Tugba Han Yilmaz

Operative techniques in pancreatic trauma—A heuristic approach

Tugba Han Yilmaz , Thorsten J. Hauer *, Martin D. Smith , Elias Degiannis , Dietrich Doll c,d Baskent University, Department of Surgery, Izmir, Turkey Military Hospital Ulm, Department of Surgery, Ulm, Germany Chris Hani Baragwanath Academic Hospital, Trauma Directorate, University of the Witwatersrand, Johannesburg, South Africa d St. Marienhospital Vechta, Department of Surgery, Vechta, Germany

Penetrating arterial trauma to the limbs: outcome of a modified protocol

BackgroundPenetrating arterial injuries to the limbs are common injuries in high volume trauma centers. Their overall surgical results reported in the literature are satisfactory - apart of those of the popliteal artery that still may lead to a significant incidence in amputations. With the present study we assessed our outcome with penetrating arterial injuries to the limb as to see if the direct involvement of vascular surgeons in the management of popliteal artery injuries leads to an improved (lowered) amputation rate. Results were benchmarked with our published results from previous years.MethodsAll patients sustaining penetrating arterial injuries to the limbs admitted to the Chris Hani Baragwanath Academic Hospital during an 18- month period ending in September 2011 were included in this study. Axillary, brachial and femoral artery injuries were operated on by the trauma surgeons as in the past. All popliteal artery injuries were operated on by the vascular surgeons (new).ResultsThere were a total of 113 patients with 116 injuries, as some patients had multiple vascular injuries: 10 axillary, 47 brachial, 34 femoral and 25 popliteal artery injuries. Outcome of axillary, brachial and femoral artery injury repair were excellent and not significantly different from our previous reported experience. Injury to the popliteal artery showed a diminished re-exploration rate from 34% down to 10% (p = 0,049) and a decrease of amputation rate from 16% to 11% which was statistically not significant (p = 0,8).ConclusionPenetrating arterial trauma to the axillary, brachial and femoral artery is followed by excellent results when operated by trauma surgeons. In the case of popliteal artery injury operated by the vascular surgeons, the results of this study do not show any statistically significant difference related to amputation rate from our previous reported studies when operated by trauma surgeons. Taking into consideration the diminished re-exploration rate and a tendency to a lower amputation rate, we feel that there is possible tendency of better outcome if operated by vascular surgeons. Multicenter studies with large number of enrolled patients will be required to prove the validity of this suggestion.

On the Ideal Emergency Thoracotomy Incision

To the Editor, We read with interest the article titled ‘‘Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomical study’’ [1]. It is an interesting report, showing the enthusiasm of the authors in furthering the management of trauma by comparing the different thoracic incisions and evaluating their access to intrathoracic organs in cadavers. Having ourselves a reasonable thoracic trauma experience, we agree with the authors that 2nd and 3rd intercostal space incisions are obsolete. It becomes impossible to spread the ribs far enough to provide adequate visual contact and access to injured viscera at that level. Median sternotomy is ideal for injuries of the anterior mediastinum, giving excellent access to the ascending aorta, the aortic arch and its branches, and the heart. It also has the advantage over the left anterolateral thoracotomy, in the presence of hemopericardium originating from an injury of the ascending aorta, which can be managed with greater ease through a median sternotomy [2, 3]. Management of the right chambers of the heart can easily be dealt with through both incisions, if we are prepared to occasionally split the sternum transversely, as a continuation of the left anterolateral thoracotomy [2]. From the above assessment it is possible to see that we more or less agree with the authors. Yet we totally disagree with their recommendation of clam shell incision for access to intra-thoracic injuries, particularly if the surgeon is not ‘‘very experienced.’’ This is a very extensive incision and has intrinsic problems that cannot be assessed in the cadaver.

Operating on penetrating trauma to the mediastinal vessels

Background and Aims: Patients with penetrating trauma of the major vessels of the chest are infrequently encountered. This is due to the fact that the majority of these patients die on scene, as well as due to the overall dramatic decline in the incidence of penetrating trauma in the Western world. A certain proportion of survivors are physiologically stable and can be transferred to adequate care. Patients who are physiologically unstable must be dealt with by the surgeons available without delay. Rapid diagnosis and operation can salvage patients who would otherwise be lost, and all general surgeons should be capable of recognizing these injuries and intervening if a trauma and/or cardiothoracic surgeon is not immediately available. Material and Methods: Technical description of practical emergency surgery approaches to patients bleeding to death from penetrating mediastinal vessel injuries. Results: The scope of this review familiarizes the “uninitiated” surgeon with the operative management of this rare and lethal type of injuries. Technical aspects are described, and pitfalls as well as tips and tricks of the trade are discussed. Conclusions: Patients with penetrating injuries to the mediastinal vessels can be saved by swift and knowing operative management of this rare and lethal type of injuries, even if a trauma and/or cardiothoracic surgeon is not immediately available.

