal cord injury. MATERIALS AND METHODS The cause of injury was motor vehicle crashes in 30%, stab wounds in 26%, gunshot wounds in 35%, and miscellaneous causes 9%. MEASUREMENTS AND MAIN RESULTS There was a significant shift from stab wounds towards bullet wounds over the last five years. Bullet spinal cord injuries increased from 30 cases in 1988 to 55 cases in 1992, while stab spinal cord injuries decreased from 39 cases in 1988 to 20 cases in 1992. The incidence of spinal cord injuries following a motor vehicle crash showed a declining tendency after a transient increase (28 cases in 1988, 40 in 1990, 31 in 1992). Moreover, the problem of severe septic complications has been investigated and various risk factors for sepsis that might impair the rehabilitation process have been examined. The risk of developing septic complications was higher in gunshot spine injuries (21 cases out of 193) than in knife injuries (5 cases out of 143). The presence of a retained bullet did not seem to increase the chances for sepsis. In seven patients the sepsis was the direct consequence of the retained bullet while in 14 patients sepsis developed with no bullet in situ. Furthermore, the site of the injury (cervical, thoracic, lumbar spine) did not correlate with the abovementioned risks. CONCLUSIONS Gunshots carry a heavier prognosis. Only 32% of our gunshot cases underwent a significant recovery as opposed to 61% of stab cases and 44% of the motor vehicle crash victims.

Selective surgical management of zone II gunshot injuries of the neck : A prospective study

BACKGROUND The management of penetrating neck trauma remains controversial, with many studies supporting either mandatory exploration or selective conservatism. METHODS AND RESULTS This is a prospective study of 75 patients with gunshot injuries to zone II of the neck. Forty patients (53.3%) underwent immediate exploration because of clinical indications or positive initial investigations. A 7.5% incidence of unnecessary explorations, a 5% mortality rate, and average hospital stay of 10.5 days were noted. Thirty-five patients with negative clinical or investigational findings underwent observation with constant monitoring. A 5.7% incidence of missed injuries, no mortality, and an average hospital stay of 3.5 days were noted for these patients. CONCLUSIONS We suggest that conservative management in gunshot injuries confined to zone II of the neck selectively supplemented by appropriate investigations is a viable proposition in this type of injury. Further contemporary studies reporting specifically on this injury will enable us to reach statistically significant conclusions.

Extraperitoneal rectal gunshot injuries

Extraperitoneal rectal gunshot injuries are rare, but may be encountered in civilian practice. We report on a series of 26 such cases. The aim of the study is to attempt to evolve a treatment policy of this injury. The principles of management include the repair of rectal wound in selected cases and the formation of a diverting colostomy. Distal rectal washout and presacral drainage, although advocated by some authors, do not seem to be indispensable adjuncts to the management of these injuries.

Early closure of colostomies in trauma patients—A prospective randomized trial

BACKGROUND Most traumatic colon injuries can be repaired primarily, but a colostomy may still be required for severe colonic or rectal injury. The current trend is to reverse the colostomy early, rather than to wait the traditional 3 months before closure. METHODS Forty-nine patients with colostomies after abdominal trauma were entered into the study. All patients had undergone a contrast enema in the second postoperative week to assess distal colon healing. Patients were excluded from early closure for nonhealing of the bowel injury, unresolving wound sepsis, or an unstable condition. We then compared the outcome of the remaining 38 (77.6%) patients allocated to either an early or a late colostomy group in a controlled, prospective, randomized trial. RESULTS We found no significant difference in morbidity between the two groups, with an overall complication rate of 26.3%. Technically the early closure of colostomies was far easier than late closure and required significantly less operating time (p = 0.036) and with less intraoperative blood loss (p = 0.020). The closure of end colostomies was more time consuming, both early (p < 0.001) and late (p < 0.001) and caused more bleeding (p < 0.001 and p < 0.001, respectively). Total hospitalization was marginally shorter overall for early closure, but late closure of end colostomies resulted in prolonged hospitalization (p = 0.023). CONCLUSIONS The early closure of colostomies and the use of loop colostomies whenever possible are recommended as both safe and beneficial for patients with colonic injury after trauma. Contraindications for early closure include nonhealing distal bowel, persistent wound sepsis, or persistent postoperative instability.

