Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation

IntroductionPortal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care.MethodsWe reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes.ResultsTwenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting.ConclusionDespite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality.     

Injuries to the portal triad

We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to be optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients (80%). Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraabdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.     

Traumatic injuries of the portal vein. The role of acute ligation.

Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a "second look" operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel.     

Traumatic injury to the portal vein.

Traumatic injuries to the upper abdominal vasculature pose difficult management problems related to both exposure and associated injuries. Among those injuries that are more difficult to manage are those involving the portal vein. While occurring rarely, portal vein injuries require specific therapeutic considerations. Between January, 1968, and July, 1974, over 2000 patients were treated operatively for abdominal trauma at the Ben Taub General Hospital. Among these patients, 22 had injury to the portal vein. Seventeen portal vein injuries were secondary to gunshot wounds, 3 to stab wounds, and 2 to blunt trauma. Associated injuries to the inferior vena cava, pancreas, liver and bile ducts were common. Three patients had associated abdominal aortic injuries, two with acute aorto-caval fistulae. Nine patients died from from failure to control hemorrhage. Eleven were long-term survivors, including two who required pancreataico-duodenectomy as well as portal venorrhaphy. Late complications were rare. The operative approach to patients with traumatic injuries to multiple organs in the upper abdomen, including the portal vein, requires aggressive management and predetermined sequential methods of repair. In spite of innumerable associated injuries, portal vein injuries can be successfully managed in a significant number of patients using generally available surgical techniques and several adjunctive maneuvers.     

Penetrating iliac vascular injuries: recent experience with 233 consecutive patients

During a recent 11-year period, 233 consecutive patients with 358 penetrating iliac vascular injuries were treated at our institution. Injuries of the common and external iliac arteries were most often repaired with lateral suture (31%) although several other techniques were also employed. Lateral suture and ligation were used with nearly equal frequency in the management of venous injuries. The hospital mortality rate for the series was 28%, and 56/66 deaths (85%) were due to exsanguination or shock. One patient, initially treated with an end-to-end anastomosis of the iliac artery, died a year after discharge from a ruptured false aneurysm. Two patients treated with lateral suture of venous injuries died of pulmonary embolism. Arterial complications occurred in 15% of patients with arterial injuries and three patients required amputation. No graft infections occurred in 16 patients treated with PTFE interpositions, including four with associated colorectal injuries. Venous complications occurred in 12% of patients with venous injuries, and most were noted in those treated with ligation. Four patients treated by venous ligation developed chronic venous insufficiency. The prevention of death from exsanguination is the greatest problem in the management of patients with iliac vascular injuries. Although some late deaths and many complications may be related to the technique of vascular repair, circumstances often prohibit alternative methods. Despite two deaths from pulmonary embolism, insufficient data exist to condemn lateral suture of venous injuries.     

Portal vein injuries. Noninvasive follow-up of venorrhaphy.

The authors report their experience with 14 patients with portal vein injuries (1976-1986) treated at a level I trauma center. Seven patients (50%) survived and included six of 10 patients (60%) who had venorrhaphy and one in whom the portal vein was ligated. Associated injuries were present in all the patients (mean Abdominal Trauma Index: 39.5) and accounted for the high mortality rate. Follow-up data after repair or ligation of the portal vein seldom are reported in the literature. The authors studied all three patients who survived portal venorrhaphy since 1982 by real-time ultrasonography. Patency of the repair could be established in two patients. In the third patient postvenorrhaphy thrombosis was diagnosed by ultrasonographic examination. Sequential ultrasonographic examinations demonstrated resolution of the thrombus on anticoagulant therapy. Ultrasonography provides a noninvasive and easily reproducible method of studying the portal vein after repair.     

Management of portal vein injuries.

