Selective Conservatism in Trauma Management: A South African Contribution

Trauma in South Africa has been termed the malignant epidemic. This heritage was the result of a violent colonial legacy which spawned the apartheid system of injustice and the struggle against it The Apartheid regime created overcrowding, unemployment, social stagnation, and the disruption of normal family life. These were the catalysts for the incredible amount of criminal and interpersonal conflict in South Africa over the last 50 years. African townships such as Soweto in Johannesburg and Umlazi in Durban were crime-ridden ghettoes where the apartheid police were more interested in fueling the "black on black" violence rather than trying to curb it. Baragwanath (Chris Hani-Baragwanath) and King Edward the VIII Hospital in Durban were the "trauma care epicenters" on the fringes of these huge urban conurbations. Both were designated black hospitals and both were underfunded and dilapidated. Even the architecture was similar, with prefabricated, poorly ventilated structures serving as wards and clinics in both institutions. Trauma volumes consisted of between 10 and 20 laparotomies on weekend nights at the height of political unrest. This led to vast individual experience in several areas of trauma typified by Demetriades' experience with 70 penetrating cardiac injuries. In this setting of limited resources and an overwhelming volume of trauma, selective conservatism as a surgical philosophy took root and has profoundly influenced the way the world manages trauma. We detail and illustrate the evolution of this approach and its continued application.     

The spectrum of injuries resulting from abdominal stab wounds with isolated omental evisceration: A South African experience

Introduction

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature in the specific setting of isolated omental evisceration is limited.

Traumatic injuries to the biliary system in children

• 1.1. Blunt abdominal trauma is an increasing problem.
• 2.2. Biliary tract injury due to blunt trauma is rare but does occur at any point in the biliary tree.
• 3.3. There is often long delay in diagnosis and treatment due to the indolent nature of bile peritonitis.
• 4.4. Facilities for operative cholangiography should be available in exploration for blunt trauma.
• 5.5. The site of injury must be identified and repair improvised to suit each case.
• 6.6. Diagnosis and treatment usually result in recovery.

     

Treatment outcomes associated with surgery for gallbladder cancer: A 20-year experience

The aim of this study was to evaluate contemporary outcomes associated with the management of gallbladder cancer. The medical records of 48 consecutive patients with gallbladder cancer treated at our institution from January 1981 through November 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method (mean follow-up period 24 months) and the log-rank test. Prognostic factors were analyzed using Cox regression. Mean patient age was 68 years. Sixty percent of patients were female. Thirty-nine patients (81%) underwent laparotomy or laparoscopy. Eighteen patients (38%) underwent complete resection (10 simple cholecystectomies and 8 radical cholecystectomies). There were no procedure-related deaths. The overall 5-year survival rate was 13%. Patients who underwent complete resection had a higher 5-year survival rate (31%) than patients who underwent palliative surgery or no surgery (0%; P < 0.05). For patients who underwent radical cholecystectomy, the 5-year survival rate was 60%. For the 18 patients who underwent curative resection, positive lymph node metastasis and patient age over 65 were factors predictive of significantly worse survival. Overall survival rates for patients with gallbladder cancer remain poor. Although radical surgery can be performed safely, it is associated with long-term survival only in a highly select subset of patients with gallbladder cancer. Presented at the Fourth Americas Hepato-Pancreato-Biliary Association Congress, Miami Beach, Florida, February 27–March 2, 2003.     

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

Introduction

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited.

Methods

We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa.

Results

Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19).

Conclusions

The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.     

Ballistic arterial trauma to the lower extremity: recent South African experience

The aim of this study was to determine the current outcome of gunshots to the arteries of the lower extremity. The authors conducted a retrospective analysis of 104 patients with gunshots to the femoral (n=71) and popliteal (n=33) artery. One hundred four patients presented over the 60-month period. Ninety-six (92%) were male and eight of 104 female. Ninety-nine were gunshot injuries, five from shotguns. Nine patients had injury to the common femoral artery, 62 patients had injury to the superficial femoral artery, and 33 had popliteal artery injury. One patient died in the emergency room and another died in the postoperative period, giving an overall in-hospital mortality of two of 104 (1.9%). Forty-three of 70 femoral reconstructions had completion angiograms compared with 20 of 32 popliteal artery reconstructions (P=1). Nineteen of 63 (30%) of the completion angiograms prompted revision of the reconstruction. Of the 63 patients who had completion angiograms, two of 63 (3%) required amputation. Seven of 39 (18%) patients who did not have completion angiograms required amputation (P = 0.025). Including the primary amputation, there were 10 amputations in the 103 patients (9.7%) who survived to undergo operation. Ballistic arterial trauma of the lower limb leads to significant disability. Completion arteriography leads to revision of the reconstruction in nearly one-third of instances and significantly reduces amputation rate.     