Penetrating injuries of the iliac arteries : a south African experience

BACKGROUND We did a retrospective study of 62 patients with penetrating injuries of the iliac arteries. METHODS The cause of injury was gunshot wound in 85.5% and stabbing in 14.5%. The arterial repair was achieved by various means: lateral arteriorrhaphy, end-to-end anastomosis, and polytetrafluoroethylene interposition grafts. RESULTS There was a 42% mortality rate from exsanguination or secondary coagulopathy directly related to the arterial injury. Persistent shock, resuscitative thoracotomy, free intraperitoneal hemorrhage, and the number of vascular injuries were directly related to mortality. CONCLUSIONS A high index of suspicion, aggressive resuscitation, and prompt surgery are necessary to improve the chances of surviving this ominous injury.

Gunshot Injuries of the Head of the Pancreas: Conservative Approach

Abstract. This study is comprised of 48 patients with gunshot injuries of the head of the pancreas, many of which were high velocity injuries. The purpose of this study was to evaluate our management policy for these injuries based on our recent wide experience. Patients with grade II and III injuries underwent conservative surgery, with 0% and 21% postoperative mortality, respectively, directly related to the pancreatic injury. For patients in whom the duodenum was involved, pyloric exclusion was applied depending on the grade of the duodenal injury. We concluded that moderate gunshot injuries of the head of the pancreas (grade II) can be safely treated by débridement and suture repair, with or without drainage. Severe (grade IV) injuries warrant a pancreaticoduodenectomy. Most grade III injuries can be treated by débridement and drainage unless an associated severe duodenal injury is present, in which case resection may be indicated.

Arterial gunshot injuries of the extremities: a South African experience.

This is a retrospective study of 173 patients with gunshot injuries of the major arteries of the extremities. A selective policy for the use of angiography was followed. The arterial repair was achieved by various means: primary end-to-end anastomosis, vein interposition graft, and polytetrafluoroethylene (Teflon) interposition grafts. Overall, there were nine amputations in the lower limb. Ninety-eight percent of the patients had a palpable pulse on discharge. There were 3 preoperative deaths, 1 intraoperative death, and 5 postoperative deaths (overall perioperative mortality, 3.5%). We conclude that the results of vascular extremity gunshot injuries are satisfactory when standard methods of management are used. Morbidity and mortality can be further reduced by prompt admission to appropriate centers.

Colonic necrosis in acute pancreatitis

Colonic necrosis is a rare complication of peripancreatic sepsis following acute pancreatitis. Three patients with colonic necrosis associated with extensive retroperitoneal suppuration are reported. The pathogenesis of this syndrome may be explained by the tendency of pancreatic abscesses to extend widely in the retroperitoneum. Management is discussed, emphasizing the need for an aggressive surgical approach and multiple operations.

Fungal infections in critically ill patients

The microbial threat posed by nosocomial fungal infections in critically ill patients has become increasingly apparent in the past 30-40 years.1 Fungi (predominantly candida species) are now among the most frequently isolated organisms in intensive care units. Two years ago, Pittet and Wenzel reported a 12-fold rise in the reported rate of candida infections in a 12 year study of over 250 000 patients.2 This trend has been confirmed in other studies in the United States3 as well as in Europe.4 The species identified most often has been Candida albicans , but other species (notably Torulopsis glabrata and Candida tropicalis ) are being isolated ever more often and are associated with more complications and a higher mortality.5 Making a diagnosis of candidiasis may often be difficult, but the risk factors are well known and most are commonly found in intensive care units. The presence of one or more risk factors should heighten clinical suspicion. Treatment with broad spectrum antibiotics (and so suppressing the normal intestinal flora6) is the single most important factor …

The place of intraoperative antegrade colonic irrigation in emergency left-sided colonic surgery

The healing of colinic or colorectal anastomoses depends, at least partially, on the volume of fecal residue. Intraoperative antegrade colonic irrigation enables the surgeon to prepara the colon adequately at the time of surgery and to perform safely an immediate resection and primary anastomosis in obstructive lesions of the left colon. Its indications have been extended to other left-sided colonic emergencies, especially perforation and hemorrhage. The technique is described in this study and its value is assessed in the light of available experimental and clinical evidence