Penetrating Colon Injury: Experience of a Single Centre

Objective: Penetrating colonic injuries are amongst the most discussed intra-abdominal injuries because of the complexity of their management and the severe complications. Penetrating colonic injuries can be managed by either primary repair or diversion. There is a debate over which procedure has to be used under which circumstances. In this retrospective study we analyzed our experience to contribute to the answer.

Patients and methods: The records of patients with penetrating colonic injury between January 1995 and December 2006 at the General Surgery Department of Atatürk University School of Medicine, were reviewed retrospectively. Results: One hundred and forty-one patients were included in the study. Ten patients did not need any surgical treatment. Seventy-nine patients (56%) were treated without formation of a stoma and fifty-two patients (36.8%) with formation of a stoma. The overall complication rate was 50.3% (71 patients). The rate of septic complications was 33.3%.

Conclusion: There is an ongoing debate whether formation of a stoma is indicated in penetrating colonic injury or not. Our clinical experience showed that severe faecal contamination, shock at presentation, and high CIS grades are associated with increased postoperative complications and mortality. Therefore the treatment of penetrating colonic injury in the presence of these risk factors should be stoma formation rather than primary repair.     

Penetrating Cardiac Injuries: Recent Experience in South Africa

Background Penetrating cardiac injury is a dramatic and lethal form of trauma. The majority of patients will die before reaching medical care, but for those who arrive at hospital alive, the diagnostic acumen and rapid surgical intervention of physicians and surgeons can lead to successful outcomes. Materials and Methods A structured diagnostic and management approach is used in our trauma unit to deal with penetrating cardiac injury. A retrospective study of 117 patients with penetrating trauma to the heart was conducted over 32 months; the purpose of this study was to describe our protocol and review overall outcome with this type of injury. Demographic details, mechanism of injury, and mode of presentation were recorded. Mortality and morbidity data were collated and echocardiographic follow-up was performed. Results There were 109 male patients, mean age 29 years (range: 15–54 years) and 8 female patients, mean age 35 years (range: 23–56 years). Most patients (96/117) had sustained stab wounds, and the associated mortality was 15.6%. Twenty-one patients had sustained gunshot wounds (GSW), with a mortality of 81%. Gunshot wounds were significantly more likely to result in death (P ≤ 0.0001). Five patients sustained multiple cardiac wounds, and three of them died. The risk of death was not different between patients sustaining single or multiple cardiac wounds (P = 0.11). Eleven patients had thoracoabdominal injury, and 3/11 (27%) died; all of those that died had sustained GSW. The risk of death was not different between patients sustaining thoracoabdominal wounds and those with isolated thoracic injury (P = 1.0). Among the 51 patients with stab wounds who presented with cardiac tamponade, the mortality was only 8%. Compared to the other patients with stab wounds, cardiac tamponade conferred a significant survival advantage (P = 0.02). Conclusions A high index of suspicion for penetrating cardiac injury and an understanding of the modes of presentation can lead to rapid diagnosis even by inexperienced junior staff. Such a structured approach to patients with penetrating trauma to the chest leads to early definitive management and acceptable results.     

Aortoiliac Steno-Occlusion in Young Women: a Single Center Experience and Review of the Literature

Peripheral obliterating arterial disease characterized by aortoiliac steno-occlusion occurring in relatively young women of small stature, is frequently reported in the literature under the name small aorta syndrome. Although it remains unclear whether small aorta syndrome represents a separate entity, the small size of the distal aorta increases risk for aortoiliac occlusive disease. Patients usually present with lower extremity claudication and typical risk factors. This paper shows an analysis of the literature focusing on the pathogenesis, clinical features, risk factors and treatment, as well as a single center experience with this disorder.     

Surgical Treatment of Metastatic Tumors to the Pancreas: A Single Center Experience and Review of the Literature

