Duration of antibiotic prophylaxis in high-risk patients with penetrating abdominal trauma: A prospective randomized trial

To evaluate the effect of varying durations of antibiotic prophylaxis in trauma patients with multiple risk factors for postoperative septic complications, a prospective randomized trial was undertaken at an urban level I trauma center. The inclusion criteria were full-thickness colon injury and one of the following: (1) Penetrating Abdominal Trauma Index ≥25, (2) transfusion of 6 units or more of packed red blood cells, or (3) more than 4 hours from injury to operation. Patients were randomly assigned to a short course (24 hours) or a long course (5 days) of antibiotic therapy. All patients received 2 g cefoxitin en route to the operating room and 2 g intravenously piggyback every 6 hours for a total of 1 day vs. 5 days. Sixty-three patients were equally divided into short-course (n = 31) and long-course (n = 32) therapy. This was a high-risk patient population, as assessed by the mean Penetrating Abdominal Trauma Index (33), number of patients with multiple blood transfusions (51 of 63; 81%), number of patients with an Injury Severity Score greater than 15 (37 of 63; 59%), number of patients with destructive colon wounds requiring resection (27 of 63; 43%), and number of patients requiring postoperative critical care (37 of 63; 59%). Differences in intra-abdominal (1-day, 19%; 5-days, 38%) and extra-abdominal (1-day, 45%; 5-days, 25%) infection rates did not achieve statistical significance. There continues to be no evidence that extending antibiotic prophylaxis beyond 24 hours is of benefit, even among the highest risk patients with penetrating abdominal trauma. A large, multi-institutional trial will be necessary to condemn this common practice with statistical validity.     

Laparoscopy in penetrating abdominal trauma

Summary BACKGROUND: Penetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. There is no doubt that persistent hemodynamic instability or signs of peritoneal irritation warrant immediate laparotomy. If the patient is hemodynamically stable and has equivocal abdominal examination findings, diagnosis may be obtained by laparoscopy. METHODS: The goal of this article is to evaluate the role of laparoscopy in the management of PAT. RESULTS: Patients with penetrating trauma to the thoracoabdominal and anterior abdominal wall are good candidates for laparoscopic evaluation. The peritoneal cavity and its contents, including the retroperitoneal space, can be thoroughly examined easily and safely. The main benefits of laparoscopy include the reduction of nontherapeutic laparotomies, identification of mostly intra-abdominal injury, and provision of potential therapy for some cases. Diagnostic laparoscopy has a high overall diagnostic accuracy, reduced morbidity, and shortened hospital stay and is also cost-effective. While laparoscopy has some limitations in the diagnosis of hollow viscus injury, it can detect and repair diaphragmatic injuries accurately and exclude the risk of nontherapeutic laparotomy due to a nonbleeding injury of the solid organs. CONCLUSIONS: The use of laparoscopy as a diagnostic or therapeutic method in patients with PAT is reserved only for hemodynamically stable patients and uncertain findings of peritonitis. Laparoscopy is an efficient and effective diagnostic tool when used by a well-trained surgeon. With experience, an increasing number of surgeons are using laparoscopy as an additional diagnostic tool for PAT in stable patients. With more experience and skills, laparoscopy may be used more therapeutically in selected patients. Minimally invasive surgery has already established itself as a useful tool in the management of PAT. The future seems to be promising for this field of surgery by innovative developments in computer technology and robotic systems.     

Blunt abdominal aortic trauma in paediatric patients

Background

Blunt abdominal aortic trauma (BAAT) is a very rare occurrence in children, with significant morbidity and mortality. Varied clinical presentations and sparse literature evidence make it difficult to define the proper management policy for paediatric patients.

Method

We report our centre's data on three consecutive children with BAAT managed between 2006 and 2010. A Medline search was also performed for relevant publications since 1966, together with a review of references in retrieved publications.

Results

Forty children (range 1–16 years) were included in our final analysis. Motor vehicle crashes (MVC) were the leading cause of injury (65%). The in-hospital mortality rate was 7.5% (3/40). Nine patients (22.5%) ended up with residual sequelae. Main primary aortic lesions were complete wall rupture (12.5%), intimal transection (70%) and pseudoaneurysm (15%). Twenty-eight children underwent aortic surgical repair (70%). Among the 12 non-operatively managed patients, 41.6% had complications, including one death.

Conclusion

Symptomatic lesions and complete ruptures should undergo immediate surgical repair. Circumferential intimal transections are at high risk of complication and should also receive intervention. Partial intimal transections and delayed pseudoaneurysms can be initially observed by clinical examination and imaging. Patients with these latter pathologies should be operated on at any sign of deterioration.     

