Željko Bušić

War injuries of the extremities: twelve-year follow-up data

BACKGROUND More than 75% of all injuries in modern wars are injuries of the extremities, usually with highly contaminated wounds and major soft tissue destruction. In this review, we present the late functional results for 35 of 41 wounded patients who sustained solitary war injuries of the extremities with open fractures. METHODS During a 6-month period from August 1991 to February 1992, of a total of 1,050 injured patients, 49 wounded patients with isolated open fractures of the extremities were treated in General Hospital Nova Gradiska (Nova Gradiska, Croatia). The mean age was 34 years (range, 17-85 years); 44 wounded patients (90%) were male and 37 (76%) were soldiers. With primary amputations for 8 (16%) of 49 injured patients, external fixation was performed for 27 wounded patients (66%); primary internal fixation was applied for eight wounded patients (19.5%). After 12 years, 35 (85%) of the injured patients were available for evaluation concerning (a) fractured bone nonunion, (b) osteomyelitis, (c) late amputation, (d) nerve palsy, and (e) function. RESULTS Osteomyelitis occurred for five patients (12%), only one with primary external fixation. In two cases of delayed conversion of external fixation to internal fixation, osteomyelitis occurred, requiring external fixator restoration. This has been no recurrence of osteomyelitis in the past 5 years and, after 12 years, more than three-fourths of wounded patients showed no or mild reduction of function of related proximal and distal joints. According to Index of Independence in Activities of Daily Living scores, grade B was found for only two wounded patients, with grade A for the others. CONCLUSION The application of external fixation is the first and definitive choice of treatment for war-related open fractures of extremities, producing good late functional results. Conversion of external fixation to internal fixation leads to osteomyelitis, demanding another operation and application of secondary external fixation.

Small Bowel Injuries in Penetrating Abdominal Trauma during War: Ten-Year Follow-Up Findings

BACKGROUND Injuries of the small intestine are common in penetrating abdominal trauma. This article presents 10-year follow-up results for 23 patients with penetrating small bowel injuries who were treated in Nova Gradiska City Hospital during the 1991-1992 war in Croatia. The early hospital mortality rate was 13% (three deaths), and good results were found for 16 (84%) of 19 patients after 10 years. METHODS The hospital charts of 23 patients who sustained small bowel injuries during an 8-month period were reviewed. Of 20 patients who survived, 19 came for an examination and interview 10 years after injury. The following criteria were used: existence of an abdominal wall defect or hernia, bowel passage problems, and reoperations attributable to the small bowel injury. RESULTS Early results revealed adhesive peritonitis and ileus for three patients demanding early reoperation (13%) and a hospital mortality rate of 13% (three deaths, mainly attributable to multiple injuries). Ten years after injury, 16 patients had no problems, whereas 3 reported occasional abdominal pain. CONCLUSION Penetrating abdominal injuries in war demand urgent diagnostic procedures and, in almost all cases, urgent laparotomy. In cases with no evidence of abdominal penetration and cases involving multiple injuries, an aggressive approach reduces the risk of missing small bowel injuries. Use of established principles for surgical management of small bowel injuries yields good results and low incidences of late complications and difficulties.

Potential use of Doppler perfusion index in detection of occult liver metastases from colorectal cancer

Many clinical and preclinical studies demonstrated that measurements of liver hemodynamic [Doppler perfusion index (DPI)] may be used to accurately diagnose and predict liver metastases from primary colorectal cancer in a research setting. However, Doppler measurements have some serious limitations when applied to general population. Ultrasound is very operator-dependent, and requires skilled examiners. Also, many conditions may limit the use of Doppler ultrasound and ultrasound in general, such as the presence of air in digestive tract, cardiac arrhythmias, vascular anomalies, obesity and other conditions. Therefore, in spite of the results from clinical studies, its value may be limited in everyday practice. On the contrary, scientific research of the DPI in detection of liver metastases is of great importance, since current research speaks strongly for the presence of systemic vasoactive substance responsible for observed hemodynamic changes. Identification of such a systemic vasoactive substance may lead to the development of a simple and reproducible laboratory test that may reliably identify the presence of occult liver metastases and therefore increase the success of adjuvant chemotherapy through better selection of patients. Further research in this subject is therefore of great importance.

The laparoscopic liver resections—an initial experience and the literature review

The laparoscopic liver resection (LLR) represents a new pathway in hepatic surgery. Several studies have reported its application in both malignant and benign liver diseases. The most common liver resections performed laparoscopically are wedge, segmental resections and metastasectomy; although in large centers the laparoscopic right and left hepatectomies have begun to perform more frequently. We report the initial experience in LLRs at our department including a case of the first laparoscopic left lateral liver bisegmentectomy performed in patient with follicular nodular hyperplasia and the 15 cases of wedge laparoscopic resections of echinococcic liver cysts. According to literature the mortality rate in LLRs is up to 0.3% and morbidity rate up to 10.5%. The most common cause of the death is liver failure, while the most frequent complication is the bile leakage. Advantages for patients include smaller incisions, less blood loss, and shorter lengths of hospital stay. The LLRs in experienced hands were shown to be safe with acceptable morbidity and mortality for both minor and major hepatic resections in benign and malignant diseases.