Raymond A. Cava

Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same.

BACKGROUND Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI). METHODS The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988. RESULTS Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001). CONCLUSION Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.

Traumatic rupture of the urinary bladder: is the suprapubic tube necessary?

BACKGROUND Although surgical principles are well accepted for the treatment of an intraperitoneal or extraperitoneal rupture of the urinary bladder, the type and number of drainage catheters needed to obtain a satisfactory outcome with minimal patient morbidity have yet to be determined. METHODS This was a retrospective review of data on injured patients with the diagnosis of an intraperitoneal or extraperitoneal rupture of the urinary bladder from penetrating or blunt trauma. RESULTS Of the 51 patients identified, 28 were treated with suprapubic and transurethral catheters, whereas 23 received a transurethral catheter only. Complications and catheter duration times were similar regardless of type of bladder injury or drainage catheter used (p > 0.5). CONCLUSION These data suggest that there are similar outcomes and complication rates for patients treated with suprapubic and transurethral catheters versus transurethral catheter only. Transurethral catheters alone seem effective in draining all types of bladder injuries.

Transmediastinal Gunshot Wounds: A Prospective Study

OBJECTIVE To evaluate admission systolic blood pressure (SBP) in the emergency center (EC) as a means by which patients with transmediastinal gunshot wounds (TM-GSWs) can be triaged to the operating room versus further diagnostic evaluation. METHODS A prospective case series presenting concurrent data collected for 68 consecutive patients with TM-GSWs admitted to one urban trauma center over a 4.5-year period. For purposes of analysis, patients were assigned to the following groups based on SBP in the EC: group I, SBP > 100 mm Hg; group II, SBP from 60 to 100 mm Hg; group III, SBP < 60 mm Hg. RESULTS The management and outcomes of 68 patients with a mean age of 29 years were evaluated. For patients in group I (n = 20), TM-GSW was diagnosed by findings on x-ray film for 15 patients (75%), at physical examination for 4 patients (20%), and at operation for 1 patient (5%). Indications for immediate operation were found in five patients (25%), whereas further diagnostic evaluation prompted operation for three additional patients. Only one patient developed persistent hypotension from neurogenic shock. There were two deaths from late complications. In patients in group II (n = 16), TM-GSW was diagnosed by findings on x-ray film for 9 patients (56%), at physical examination for 5 patients (31%), and at operation for 2 patients (13%). Six patients with persistent hypotension had indications for immediate operation, whereas further diagnostic evaluation in the remaining patients, who became hemodynamically normal during resuscitation, prompted operation in an additional two patients. There were two intraoperative deaths. For the patients in group III (n = 32), six patients with signs of life underwent immediate operation with one intraoperative death, seventeen patients required EC thoracotomy with 100% mortality, and nine patients were pronounced dead in the EC without an attempt at operation. CONCLUSION The diagnosis of TM-GSW for patients in groups I and II is confirmed by finding at physical examination and on chest x-ray films in 90% of cases. In the absence of obvious bleeding, patients with TM-GSWs and SBP > 100 mm Hg may safely undergo further diagnostic evaluation. Sixty percent of such patients did not require an operation. All patients with TM-GSWs and SBP < 60 mm Hg (group III) require immediate operation. For patients with TM-GSWs, SBP from 60 to 100 mm Hg (group II), and without obvious bleeding, it is the response to resuscitation and the results of further diagnostic evaluation that determine the need for operation. Fifty percent of such patients did not require operation.

Three Hundred Consecutive Emergent Celiotomies in General Surgery Patients: Influence of Advanced Diagnostic Imaging Techniques and Procedures on Diagnosis

ObjectivesTo assess the utility of advanced tests performed before surgery on patients who needed emergent abdominal operations, and to assess the outcomes of these patients relative to their diagnoses. Summary Background DataPatients with a potential abdominal catastrophe may have various presentations, contributing to the difficulty of the decision about whether an operation is indicated. Advanced tests can be valuable, but the use of these adjuncts should be appropriate to the clinical status of the patient so that treatment is not delayed. The role of these tools in the evaluation of the patient who may need an emergent abdominal operation is less well defined. MethodsData were reviewed on adult patients undergoing emergent abdominal operations. Entrance criteria included patients who had an emergent abdominal operation, defined as one performed for presumed gastrointestinal perforation, infarction, or hemorrhage within 6 hours of admission or surgical consultation. Advanced tests were those that were time-consuming or invasive or required scheduling with other departments so that the risk/benefit ratio of these tests could be questioned. A useful test was one that provided information that contributed to a change in the patient’s management. ResultsDuring a 5-year period, 300 consecutive adult patients (158 perforations, 66 hemorrhage, 53 ischemia/infarction, and 23 “other”) underwent emergent nontrauma celiotomies. Overall, the death rate was 20%. Advanced preoperative tests were performed in 135 (45%) of the 300 patients, and 40 of these patients had delayed treatments. Preoperative localization of bleeding sites was accomplished in 77% of patients with upper gastrointestinal bleeding and 86% of patients with lower gastrointestinal bleeding. ConclusionsMost patients in need of emergent abdominal operations should not undergo advanced tests. The primary role of advanced tests in these patients is in the localization of a bleeding site. With the exception of patients who present with hemorrhage, advanced tests frequently cause a delay in treatment.