Background Unlike primary pancreatic carcinoma, metastases to the pancreas are rare, and their resection may be performed as palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases. Materials and Methods Between January 1994 and December 2004 13 patients (nine women and four men; median age: 59 years; range: 36–79 years) were admitted to our institution with metastatic lesion to the pancreas. The clinical features of the treatment and results were examined. Results Primary tumors were renal cell carcinoma (n = 5), lobular carcinoma of the breast (n = 3), endometrioid carcinoma of the ovary (n = 1), colonic adenocarcinoma (n = 1), jejunal leiomyosarcoma (n = 1), melanoma (n = 1), and non-small-cell lung cancer (n = 1). The median interval between primary tumor and pancreatic metastases was 36 months (range: 5–192 months). Six patients (46%) were asymptomatic, while the other seven patients presented with jaundice, pain, and duodenal obstruction. Two patients with extrapancreatic disease underwent palliative surgery, and the remaining 11 patients underwent operative procedures that included seven pancreaticoduodenectomy and four distal pancreatectomies with splenectomy. Postoperative mortality was nil, and the morbidity rate was 30%. The two patients who underwent palliative surgery died after 7 and 9 months, respectively. The median survival of the resected patients was 26 months (range: 13–95 months). Five patients died of disease, eight are alive at the time of this report. Conclusion A trend towards improved survival, even if not statistically significant, was observed in the renal carcinoma patients reported here. Surgical resection can be performed safely in selected patients with isolated metastases to the pancreas, achieving long-term survival as well as good palliation.     

Hepatic Resection in Liver Transplant Recipients: Single Center Experience and Review of the Literature

Biliary complications such as ischemic (type) biliary lesions frequently develop following liver transplantation, requiring costly medical and endoscopic treatment. If conservative approaches fail, re-transplantation is most often an inevitable sequel. Because of an increasing donor organ shortage and unfavorable outcomes in hepatic re-transplantation, efforts to prolong graft survival become of particular interest. From a series of 1685 liver transplants, we herein report on three patients who underwent partial hepatic graft resection for (ischemic type) biliary lesions. In all cases, left hepatectomy (Couinaud's segments II, III and IV) was performed without Pringle maneuver or mobilization of the right liver. All patients fully recovered postoperatively, but biliary leakage required surgical revision twice in one patient. At last follow-up, two patients presented alive and well. The other patient with persistent hepatic artery thrombosis (HAT), however, demonstrated progression of disease in the right liver remnant and required re-transplantation 13 months after hepatic graft resection. Including our own patients, review of the literature identified 24 adult patients who underwent hepatic graft resection. In conclusion, partial graft hepatectomy can be considered a safe and beneficial procedure in selected liver transplant recipients with anatomical limited biliary injury, thereby, preserving scarce donor organs.     

Management of Hypoglossal Schwannomas: Single Institutional Experience of 14 Cases

Background Hypoglossal schwannomas are rare intracranial neoplasms. Microsurgical resection with the goal of cure is the aim of management but is associated with a high rate of postoperative morbidity. Objective The objective of the study was to outline the clinical presentation, radiologic characteristics, surgical techniques, postoperative morbidity, and long-term follow-up results for hypoglossal schwannomas. Methods Patients treated for hypoglossal schwannoma at the Department of Neurosurgery of a tertiary-level referral institution from January 2001 until December 2010 were analyzed retrospectively using hospital records. Results There were 14 patients who were treated in the study period. Tongue atrophy and swallowing difficulties were the most common presenting symptoms. Surgery done in 12 patients using a variety of approaches (retromastoid retrosigmoid suboccipital in 9, midline suboccipital in 2, and far lateral in 1). Five patients having small residual tumors received gamma knife (GK) subsequently. two patients received primary GK stereotactic radiosurgery. Three patients had permanent morbidity in the form of cranial nerve paresis. Immediate postoperative complications like cerebrospinal fluid leak and pneumonia were present in three patients. Conclusion Complete microsurgical resection is often associated with a high rate of morbidity. Subtotal and near-total resection followed by stereotactic radiosurgery or observation now offers an alternative approach.     

Biological Implant for Complex Abdominal Wall Reconstruction: A Single Institution Experience and Review of Literature

Aim

To present our single institution and surgeon’s complex abdominal wall reconstructions (CAWR) experience with Permacol? mesh through a non-randomized study.

Patients and method

Data of 51 consecutive patients were prospectively collected between 2003 and 2015. Patients had a median of 3 comorbidities (range 0–10) and 68% were Center for Disease Control class II–IV. The mean previous repair was 1.3 (range, 0–12), and 25 (44%) had a mesh in situ. The median defect size was 625 cm².

Results

Among the 56 CAWR procedures, in 16 (29%) bowel resection/anastomosis was performed. The overall post-operative complication rate was 45%, and it was wound-related except from 1 patient dead for myocardial infarction. One was lost at follow-up. Five were re-operated for recurrence with a second Permacol mesh, leading to 14 (26%) overall recurrences at a mean follow-up of 44 months (range, 4–123). In 33 (59%) cases, fascial closure was achieved. The mesh placement was intraperitoneal in 89%, retro-muscular in 9% and supra-fascial in 1% of cases. A multivariate analysis showed that predictor risk for recurrence was more than 3 previous repairs, wound class III–IV, whereas age, type of comorbidities, defect size and fascial closure did not influence the recurrence. Median post-operative performance status was 0 (range; 0–3). A satisfaction questionnaire was obtained in 43 patients, and 86% of them were satisfied with the outcome.

