Gunshot wounds to the scrotum: a large single-institutional 20-year experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Penetrating trauma to the scrotum often requires operative intervention, with testicular salvage only possible when enough testicular tissue can be re‐approximated in the traumatic setting. The present report represents the largest series of gunshot wound trauma to the scrotum in the literature. Further, it validates recommendations of the European Association of Urology guidelines on urological trauma that advocate operative intervention due to minimal rates of patient morbidity and the inherent limitations of scrotal ultrasonography in discerning testicular compromise.

OBJECTIVE

• ? To report our 20‐year experience of gunshot wounds (GSWs) to the scrotum and outline the management of this traumatic injury.

PATIENTS AND METHODS

• ? We queried our institutional database for patients presenting with GSWs to the scrotum between 1985 and 2006.
• ? All patients underwent the standard trauma evaluation upon presentation, including physical examination of the external genitalia. Management was dictated by the presence or absence of a penetrating injury to the scrotum and associated traumatic injuries.
• ? Nonoperative and operative management of traumatic injury to the scrotum were used. Testicular salvage was performed when anatomically feasible. If testicular salvage was not feasible, an orchiectomy was performed.

RESULTS

• ? Scrotal exploration was performed in 91 (94%) patients while six (6%) patients were treated nonoperatively.
• ? Testicular injury was found in 44 (48%) patients undergoing exploration, six (7%) of whom had bilateral testicular injuries, which gave a total of 50 injured testicles.
• ? Of the injured testicles, 24 (48%) could not be salvaged and required orchiectomy, while 26 (52%) were debrided and repaired.
• ? The most common associated genitourinary (GU) injuries were to the corpora cavernosum (n= 20 [21%]) and urethra (n= 10 [10%]). Soft tissue injury of the extremities occurred in 54 patients (56%), representing the most common non‐GU‐associated injury.
• ? Postoperative complications occurred infrequently: one patient (1%) returned for abscess drainage and one (1%) for haematoma evacuation.

CONCLUSIONS

• ? The present report confirms that any patient with a penetrating injury to the scrotum should undergo immediate scrotal exploration.
• ? A low clinical suspicion for performing additional studies to rule out associated urethral and/or penile injury is clinically warranted.
• ? Testicular loss occurs in ≈50% of injured testicles.

     

Cerebral gunshot wounds: a score based on three clinical parameters to predict the risk of early mortality

Background: To provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (GSW) based on three clinical parameters. Methods: All patients admitted to Baragwanath Hospital, Johannesburg, South Africa, between October 2000 and May 2005 for an isolated single craniocerebral GSW were retrospectively evaluated for the documentation of (i) blood pressure (BP) on admission; (ii) inspection of the bullet entry and exit site; and (iii) initial consciousness (n= 214). Results: Conscious GSW victims had an early mortality risk of 8.3%, unconscious patients a more than fourfold higher risk (39.2%). Patients with a systolic BP between 100 and 199 mm Hg had an 18.2% risk of mortality. Hypotension (<100 mm Hg) doubled this risk (37.7%) and severe hypertension (≥200 mm Hg) was associated with an even higher mortality rate of 57.1%. Patients without brain spilling out of the wound (‘non‐oozer’) exhibited a mortality of 19.7%, whereas it was twice as high (43.3%) in patients with brain spill (‘oozer’). By logistic regression, a prognostic index for each variant of the evaluated parameters could be established: non‐oozer:0, oozer:1, conscious:0, unconscious:2, 100 ≤RR_sys < 200 mm Hg:0, RR_sys < 100 mm Hg:1, RR_sys≥ 200 mm Hg:2. This resulted in a score (0–5) by which the individual risk of early mortality after GSW can be anticipated. Conclusions: Three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral GSW was established.     

The early prognosis of craniocerebral gunshot wounds in civilian practice as an aid to the choice of treatment

Summary The authors report a series of 56 cases of craniocerebral lesions secondary to missile injuries studied by means of CT scan. CT scans demonstrate the track of the missile, destruction of deep cerebral parenchyma, dissection of the white matter (intracerebral air) and reactive oedema. The prognostic incidence of CT is discussed. The CT scan helps to choose the best therapeutic management with respect to each particular case.     

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).     

Gunshot wounds of the colon: A review of 100 consecutive patients,with emphasis on complications and their causes

The cases of one hundred civilian patients with gunshot wounds of the colon treated at the Louisville General Hospital have been reviewed. Most injuries were in the transverse colon (44 per cent), followed by the ascending colon (27 per cent), rectosigmoid (19 per cent), and descending colon (10 per cent). Associated injuries occurred in 81 per cent of the patients; the small bowel was the most common structure injured.Primary closure was used in 52 per cent of the patients, with a resultant 19 per cent rate of wound infection and 14 per cent rate of serious complication. When the extent of contamination or tissue destruction required resection, an attempted primary anastomosis was followed by a high rate of wound infection (57 per cent) and serious complications (36 per cent) as compared with end-colostomy and mucous fistula, which resulted in a 24 per cent rate of wound infection and 24 per cent rate of serious complication. The rate of wound infection between these groups is significant (p = 0.05). Results with end-colostomy and mucous fistula were better than with attempted primary anastomosis.Primary closure of missile injuries of the colon is feasible but should not be attempted in the presence of gross fecal peritonitis or massive tissue destruction. If resection is undertaken, end-colostomy (or ileostomy) and distal mucous fistula should be performed in the presence of intra-abdominal contamination to reduce the incidence of postoperative wound infection and serious complications. Delayed primary closure should also reduce the rate of wound infection in these patients.     