Severe hepatic trauma: a multi-center experience with 1,335 liver injuries

The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical experience of biliary tract carcinoma associated with anomalous union of the pancreaticobiliary ductal system

Between 1978 and 1988, 15 patients with gallbladder cancer and 2 patients with bile duct cancer were seen among 49 patients with anomalous union of the pancreaticobiliary ductal system. Radiographic findings revealed two types of this anomalous condition: one in which the pancreatic duct entered the common bile duct(type 1) and one in which the common bile duct entered the pancreatic duct (type 2). In gallbladder cancer, the common bile duct presented no dilatation, or in some patients, mild dilatation, and type-1 anomalous union was frequently found among these patients. In contrast, the two patients with bile duct cancer had cystic dilatation of the common bile duct and type-2 anomalous union. The bile amylase level, which was determined in seven patients, was extremely high in all the patients. Histopathologically, the tumors in most patients showed papillary to papillo-tubular proliferation in the mucosal layer while atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that this congenital anomaly in both ducts results in a loss of the normal sphincteric mechanism of the doudenal papilla, and that chronic relapsing cholecystitis or cholangitis, caused by the reflux of pancreatic juice into the biliary tract, can induced progressive changes to atypical epithelial hyperplasia which may develop into carcinoma.     

Clinical experience of biliary tract carcinoma associated with anomalous union of the pancreaticobiliary ductal system

Between 1978 and 1988, 15 patients with gallbladder cancer and 2 patients with bile duct cancer were seen among 49 patients with anomalous union of the pancreaticobiliary ductal system. Radiographic findings revealed two types of this anomalous condition: one in which the pancreatic duct entered the common bile duct (type 1) and one in which the common bile duct entered the pancreatic duct (type 2). In gallbladder cancer, the common bile duct presented no dilatation, or in some patients, mild dilatation, and type-1 anomalous union was frequently found among these patients. In contrast, the two patients with bile duct cancer had cystic dilatation of the common bile duct and type-2 anomalous union. The bile amylase level, which was determined in seven patients, was extremely high in all the patients. Histopathologically, the tumors in most patients showed papillary to papillo-tubular proliferation in the mucosal layer while atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that this congenital anomaly in both ducts results in a loss of the normal sphincteric mechanism of the duodenal papilla, and that chronic relapsing cholecystitis or cholangitis, caused by the reflux of pancreatic juice into the biliary tract, can induced progressive changes to atypical epithelial hyperplasia which may develop into carcinoma.     

Carcinogenesis in the biliary system associated with APDJ

Anomalous pancreaticobiliary ductal junction (APDJ) is a rare congenital anomaly which is considered to be an etiological factor in the development of carcinoma of the biliary tract. It is generally accepted that pancreatic juice reflux into the biliary tract due to APDJ is one of the etiologies of biliary tract cancers. Refluxing pancreatic juice results in changes of bile and induces chronic inflammation and increased cellular proliferation, leading to epithelial hyperplasia, metaplasia, and carcinoma of the biliary tract. K-ras mutations are more prevalent in the carcinomas of biliary tract associated with APDJ compared with those without APDJ. There is no difference in the overexpression of p53 between biliary tract carcinomas associated with APDJ and those unassociated with APDJ. Further studies are needed to evaluate the role of cytokines and growth factors in carcinogenesis of the biliary system associated with APDJ. Received for publication on Feb. 15, 1999; accepted on March 29, 1999     

Congenital duplication of the gallbladder associated with an anomalous right hepatic artery

A case report describing the incidental finding of a double gallbladder associated with an anomalous anteriorly displaced right hepatic artery has been presented. The literature has also been reviewed and the appropriate surgical intervention for supranumerary gallbladder suggested.     

The predictive criteria of lithiasis of the main biliary tract associated with gallbladder lithiasis

Before the laparoscopic era, detection of CBD stones in patients with lithiasis of the gallbladder has been made, preferably, by intraoperative cholangiography. Development of laparoscopy gives the necessity of a preoperative detection of CBD stones, especially when a previous endoscopic treatment is preferred. Tenon's multifactorial score, in the Author's opinion, is able to detect patients "at risk" for CBD stones. This score includes the following parameters: age, CBD diameter, size of gallstones, colic pain and cholecystitis. The chance of CBD stones was 2% for a score lower than 3.5 and 81% for a score greater than 5.9. In this way, patients with high probability of CBD stones can be submitted to a preoperative ERCP or to a intraoperative cholangiography, according to the choices of the surgeon.     

Anomalies of extrahepatic biliary duct and gallbladder associated with intestinal malrotation: a case report

Knowledge of congenital anomalies in abdominal viscera is important for surgeons, if they are to treat such patients and solve their problems adequately. This article presents an unusual case of reversed rotation of the intestine associated with anomalies in the biliary tract and gallbladder. This patient underwent surgery because of a bleeding duodenal ulcer. During surgery the following viscera positions were detected: the gallbladder was located to the left of the round ligament, the choledochus was in front of the first portion of the duodenum, the small intestine was in the left portion of the abdomen, and the colon was exclusively at the right side of the abdomen. This reversed rotation is a rare condition, only occasionally reported in the literature. However, the simultaneous association with anomalies in the gallbladder position (in the left lobe) and the biliary tract (the choledochus located in front of the duodenum) makes this a case unlike any other described in the medical literature.     

Laparotomy for organ evisceration from abdominal stab wounds: A South African experience

Introduction

Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited.

Jejunal varices with extra hepatic portal vein obstruction: A case report

Introduction and importanceExtrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare.Presentation of caseWe report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices.DiscussionPortal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices.ConclusionJejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.