Walter Forno

Operative management and outcome of 302 abdominal vascular injuries

BACKGROUND Abdominal vascular injuries incur high mortality rates. The purposes of this study are (1) review institutional experience, (2) determine additive effect on mortality of multiple vessel injuries, (3) determine mortality of combined arterial and venous injuries, and (4) correlate mortality with American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury. METHODS A retrospective 6-year study was made at an urban level I trauma center of patients with abdominal vascular injuries. Main outcome measure was survival. RESULTS (1) There was a total of 302 patients, mean age 28, mean Injury Severity Score (ISS) 25 (range 4 to 75). Mechanism of injury was penetrating in 266 (88%), blunt in 36 (12%). Emergency Department thoracotomy was done in 43 of 302 (14%), 504 vessels were injured: arteries 238(47%), veins 266(53%). Surgical management was ligation 245, primary repair 141, prosthetic interposition grafts 24, autogenous 2. Overall mortality was 162 of 302 (54%). (2) Mortality multiple vessels injured: 1 vessel 160 (45%), 2 vessels 102 (60%), 3 vessels 33 (73%), >4 vessels 5 (100%). Mortality arterial injuries: aorta isolated (I) 78% versus combined with other arterial injuries (C) 82.4%, superior mesenteric artery (SMA) I 47.6% versus C 71.4%, iliac I 53% versus C 72.7%, renal I 37.5% versus C 66.7%. Venous injuries: inferior vena cava (IVC) isolated (I) 70% versus combined with other venous injuries (C) 77.7%, superior mesenteric vein (SMV) I 52.7% versus C 65%, IMV I 16% versus C 50%. (3) Specific mortality combined arterial and venous injuries: aorta plus IVC 93%, SMA plus SMV 43%, iliac artery plus vein 45.5%. (4) Mortality versus AAST-OIS: grade II 25%, grade III 32%, grade IV 65%, grade V 88%. CONCLUSION Abdominal vascular injuries are highly lethal. Multiple arterial and venous injuries increase mortality. Mortality correlates with AAST-OIS for abdominal vascular injury.

Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fishers exact test, Students T test, and logistic regression analysis. RESULTS The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Penetrating thoracoabdominal injuries: Ongoing dilemma - Which cavity and when?