Sternotomy for penetrating trauma to the heart: A heuristic approach for the non-initiated

Tugba Han Yilmaz , Pantelis Vassiliu *, Elias Degiannis , Dietrich Doll c,d Department of Surgery, Baskent University, Izmir, Turkey b 4th Surgical Clinic, ‘‘Attikon’’ University Hospital, University of Athens, Athens, Greece Department of Visceral, Vascular and Thoracic Surgery, Phillips University of Marburg, Marburg, Germany d Trauma Directorate, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa

Penetrating Cardiac Trauma

In the last three decades, there have been numerous publications on the subject of penetrating cardiac injuries including a number of large series. Controversial issues remain; they relate to the diagnostic procedures that may be indicated and the therapeutic strategy best suited to each patient. These controversies are partly a reflection of differences in personal surgical preferences and logistical organization of trauma care. To a large extent, however, they stem from a lack of consistent stratification of patients. An elaborate scoring system for the purpose of predicting outcome has been devised, but attempts as classifying patients to involve rational management decisions have been rare and incomplete. In our clinical practice, we classify our patients in five categories. Although this classification facilitates diagnosis and therefore management of the patient, the recent advent of e-FAST availability at the emergency department, performed immediately on admission by the emergency physician or trauma surgeon, results in a reliable diagnosis of cardiac tamponade irrespective of the intensity of the clinical findings.

Changes in serum lipid levels after laparoscopic sleeve gastrectomy in morbidly obese dyslipidemic and normolipidemic patients

Abstract Background: This study investigated the effect of laparoscopic sleeve gastrectomy (LSG) performed for morbid obesity on serum lipid levels of dyslipidemic and normolipidemic patients. Methods: 141 patients who underwent LSG between September 2014 and January 2016 were included in the study. Results: The patients’ mean body mass index was 46.27 ± 6.79 kg/m2 preoperatively, 31.60 ± 5.37 kg/m2 in the 6th month postoperatively and 27.80 ± 4.25 kg/m2 in the 12th month (p < .001). Preoperatively and 12 months after the operation, mean total cholesterol (TC) levels and mean LDL cholesterol, mean HDL cholesterol, and mean triglyceride (TG) levels were statistically significantly decreased (p < .01). Comparing TC levels in the 12th month with preoperative levels, dyslipidemic patients showed a statistically more significant decrease than normolipidemic patients. LDL cholesterol levels were significantly decreased in both the groups. HDL cholesterol levels increased significantly in both groups while mean TG levels decreased significantly in patients with high preoperative TG levels, but not in patients with normal preoperative TG levels. Conclusions: Although this technique exerts its effect primarily by reducing gastric volume, besides its metabolic and hormonal effects, it also improves serum lipid levels (decreasing TC, LDL cholesterol and TG levels, and increasing HDL cholesterol levels). It therefore contributes to decreasing cardiovascular diseases.

Haemodialysis for post-traumatic acute renal failure – factors predicting outcome

BACKGROUND Post-traumatic acute renal failure requiring renal replacement therapy in an intensive care unit (ICU) is associated with high mortality. OBJECTIVE To assess indicators of improved survival. METHODS This was a retrospective cohort study of 64 consecutive trauma patients (penetrating and blunt trauma and burns) who underwent haemodialysis (HD) over a period of 5 years. Information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily ICU records were collected. The majority of the patients were dialysed with continuous venovenous haemofiltration in the early years of the study and later with sustained low-efficiency dialysis. RESULTS Of the 64 patients 47 died, giving an overall mortality rate of 73%. Mortality was highest in the burns patients (84%). Survival in all patients, irrespective of injury, was unrelated to the Revised Trauma Score, Injury Severity Score, Acute Physiology and Chronic Health Evaluation Score or Trauma Injury Severity Score. The duration of HD did not differ significantly between the three trauma groups, and age was not a significant predictor of survival. Patients who were polyuric at the time of the initiation of HD had a lower mortality rate than those who were oliguric, anuric or normouric, although this did not reach statistical significance (p=0.09). CONCLUSIONS Acute renal failure in trauma patients is associated with a low survival rate. Controversial conclusions have been presented in the literature. In this study, none of the parameters previously reported to affect survival proved to be valid, although the number of patients was comparable with those in other studies. Since understanding of the predictors and course of renal failure in trauma patients is still at an early stage, there is a need for multicentre prospective studies.

Pulmonary and Bronchotracheal Trauma

The majority of thoracic trauma can be managed by conservative methods such as chest tube insertion and observation. Only 15–30% of penetrating chest trauma requires thoracotomy.

Penetrating Trauma to the Thoracic Oesophagus

Penetrating trauma to the thoracic oesophagus is a rare injury. There are several reasons for that. The thoracic oesophagus is too deep for most stab wounds and penetrating trauma to the mid-thoracic oesophagus is also likely to involve the heart and mediastinum vessels leading to death. Remember that the patients survival with this type of injury is directly related to time interval between injury and repair. A practical approach to the operative management of penetrating trauma to the thoracic oesophagus is given