Significance of traumatology in abdominal and vascular surgery

Frequency of polytrauma accounts for the numerous abdominal traumas. Abdominal injuries should be treated by an abdominal surgeon. Three hundred and seventy traumas of the abdomen were checked regarding other injuries and their percentages given. Mortality rate was 16.6 percent. The different steps of diagnosis are shown with special reference to intraperitoneal lavage and sonography. Frequency of possible organ injuries in patients at Göttingen Medical Center is noted and the special surgical care is explained. The importance and urgency of vascular injuries are discussed with reference to different types of arterial and venous injuries in the abdominal cavity and in retroperitoneal spaces.     

腹部创伤定点超声检查在急诊腹部闭合性创伤的应用

目的总结腹部创伤定点超声（focussedassessmentsonographtrauma,FAST）检查在急诊科的应用价值。方法对76例腹部闭合性创伤的患者进行FAST检查,与腹部CT或手术探查结果进行比较,评价FAST检查对腹部闭合性创伤患者的快速诊断效能。结果FAST的敏感性90．7％,特异性69．7％,阳性预测值79．6％,阴性预测值85．2％,假阳性率30．3％,假阴性率9．3％,准确性81．6％。FAST检查平均用时（3．5±1．3）min,远优于CT检查的（29．1±12．5）min。两者差异有统计学意义（P〈0．05）。结论FAST检查法对腹部闭合性创伤患者具有快速评价诊断效能,可作为急诊医生判断腹部外伤患者是否存在腹部损伤的初步检查方法。     

Blunt and penetrating cervical trauma

Trauma to the cervical region may result in critical injury to the airway, the neck vasculature, and the pharynx or oesophagus. These three systems should be systematically assessed, alongside ATLS protocols, in all patients presenting with blunt or penetrating trauma to the head and neck region. The majority of trauma centres now have a policy of selective neck exploration based on clinical and radiological findings. It is therefore essential to be aware of the symptoms and clinical signs of injury of key neck structures, so that neck exploration can be performed promptly in patients who require it.     

Blunt and penetrating cervical trauma

Trauma to the cervical region may result in critical injury to the airway, the neck vasculature, and the pharynx or oesophagus. These three systems should be systematically assessed, alongside ATLS protocols, in all patients presenting with blunt or penetrating trauma to the head and neck region. The majority of trauma centres now have a policy of selective neck exploration based on clinical and radiological findings. It is therefore essential to be aware of the symptoms and clinical signs of injury of key neck structures, so that neck exploration can be performed promptly in patients who require it.     

Applying peripheral vascular injury guidelines to penetrating trauma

Introduction

Treatment of traumatic vascular injury is evolving because of endovascular therapies. National guidelines advocate for embolization of injuries to lower extremity branch vessels, including pseudoaneurysms or arteriovenous fistulas, in hemodynamically normal patients without hard signs of vascular injury. However, patient stability and injury type may limit endovascular applicability at some centers. We hypothesized that for penetrating trauma, indications for endovascular treatment of peripheral vascular injuries, as outlined by national guidelines, are infrequent.

Methods

We reviewed records of patients sustaining penetrating peripheral vascular injuries treated at our university-based urban trauma center from 2006–2010. Patient demographics and outcomes were analyzed.

Results

In 92 patients with penetrating peripheral vascular injuries, 82 were managed operatively and 10 were managed nonoperatively. Seventeen (18%) were hemodynamically unstable on arrival, 44 (48%) had multiple vessels injured, and 76 (83%) presented at night and/or on the weekend. No pseudoaneurysms or arteriovenous fistulas were seen initially or at follow-up. Applying national guidelines to our cohort, only two patients (2.2%) met recommended criteria for endovascular treatment.

Conclusions

According to national guidelines, indications for endovascular treatment of penetrating peripheral vascular injury are infrequent. Nearly two-thirds of patients with penetrating peripheral vascular injuries were hemodynamically unstable or had multiple vessels injured, making endovascular repair less desirable. Additionally, over 80% presented at night and/or on the weekend, which could delay treatment at some centers due to mobilization of the endovascular team. Trauma centers need to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma.     

Impact of laparoscopy on the perioperative outcomes of penetrating abdominal trauma

BackgroundPenetrating abdominal trauma (PAT) poses a significant challenge to trauma surgeons. Laparotomy is still the most popular procedure for managing PAT but has high morbidity and mortality rates. Presently, laparoscopy aims to provide equal or superior visualization compared to open approaches but with less morbidity, postoperative discomfort, and recovery time. The aim of this research is to assess the impact of laparoscopy on the management of PAT.MethodsThis was a retrospective observational study carried out at the Emergency Hospital of Mansoura University/Egypt and at King Faisal Medical Complex, Taif/KSA from September 2014 to September 2018. All hemodynamically stable patients with PAT who were managed by laparoscopy were included in this study. Data extracted for analysis included demographic information, criteria of abdominal stabs, type of management, and perioperative outcome.ResultsForty patients were recruited in this research and the male-to-female ratio was 5.6:1. The mean age of the patients was 31.4 ± 12.318 years. During the laparoscopic procedure, no peritoneal penetration was observed in 4 patients (negative laparoscopy), while peritoneal penetration was observed in the remaining 36 patients. No visceral injuries were noted in 2 patients of the 36 patients with peritoneal penetration, while the remaining 34 patients had intra-abdominal injuries.ConclusionLaparoscopy performed on hemodynamically stable trauma patients was found to be safe and technically feasible. It also reduced negative and non-therapeutic laparotomies and offered paramount therapeutic and diagnostic advantages for traumatic diaphragmatic injuries.     