The aims of this study were to (1) define characteristics for the thoracoabdominal injury patient population; (2) describe sequences of surgical interventions with combined procedures (i.e., thoracotomy and laparotomy); and (3) describe pitfalls leading to inappropriate sequencing of surgical interventions for thoracoabdominal injuries. It was a retrospective 4-year study (January 1995 to December 1998) conducted at an urban level I trauma center. The study population comprised 254 patients who had sustained thoracoabdominal injuries requiring surgical intervention: 187 (73%) gunshot wounds (GSWs), 64 (25%) stab wounds (SWs), and 3 (2%) shotgun wounds (STWs). The mean revised (RTS) was 6.04; the mean Injury Severity Score (ISS) was 27; the mean estimated blood loss (EBL) was 3000 ml. The overall survival was 175 of 254 (69%). Of the 254, 51 (20%) underwent emergency department (ED) thoracotomy. Altogether, 73 (29%) underwent combined thoracotomy and laparotomy: 59 (81%) GSW, 13 (18%) SW, 1 (1%) STW (mean RTS 5.2, mean ISS 34, mean EBL 6800 ml). Overall survival was 30 of these 73 (41%). A total of 21 of the 73 (29%) underwent ED thoracotomy. In group I (laparotomy then thoracotomy: Lap + Thor, n=34) the initial procedure was interrupted in 18 (53%). In group II (thoracotomy then laparotomy: Thor + Lap, n=39) the initial procedure was interrupted in 14 (36%). Pitfalls leading to inappropriate surgical sequencing were persistent hypotension (13/73,18%) and misleading chest tube output (8/73,10%). It was concluded that penetrating thoracoabdominal injuries incur high mortality (31%), and the mortality doubles for patients who require combined procedures (59%). Inappropriate surgical sequencing occurred in 32 of 73 (44%) patients undergoing combined procedures. Persistent hypotension, indicating that the wrong cavity was accessed, and misleading chest tube output are the leading pitfalls in thoracoabdominal injury management.RésuméObjectifs: 1) Définir les caractéristiques des traumatisés thoracoabdominaux 2) Décrire la séquence idéale d’interventions chirurgicales lorsque plus d’une opération est nécessaire (i.e., thoracotomie et laparotomie) chez ces patients; 3) décrire les erreurs qui peuvent conduire à une séquence opératoire inappropriée en cas de lésions thoracoabdominales combinées. Méthodes: Dans une étude rétrospective entre janvier 1995 et décembre 1998 (4 ans), dans un Trauma center urbain niveau I, on a relevé 254 patients ayant eu une lésion combinée thoracoabdominale nécessitant une intervention chirurgicale. Résultats: 1) Il y a eu 187 (73%) plaies par balles (GSW), 64 (25%) plaies par arme blanche (SW) et 3 (2%) plaies par fusil de chasse (STW). Les scores et valeurs moyens du «revised trauma score» (RTS), de l’«injury severity score» (ISS), et l’«estimated blood loss» (EBL) ont été, respectivement, de 6,04, de 27, et de 3000 ml. La survie globale a été de 175/254 (69%). 51/254 (20%) ont eu une thoracotomie d’urgence en salle d’urgences. 2) 73/254 (29%) ont eu une thoracotomie et une laparotomie: 59 (81%) par GSW, 13 (18%) par SW, 1 (1%) par STW. Les scores et valeurs moyens RTS, ISS, EBL ont été, respectivement, de 5,2, de 34 et de 6800 ml. La survie globale a été de 30/73 (41%). 21/73 (29%) ont eu une thoracotomie en salle d’urgences. Dans la séquence laparotomie suivie de thoracotomie (groupe I), on a du interrompre l’intervention initiale pour changer de cavité chez 18/34 (53%) patients. Dans la séquence thoracotomie suivie de laparotomie (groupe II), on a du interrompre le procédé initial pour changer de cavité chez 14/39 (36%). 3) Les erreurs amenant à pratiquer une séquence inappropriée ont été: une hypotension persistante chez 13/73 (18%), un drainage thoracique faussement interprété chez 8/73 (10%). Conclusions: 1) La mortalité des traumatismes thoraco-abdominaux pénétrants est élevée—31%. La mortalité est doublée chez les patients ayant besoin de deux voies d’abord—59%. 2) Une séquence inappropriée a été enregistrée chez 32/73 (44%) patients; 3) Une hypotension persistante indicative d’une hémorragie et un drainage du tube thoracique faussement interprété sont les cause principales de séquence inappropriée dans le traitement de lésions thoracoabdominales combinées.ResumenObjetivos: 1) Definir las caracteristicas de los pacientes con traumatismo toracoabdominal. 2) Describir la secuencia de las intervenciones quirúrgicas en abordajes combinados p. ej. toracotomía y laparotomía. 3) Descubrir los errores que inducen a una secuencia inapropiada de las intervenciones quirúrgicas en traumatizados toracoabdominales. Métodos: Estudio retrospectivo de 4 años (1/95–12/98) en un centro traumatológico urbano de nivel I. 254 pacientes con traumatismos toracoabdominales requirieron tratamiento quirúrgico. Resultados: 1) Se registraron 187 (73%) heridas por bala (GSW), 64 (25%) por arma blanca (SW) y 3 (2%) heridas por perdigones (STW). Puntuación media en la escala RTS=6.04, en la ISS=27 y la media de la pérdida sanguinea estimada (EBL)=3.000 ml. Supervivencia global 175/254 (69%). 51/254 (20%) sufrieron toracotomies ED. 2) A 73/254 (29%) se les practicó una toracotomÍa y laparotomÍa combinadas; en 59 (81%) por GSW 13 (18%) por SW y 1 (1%) por STW. Puntuación media en las escalas RTS=5.2 y ISS=34, media de la pérdida sanguÍnea estimada (EBL)=6.800 mL Supervivencia total 30/73 (41%), 21/73 (29%) sufrieron una toracotomÍa ED. Grupo I: laparotomÍzados y después toracotomizados (Lap-Thor)—34, en 18/34 (53%) el abordaje inicial se interrumpió. Grupo II: toracotomÍa y después laparotomÍa (Thor y Lap)—39, en 14/39 (36%) se interrumpió el abordaje quirúrgico inicial. 3) Los errores que indujeron a una inapropiada secuencia operatoria fueron: hipotensión persistente 13/73 (18%) y erronéa valoración de la cantidad drenada por el tubo intratorácico 8/73 (10%). Conclusiones: 1) Los traumatismo toracoabdominales penetrantes (abiertos) conllevan una mortalidad elevada (31%). La mortalidad se duplica en aquellos pacientes que requieren intervenciones combinadas (59%). 2) Una secuencia inapropiada del abordaje quirúrgico se observó en 32/73 pacientes sometidos a intervenciones combinadas. 3) La hipotensión persistente (evidencia que se ha accedido a la cavidad equivocada) y la errónea valoración del flujo del drenaje torácico constituyen los errores principales en el tratamiento de los traumatismos toracoabdominales.