Injuries to the portal vein are associated with a high mortality because of a high incidence of concomitant injury to surrounding structures and refractory shock. Repair of the portal vein injury is often difficult or impossible because of massive hemorrhage. The key to successful management of a portal vein injury is rapid blood volume resuscitation and obtaining rapid and adequate exposure. The optimal exposure for repair consists of reflection of the hepatic flexure of the colon with mobilization of the root of the mesentery, pancreas, and duodenum. Lateral venorrhaphy is the preferred method of management, but in hemodynamically unstable patients, ligation of the portal vein is an acceptable method of treatment.     

Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication

PURPOSE: Epidemiologic studies of vascular injuries are usually limited to those caused by trauma. The purpose of this study was to review the management and clinical outcome in patients with operative injuries to abdominal and pelvic veins. METHODS: Clinical data and outcome in all patients with iatrogenic venous injuries during abdominal and pelvic operations between 1985 and 2002 were reviewed. RESULTS: Forty patients (21 men, 19 women; mean age, 51 years [range, 27-87 years]) sustained 44 venous injuries. Injuries occurred during general (30%), colorectal (23%), orthopedic (20%), gynecologic (15%), and other (12%) operations. Factors leading to injury included oncologic resection (65%), difficult anatomic exposure (63%), previous operation (48%), recurrent tumor (28%), and radiation therapy (20%). All patients had substantial bleeding (mean, 3985 mL; range, 500-20,000 mL). Injuries were located in the inferior vena cava (n = 6), portal vein (n = 7), renal vein (n = 1), and iliac vein (n = 30). Repair was performed with venorrhaphy (64%), end-to-end anastomosis (14%), interposition graft (20%), and vessel ligation (2%). Seven patients (18%) died of injury-related causes, including multisystem organ failure (n = 4), uncontrollable bleeding (n = 2), and pulmonary embolism (n = 1). Thirteen patients (32.5%) had major injury-related complications, including repeat exploration because of bleeding (n = 6), multisystem organ failure (n = 6), and venous thrombosis (n = 4). In two patients (5%) unilateral lower extremity edema developed, with no evidence of thrombosis. There was no late graft or venous thrombosis. Variables associated with increased risk for death were massive bleeding, acidosis, hypotension, and hypothermia (P <.05). CONCLUSION: Operative injuries of abdominal and pelvic veins occur in patients undergoing oncologic resection and those with difficult anatomic exposure, owing to previous operation, recurrent tumor, or radiation therapy. Massive blood loss, acidosis, hypotension, and hypothermia are associated with increased risk for death. Repair of venous injuries offers durable results with low incidence of graft or venous thrombosis.     

Portal venous system injuries

Traumatic injuries of the portal venous circulation occur infrequently but often pose management problems. During the past 13 years, 94 patients have been treated at the Ben Taub General Hospital for traumatic injury to the portal venous system, including 37 portal, 45 superior mesenteric, seven splenic, and nine inferior mesenteric venous injuries. Injury resulted from penetrating wounds in all but 17 patients. Associated vascular injuries were present in 80 patients. Twenty-six patients died from failure to control hemorrhage. Six deaths resulted from postoperative complications. Operative approach necessitated lateral venorrhaphy in 66 patients, ligation in 23, end-to-end anastomosis in one, saphenous vein mesocaval shunt in two, end-to-side portacaval shunt in one, and clamping and packing in five. In spite of numerous associated vascular and visceral injuries, portal venous injuries can be successfully managed utilizing generally available vascular reconstructive techniques.     