Conclusions

Biological materials have the potential to reduce morbidity and improve outcome of definitive repair of CAWR.

     

Pancreatic VIPomas: Subject Review and One Institutional Experience

VIPomas are rare pancreatic endocrine tumors associated with a well-defined clinical syndrome characterized by watery diarrhea, hypokalemia, and metabolic acidosis. The objective of this study was to review a single institution’s experience with VIPomas, as well as to review the English literature. A retrospective review of the Johns Hopkins pancreatic database revealed four cases of VIPoma, with three patients being male. All patients presented with watery diarrhea, hypokalemia, hypercalcemia, and acidosis. All patients had no family history of multiple endocrine neoplasia. Computed tomography revealed the primary pancreatic tumor in all patients, with three tumors located in the tail of the pancreas. One tumor involved the entire pancreas. Computed tomography and/or octreotide radionuclide scans identified hepatic metastasis in three patients. Mean serum vasoactive intestinal polypeptide levels were 683 pg/ml (range 293 to 1,500 pg/ml). All patients underwent resection of the pancreatic primary tumor. Two patients also had simultaneous liver resections. All patients had evidence of malignancy as defined by the presence of metastatic lymph nodes and/or hepatic metastases. Two patients had complete resolution of symptoms after surgical resection. One patient required radioablation of liver metastases and adjuvant octreotide therapy for control of symptoms. One patient died of progressive metastatic disease 96 months after surgery, whereas the other three remain alive. Extended, meaningful survival can be achieved for VIPoma patients, combining an aggressive surgical approach with additional strategies for treatment of unresected disease.     

Management of Blunt and Penetrating Injuries to the Porta Hepatis

Injuries to the porta hepatis pose difficult problems in management, and transection of the bile ducts, portal vein and hepatic artery is among the most challenging. Twenty-one patients with severe injuries to the porta hepatis were treated over a ten-year period. Ages ranged from 13 to 56 years, and follow-up was up to nine years. Among the 14 patients with bile duct injury, eight were found to have complete transection, and five suffered a tangential laceration or incomplete disruption with a portion of a duct wall remaining intact. Five of the eight patients who had complete transection underwent primary end-to-end repair with T-tube splinting, while three were treated with primary Roux-en-Y choledocojejunostomy. All patients with incomplete disruption underwent primary repair with or without T-tube splinting. Of the five patients with complete disruption who were treated with primary end-to-end anastomosis of the bile duct in conjunction with T-tube splinting, all required secondary biliary tract reconstruction of some type. No patient with complete transection that was treated with primary Roux-en-Y biliary enteric anastomosis required reoperation. Partial transections were successfully treated with primary repair. Portal vein injury was encountered in ten patients. Injury was successfully managed by primary closure, interposition of a vein, or splenicmesenteric vein bypass. Associated injuries to liver, pancreas, kidney and duodenum were common. In four patients there was injury to the main or left or right hepatic artery which was managed successfully by repair or ligation, with or without hepatic lobectomy. By adhering to the principles of management to be outlined, many patients with injury to the porta hepatis will survive, and the long term outcome can be gratifying.     

Analysis of 203 Patients with Penetrating Neck Injuries

Background  Selective nonoperative management (SNOM) of penetrating neck injuries (PNI) has steadily gained favor, but indications for surgery and adjunctive diagnostic studies remain debated. The purpose of the present study is to validate a protocol of SNOM of PNI based on physical examination, which further dictates complementary investigations and management. Patients and methods  A prospective observational study was conducted in a South African tertiary urban trauma center with a high prevalence of penetrating trauma. All consecutive patients admitted with penetrating neck injuries over a 13-month period were included. Results  A total of 203 patients were included in the study: 159 with stab wounds and 42 with gunshot wounds. A vascular injury was identified in 27 (13.3%) patients, pharyngoesophageal injury in 18 (8.9%) patients, and an upper airway injury in 8 (3.9%) patients. Only 25 (12.3%) patients required surgical intervention. A further 8 (3.9%) patients had therapeutic endovascular procedures. The remaining 158 (77.8%) patients, either asymptomatic or with negative work-up, were managed expectantly. There were no clinically relevant missed injuries. Conclusions  Selective nonoperative management of neck injuries based on clinical examination and selective use of adjunctive investigational studies is safe in a high-volume trauma center.