Civilian abdominal gunshot wounds in Durban, South Africa: a prospective study of 78 cases

INTRODUCTION

Violence has become part and parcel of the daily routine of living in South Africa. This prospective study of 78 patients who sustained abdominal gunshot wounds was undertaken to evaluate the pattern of injuries, treatment outcome and the role of selective conservative management.

PATIENTS AND METHODS

All patients with abdominal gunshot wounds admitted into the accident and emergency department of Prince Mshyeni Memorial Hospital (PMMH) between January 2005 and June 2005 were included in this prospective study. Case notes were reviewed and data entered on a standard proforma by a single observer (IC).

RESULTS

A total of 78 patients who sustained abdominal gunshot wounds were included in the study. There were 68 males and 10 females with an age range of 16–60 years (median age, 25 years). Of these, 59 (76%) underwent emergency laparotomy and 19 (24%) were initially observed. Two patients in the observed group needed a delayed laparotomy, both with positive findings. Fifty-five (71%) patients had one entrance wound each and 23 (29%) had multiple entrance wounds. Forty-one (53%) patients had exit wounds and in 37 (47%) the bullet remained lodged in the body. The entrance wounds were in anterior abdominal wall in 50 patients, posterior trunk in 13, gluteal region in 11 and thorax in 4 patients, respectively. Twelve patients died, all from the emergency laparotomy group. There were two negative laparotomies from the laparotomy group.

CONCLUSIONS

Management of gunshot wounds is expensive and requires a variety of surgical skills. We recommend that a national database to which all gunshot wounds must be reported is required in order to assess the magnitude of the problem nationally as well as funding of research in injury control. This study along with many others shows that selective conservative management is feasible without the use of expensive investigations.     

Evaluation of risk factors in the development of postoperative complications in patients undergoing liver resection for cancer

A consecutive series of 134 hepatic resections for primary and metastatic cancer were analyzed to identify the risk factors for post-operative complications in patients with and without impaired liver reserve. Between January 1992 and January 2000 were performed 55 hepatectomies (41%--group 1) in 54 cirrhotic patients for hepatocarcinoma and 79 hepatic resections (59%--group 2) in 66 patients for primary hepatic malignancies or metastatic liver tumours in non cirrhotic liver. Among major postoperative complications bile leakage was recorded in 8 patients (6%) (6% with impaired liver reserve and 6% with normal reserve), hepatic failure in 8 patients (6%) (9% vs 4%; P = NS), ascites in 7 patients (5%) (11% vs 1%; P = 0.01), pneumonia in 4 patients (3%) (5% vs 1%; P = NS), intra-abdominal abscess in 2 patients (1%) (2% vs 1%; P = NS), postoperative haemorrhage in 2 patients (1%) (4% vs 0; P = NS), and gastrointestinal bleeding in 2 patients (1%) (4% vs 0; P = NS). There were 6 perioperative deaths (4%) (7% vs 2%; P = NS). The mean hospital stay was 21 +/- 10 days (range: 5-57) (24 +/- 10 vs 20 +/- 10; P = 0.02). Liver resection is a safe procedure even in cirrhotic patients providing they are well selected and there is minimal intraoperative blood loss.     

The risk factors and clinical significance of acute postoperative complications after unstented pediatric pyeloplasty: A single surgeon’s experience

Purpose

To analyze the risk factors and clinical significance of postoperative complications after unstented pediatric pyeloplasty.

Materials and Methods

We analyzed 285 kidney units (KUs) on which unstented pyeloplasty was performed between April 2002 and March 2010. Measures included preoperative factors, postoperative complications, change in postoperative differential renal function (DRF), and failure of pyeloplasty. Risk factors for acute complications requiring additional ureteral stenting and decreased DRF were analyzed.

Results

During a median follow-up period of 67.0 months, an additional ureteral stenting was required in 28 KUs (9.8%) due to the development of acute postoperative complications after unstented pyeloplasty. The incidence of complications increased significantly as preoperative DRF increased. DRF of more than 60% was the only independent risk factor for acute complications. Postoperative decrease in DRF was observed in 58 KUs (22.4%) among 259 KUs analyzed. Pyeloplasty failure was observed in 10 KUs (3.5%). The development of acute complications was not a risk factor for a decrease in DRF or pyeloplasty failure.

Conclusions

Urinary diversion during pyeloplasty is not related to a decrease in DRF or pyeloplasty failure. However, in patients with a preoperative DRF of greater than 60%, diversion could be considered due to the high prevalence of complications.     