Management and outcome of traumatic aortic injuries

BACKGROUND AND AIMS: Aortic injuries are rare and associated with high early mortality challenging the surgical services both from a technical as well as organisational point of view, especially in countries with low incidence of trauma. A Finnish experience in the management of aortic injuries is reported with special emphasis on outcome after early involvement of cardiothoracic surgeons. MATERIAL AND METHODS: Retrospective analysis of hospital records identified 36 consecutive patients with aortic injuries arriving alive to the hospital during a 32-year period of 1967-98. RESULTS: Of the 19 thoracic aortic injuries, 17 (89%) were caused by blunt trauma, 8 (42%) of the patients arrived in shock, 7 (37%) died before repair could be attempted, 11 (58%) underwent repair with prosthesis and one (5%) with sutures, with an overall mortality rate of 9/19 (47%). Of the 17 patients with abdominal aortic injuries (15 penetrating), 13 (76%) arrived in shock, 3 (18%) died before repair, 13 (76%) were repaired with sutures and one (6%) with prosthesis, with an overall mortality rate of 8/17 (47%). Fourteen (82%) of the 17 non-survivors died within 24 hours from the injury, 13 from exsanguination and one from associated brain injury. CONCLUSIONS: Abdominal aortic injuries are usually penetrating, diagnosed intraoperatively and amenable to suture repair with good results indicating that stable and unstable patients with potential aortic injuries after penetrating abdominal trauma can safely be managed in hospitals with experienced general surgeons on call. In contrast, stable patients with suspected thoracic aortic injuries could benefit from early transfer to a hospital with cardiothoracic surgical facilities and personnel.     

Retrohepatic vein injuries: experience with 20 cases

The mortality for injury of the retrohepatic veins is reported to vary from 50 to 100%. The use of hepatic bypass techniques, introduced in the 1960's, has not significantly decreased this mortality. We reviewed our experience with liver injuries over a 5-year period from 1982 to 1987 to determine our results with these particular injuries. Twenty patients had retrohepatic vein injuries. There were 11 patients with penetrating trauma and nine with blunt trauma. A total of 15 patients died, for a mortality rate of 75%. Fourteen patients died intraoperatively from exsanguination and one postoperatively from sepsis. A shunt was used in an attempt to bypass the injury in ten patients, with nine deaths. In the ten remaining patients who were not shunted, there were six deaths. Thus, in ten shunted patients the mortality was 90% and in ten non-shunted patients, 60%. Our review supports other studies reporting a lower mortality by direct exposure and repair of retrohepatic vein injuries. Although total vascular occlusion of the liver may not be well tolerated in hypotensive patients, rapid application of the above approach resulted in better patient survival than the use of shunts.     

Hepatic venous injury after blunt abdominal trauma

Data on 306 liver injuries were collected prospectively during a 10-year period. Of the 306 injuries, 281 were the result of blunt trauma. Major hepatic venous injuries were encountered in 41 of 306 patients (13%). Blunt trauma was responsible for 39 of the 41 venous injuries. Twenty-five (61%) of these patients died compared with an overall mortality rate of 31% (chi 2; p less than 0.001). Twenty-two of the 25 deaths were caused by blood loss. Two patterns of hepatic venous injury appeared to predominate: avulsion of the trunk of the right hepatic vein from the inferior vena cava and avulsion of the upper branch of the right hepatic vein. The trunk injury was seen in 15 patients, 12 of whom died. The branch injury was seen in 13 patients, only 4 of whom died (Fisher's exact test; p = 0.006). In what appears to be the largest series of blunt hepatic venous injuries published, the injuries have been classified according to the anatomic site of the injury. Such a classification correlates with prognosis. Differences between blunt and penetrating hepatic venous trauma have been discussed.     

Delayed evaluation of combat-related penetrating neck trauma

OBJECTIVE: The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States. METHOD: From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed. RESULTS: Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1). CONCLUSIONS: Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.     

Results with abdominal vascular trauma in the modern era.

This is a report of a 10-year experience (1989-1998) with 300 consecutive patients found to have an injury to a named abdominal vessel at the time of an exploratory laparotomy for trauma. An abdominal gunshot wound was the mechanism of injury in 78 per cent of patients, and injury to more than one named abdominal vessel was present in 42 per cent. The abdominal aorta, inferior vena cava, and external iliac artery and vein were the most commonly injured vessels. When management for the five most commonly injured arteries was grouped, exsanguination before attempts at repair occurred in 11 to 15 per cent of patients and the mean survival in the remainder was 46 per cent. When management for the five most commonly injured veins was grouped, exsanguination before attempts at repair occurred in 5 per cent of patients and the mean survival in the remainder was 64 per cent. A number of administrative and medical changes in the management of patients with abdominal trauma occurred from 1992 through 1994. Despite significantly increased Injury Severity Scores for patients treated from 1993 through 1998 as compared with those treated from 1989 through 1992 survival rates for patients with injuries to the abdominal aorta and inferior vena cava were unchanged. Survival rates for injuries to the external iliac artery and vein increased significantly. The local changes in management should be considered for prospective studies in other urban trauma centers.     