Visceral vascular injuries

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Abdominal vascular injuries: the trauma surgeon's challenge.

ucts for intravascular volume replacement. Coupled with the frequent need to cross-clamp the aorta or other major intra-abdominal vessels, this scenario predisposes these patients to the development of reperfusion injuries and their sequelae.1–4 The concept of “bail out,” popularized by Stone et al.5 in the early 1980s and later known as “damage control,”6 is usually applied to patients sustaining abdominal vascular injuries. Similarly, these patients often demand heroic abdominal wall closures with prosthetic materials which initiates a cycle of frequent surgical reinterventions, adding multiple and additive physiologic insults to an already compromised patient. The classical dilemma of how to repair vascular injuries under conditions of massive contamination while avoiding graft infections and vessel blowouts, remains one of the most difficult problems that face modern-day trauma surgeons.7,8 Septic processes and multiple system organ failure (MSOF) are frequent complications encountered by these patients, precipitated by profound shock, tissue hypoperfusion, massive blood volume replacement, generalized edema, and prolonged contamination. All of these factors clearly conspire to produce high morbidity and mortality rates for patients sustaining these injuries. It is clear that improved outcomes are generally the result of expedient and precise surgical interventions by trauma surgeons with extensive experience in the management of these injuries, along with the vast surgical armamentarium needed to effectively deal with them.5–14

Abdominal vascular injuries: Injuries to the aorta

This article discusses injuries to the abdominal aorta at its supra- and infrarenal positions, focusing on the surgical approaches to abdominal aorta injuries and renal vascular pedicles. The controversy regarding the use of bioprosthetic materials and the coLlective experience with these injuries as reported in the literature are reviewed. Primary renal artery repair versus nephrectomy also is examined.

Penetrating cardiac injuries: a complex challenge.

The heart is a unique organ, vital and constant in its tireless function, working 24 h a day during the entire life time of an individual. It has inspired many talented poets, writers and musicians throughout the ages. The first description of a cardiac injury is found is Homer’s poetic description of the death of Sarpedon from the classical Greek epic The Iliad [1,2]. Cardiac injuries remain amongst the most challenging of all injuries seen in the field of trauma surgery. Their management often requires immediate surgical intervention, excellent surgical technique and the ability to provide excellent surgical critical care to these patients postoperatively.

Lesiones vasculares abdominales. El desafío del cirujano traumatológico

Resumen Introduccion Las lesiones vasculares abdominales presentan los mayores indices de mortalidad y morbilidad de entre todas las lesiones que puede sufrir un enfermo traumatico. Metodo Revision de la clinica, diagnostico, vias de abordaje y tratamiento de los pacientes con lesiones vasculares intraabdominales, basada en la experiencia en el tratamiento de 302 enfermos. Resultados Las heridas penetrantes abdominales constituyen entre el 90 y el 95% de las lesiones que afectan a los vasos abdominales. La lesion abdominal multiorganica es frecuente. Los hallazgos clinicos compatibles con hemoperitoneo o peritonitis y la ausencia de pulsos femorales son tributarios de laparotomia. En los pacientes que presentan paro cardiorrespiratorio se debe realizar una toracotomia de urgencia para el masaje cardiaco abierto y el pinzamiento aortico. La mortalidad global es del 54% y la exsanguinacion representa el 85% de la misma. El sindrome compartimental en el abdomen y en las extremidades, asi como el circulo vicioso de la acidosis, la hipotermia y la coagulopatia, son las principales complicaciones. Conclusiones Las lesiones vasculares abdominales presentan una alta mortalidad y morbilidad. El conocimiento anatomico del retroperitoneo y de las vias de abordaje de los vasos, asi como una exploracion clinica adecuada, ayudaran a disminuir las complicaciones y la mortalidad de estos pacientes.