The influence of the risk factor on the abdominal complications in colon injury management

Introduction

The management of colon injuries has distinctly evolved over the last three decades. However, trauma surgeons often find themselves in a dilemma, whether to perform a diversion or to perform a primary repair. The purpose of this study is to evaluate risk factors in colon injury management and their influence on abdominal complications.

Patients and methods

This is a prospective study conducted at a national level I trauma center in Tirana, Albania from January 2009 to December 2012. The data with respect to demographics, physiological risk factors, intraoperative findings, and surgical procedures were collected. Colonic injury-related morbidity and mortality were analyzed. Multivariate logistic regression analysis was performed by assessing the influence of risk factors on abdominal complications.

Results

Of the 157 patients treated with colon injury, was performed a primary repair in 107 (68.15%) of the patients and a diversion in the remaining 50 (31.85%). The mean PATI was 18.6, while 37 (23.6%) of patients had PATI greater than 25. The complications and their frequencies according to the surgical technique used (primay repair vs diversion respectively) includes: wound infections (9.3% vs 50%), anastomotic leak (1.8% vs 8.7%), and intra-abdominal abscess (1.8% vs 6.5%). The multivariate analysis identified two independent risk factors for abdominal complications: transfusions of 4 units of blood within the first 24 hours (OR = 1.2 95% CI (1.03 –1.57) p =0.02), and diversion (OR = 9.6, 95% CI 4.4 – 21.3, p<0.001).

Conclusion

Blood transfusions of more than 4 units within the first 24 hours and diversion during the management of destructive colon injuries are both independent risk factors for abdominal complications. The socioeconomic impact and the need for a subsequent operation in colostomy patients are strong reasons to consider primary repair in the management of colon injuries.     

A review of 103 cases with elective repair for abdominal aortic aneurysm: an analysis of the risk factors based on postoperative complications and long-term follow-up

From 1982 through 1992, 103 patients (mean age: 69 years) underwent an elective repair of an abdominal aortic aneurysm (AAA) at our institution. One or more postoperative complications occurred in 30 patients (29%), with a mortality rate of 1.9%. Factors which were found to be significantly associated with postoperative complications based on an univariate analysis included male sex (P = 0.0082), operation time (P = 0.0006), the size of the aneurysm (P = 0.0045), the amount of blood loss during operation (P = 0.0037), poor lung function (P = 0.0155), and the platelet count (P = 0.0468),. A simple linear regression analysis showed that there were significant correlations among the AAA size, the duration of operation and the amount of blood loss. The age at operation, however, did not influence morbidity or mortality. Complete survival information was obtained in 96 (95%) patients, while the influence of preoperative risk factors on late survival was also examined by the Kaplan-Meier method. The factors influencing long-term survival were determined to be renal dysfunction and age at the time of operation.     

嗜铬细胞瘤患者术后急性肾功能损伤的危险因素分析

目的探究嗜铬细胞瘤患者术后急性肾功能损伤(AKI)的独立危险因素。方法收集2005年1月至2017年10月行嗜铬细胞瘤手术患者的人口学信息、术前症状、合并症、实验室检查、肿瘤的位置和直径、手术时间、血管活性药物的使用情况、出入量、血流动力学指标等。采用Logistic回归模型分析嗜铬细胞瘤患者术后AKI的独立危险因素。结果共纳入308例患者,其中42例(13.6%)患者术后出现AKI。在单因素Logistic回归分析中,男性、糖尿病史、术前白蛋白40 g/L、术前肌酐95μmol/L、肿瘤直径10 cm、手术时间120 min、术中使用血管收缩药、术中人工胶体液输注≥2 000 ml、输注异体血、出血量≥1 000 ml和SBP70%基础值累计时间10 min与嗜铬细胞瘤患者术后AKI相关;多因素Logistic回归分析显示,男性、白蛋白40 g/L、术中出血量≥1 000 ml和SBP70%基础值累计时间10 min是嗜铬细胞瘤术后AKI的独立危险因素。结论男性、白蛋白40 g/L、术中出血量≥1 000 ml和SBP70%基础值累计时间10 min是嗜铬细胞瘤患者术后AKI的独立危险因素。     

HIV感染者术后感染并发症风险因素分析

目的 探讨HIV病人术后发生感染并发症的风险因素及治疗措施。方法 对2009年1月至2010年6月上海市公共卫生临床中心外科收治的97例HIV感染手术病人的临床资料做回顾性分析。结果 手术前后HIV病人血常规、肝肾功能、CD4、CD8、CD4/CD8差异无统计学意义（P<0.05）。CD4<200个/μL病人（A组,51例）33例发生感染性并发症,2例死于脓毒症;CD4 200～350个/μL者（B组,31例）12例发生感染性并发症;CD4＞350 个/μL者（C组,15例）5例发生感染性并发症。A组的感染并发症发生率显著高于B组和C组（P<0.05）。结论 CD4<200个/μL的HIV病人手术后感染并发症发生风险明显增高,应加强围手术期处理。