Management of transpelvic gunshot wounds

The records of 98 patients with transpelvic gunshot wounds from 1983 to 1988 were reviewed: 22 patients were admitted in shock and required aggressive resuscitation and immediate exploration, and 76 patients were normotensive and were evaluated with diagnostic peritoneal lavage, angiography, cystography, proctoscopy, CT scan, and contrast-enhanced CT enema in various combinations as indicated. Using this approach, 40 stable patients were observed without operation and discharged without complications. Fifty-eight patients were explored: 20 had both arterial and hollow viscus injuries. Thirty-nine major vascular injuries were evaluated: 27 were ligated and 12 repaired. Other injuries were colon, 27; including seven rectal perforations, multiple small bowel perforations, five bladder, one ovarian, four ureteral, three caval, three renal, and two distal aortic injuries. Colon injuries associated with vascular injuries were treated with colostomy and ligation of the vessel with extra-anatomic bypass when revascularization was required. Overall 12 patients died as a result of their injuries, a mortality of 12.2%. However, 50% of the patients who were admitted in shock died. Two external iliac artery injuries and two ureteral injuries were missed at initial operation. Penetrating trauma to the pelvis presents a serious challenge because of the complex anatomy of the region. Patients in shock have a high incidence of vascular injury and subsequent exsanguination, and associated visceral injuries may complicate their management. However, stable patients may be managed without operation, when appropriate diagnostic techniques fail to demonstrate an injury. Arterial ligation and extra-anatomic bypass should be considered for vascular injury with gross fecal contamination.     

Carotid artery injuries and their management

BACKGROUND: Major vascular injuries in the region of the neck are most frequently the result of penetrating trauma. Evaluation and management of patients with injury to Zone II of the neck remains highly controversial. Most studies involve small number of patients with a lack of standardization of the nature of the injury in reporting outcome. It is the purpose of this study to propose a grading scale for vascular injuries in the neck that would allow for more uniform reporting of such injuries. METHODS: Experimental design: A retrospective review of all patients treated for penetrating trauma to the neck was performed and the subset of patients with major vascular injuries identified. Data from this group of patients are presented. Setting: Level II urban trauma center. Patients and interventions: During the period July 1984 to June 1994, 107 patients were treated for penetrating neck trauma. Injuries to the major arteries of the neck were present in 18 of the 107 patients (16.8%). All injuries were graded on the developed scale. Management protocol was based on the grade of the injury. Grade 1 injuries were managed non-operatively with systemic anticoagulation and low molecular weight dextran. Grade 2 injuries were treated with primary repair. Injuries of Grades 3 and 4 were treated by primary repair or interposition graft. Exceptions were isolated injuries of the external carotid artery, which were treated by ligation alone. RESULTS: Of the 18 patients with carotid artery injuries, 2 had injuries of the external carotid artery, treated with ligation alone. The internal carotid artery was injured in 7 cases. An interposition saphenous vein/PTFE graft was used in all cases. In 9 cases the common carotid artery was injured. Repair was accomplished by a combination of either a primary repair or interposition graft. Overall mortality was 3/16 (16.6%). No new or worsening of neurologic deficit occurred in any patient. CONCLUSIONS: Carotid artery injuries occur in about 17% of patients with penetrating neck trauma. Data regarding management and prognosis in these patients are at best concflicting, in part, due to lack of a standardized classification system. The proposed grading scale is designed to overcome this problem.     

Superior mesenteric venous injuries: to ligate or to repair remains the question

BACKGROUND: Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL: Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS: There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS: SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.     

Outcome of Portal Injuries Following Bariatric Operations

Background: Portal vein thrombosis is rare following Roux-en-Y gastric bypass (RYGBP). Its natural history is dependent on the etiology of the thrombosis. Iatrogenic injuries at bariatric operations resulting in portal vein thrombosis are lethal complications typically necessitating a liver transplant, whereas postoperative portal vein thrombosis without an injury to the portal vein has a benign course. There are currently no data on management or prognostic factors of portal vein thrombosis after bariatric operations. Methods: 3 patients referred for liver transplantation secondary to portal vein injury following bariatric surgery between 2000 and 2003 are presented. Results: 2 super-obese (BMI ≥50 kg/m²) and 1 morbidly obese (BMI 44 kg/m²) patients sustained portal vein injuries during bariatric surgery (RYGBP 2, VBG 1) by experienced bariatric surgeons. In each case, the portal injury was identified and repaired. Thrombosis followed reconstruction in all 3 patients. All 3 underwent emergency liver transplantation, but died of sepsis and multi-organ failure following transplantation. Review of the literature found no cases of traumatic portal vein injuries following bariatric operations and 2 cases of postoperative portal vein thrombosis: 1 following LRYGBP (BMI 46) and one after a Lap-Band (BMI 41). Conclusion: Injury to the portal vein resulting from difficulty in discerning the anatomy of the intra-abdominal structures in the morbidly obese, is a lethal complication of bariatric surgery. Super-obese patients submitting to bariatic surgery should lose weight, undergo a two-stage bariatric procedure, or undergo laparoscopic RYGBP to minimize the risk of portal injury. Postoperative portal vein thrombosis has a benign course and can be managed conservatively.     

Penetrating injuries of the abdominal inferior vena cava.

This is a retrospective study of 74 patients with penetrating injuries of the abdominal inferior vena cava; the cause of injury was gunshot in 91% and stabbing in 9%. Of the patients, 77% underwent lateral venorrhaphy, 5% underwent infrarenal ligation of the inferior vena cava (IVC), and 18% died perioperatively before any caval repair could be carried out. There was an overall perioperative mortality of 39%. Persistent shock, the site of the venous injury, particularly in the retrohepatic position, and the number of associated vascular injuries were directly related to mortality. Irrespective of the improvements in resuscitation and the various operative methods available, penetrating trauma of the abdominal IVC remains a life-threatening injury.     

Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries

PURPOSE: Nonoperative treatment of serious renal injuries has been advocated and yet to our knowledge the optimum level of operative treatment has not been established to date. We report a unique data set, in which patients with severe renal injuries were treated with an ultraconservative nonoperative approach during a period when urological consultation was not available at a major urban trauma center. MATERIALS AND METHODS: We retrospectively reviewed the charts of 51 patients identified with renal trauma in the Detroit Receiving Hospital trauma data base from 1997 to 2001. RESULTS: Injuries were grades I to V in 15, 7, 11, 14 and 4 cases, respectively, and had a tendency toward serious injury. Renorrhaphy was never performed. Nephrectomy was done sparingly, only for grade V renal injuries and only in patients who were exsanguinating from the kidney. Two of the 4 patients with grade V injury died of multiple injuries, including massive head injuries. Only 2 of the patients treated nonoperatively (4%) had complications, including fever and hematuria in 1 each. CONCLUSIONS: This data set seems to support an ultraconservative approach of limiting renal surgery to only patients with active exsanguination. The nephrectomy rate for 14 grade IV injuries, including some gunshot wounds to the kidney, was 0%. When comparing this rate with that in the literature, we would expect it to be 1 patient to as high as 10. This approach was safe and resulted in a low complication rate of 4%. Series in which more aggressive therapy for renal injuries is advocated should compare favorably to ultraconservative therapy if aggressive therapy is to continue to be widely advocated.