Hepatobiliary scintigraphy in management of bile leaks in patients with blunt abdominal trauma

Background: Hepatobiliary scintigraphy (HBS) is a useful diagnostic tool in detecting the presence and site of bile leaks. Methods: We present a retrospective analysis of HBS carried out in 35 patients with blunt abdominal trauma over a period of 5 years from 2001 to 2006. Results: Twenty‐three of 35 patients with blunt abdominal trauma had localized bile leaks and were managed conservatively. The bile leak was found to have completely resolved in the follow‐up HBS. Two patients did not show any evidence of bile leak. Remaining 10 of 35 patients with blunt abdominal trauma showed active bile leak and were subjected to surgical management. Follow‐up scans in these patients showed resolution of bile leaks and patent bilioenteric pathway. Clinical management decisions based on scintigraphic evidence led to less invasive drainage procedures over time and shorter hospital stay. Conclusion: Our study thus suggests that HBS facilitates rapid and precise diagnosis of bile leaks.     

Two types of major venous anomalies associated with abdominal aneurysmectomy: A report of two cases

We report herein the cases of two patients with major venous anomalies associated with abdominal aneurysmectomy, one being an isolated left-sided vena cava and the other, a retroaortic left renal vein, and discuss the clinical significance of such anomalies. In the first patient, an isolated left-sided vena cava was correctly diagnosed preoperatively by contrast-enhanced computed tomography (CE-CT) and digital subtraction angiography (DSA) which revealed that the vena cava crossed the normal portion of the aorta and the right renal vein ran cephalad. In the second patient, a retroaortic left renal vein was also preoperatively diagnosed with CE-CT and DSA. In both patients, dissection was performed, taking care to avoid injury to anomalous venous tributaries, and graft replacement for abdominal aneurysm was successfully carried out. Thus, careful preoperative evaluations using such imaging techniques as CE-CT, DSA, and venographic studies, are important for establishing the presence of an associated venous anomaly preoperatively to ensure the success of abdominal aneurysmal surgery.     

Multiple vascular anomalies in a paediatric kidney transplant recipient.

A 9-year-old girl with end-stage kidney disease secondary toright renal agenesis, and left hydronephrosis due to severevesicoureteral reflux complicated by recurrent urinary tractinfections, was referred to our hospital, to be considered forrenal transplantation. Significant past surgical history includedsurgical     

Laparoscopy in blunt abdominal trauma

Summary BACKGROUND: The decision in favor of surgery or nonoperative conservative treatment in abdominal trauma requires a precise diagnosis that is not always possible with imaging techniques. As there is particular danger that an injury to the diaphragm or intestines be overlooked, the indications for exploratory laparotomy should be generous. Owing to this circumstance, however, up to 41% of exploratory laparotomies turn out to be nontherapeutic and could be, or could have been, avoided with laparoscopy. METHODS: A diagnostic laparoscopy with therapeutic option in blunt abdominal trauma should only be attempted in stable patients. Usually three trocars are used and the exploration of the abdomen is systematic, beginning with the right upper quadrant and continuing clockwise. Small lacerations of the intestines and mesentery can be detected and sutured endoscopically, as well as injuries to the diaphragm. Injuries to parenchymal organs are not a primary indication for laparoscopy, but they can be sealed with tissue adhesive and collagen tamponade to prevent further bleeding. RESULTS: Routine use of laparoscopy can achieve a sensitivity of 90–100% in abdominal trauma. This can reduce the number of unnecessary laparotomies and the related morbidity. CONCLUSIONS: Laparoscopy can be performed safely and effectively in stable patients with abdominal trauma. The most important advantages are reduction of morbidity, shortening of hospitalization and cost-effectiveness. In the future, new developments in laparoscopy equipment and the introduction of computer technology and robotic devices can be expected to have a decisive influence on the treatment of trauma patients.     

Mini-laparoscopy in blunt abdominal trauma

Summary Blunt abdominal trauma in multiorgan injured or comatose patients always presents a problem. The aim is to assess, in the shortest period of time, which organ injury requires priority and whether intra-abdominal bleeding or perforation exists. Abdominal lavage proved to be too sensitive. Not every positive case needs exploration. Approximately 15%–20% of the cases explored because of positive lavage did not show a significant bleeding site that would require surgical treatment. The authors developed a mini-laparoscope that can be used at the bedside, in the emergency room, or in the intensive care unit. The procedure can be performed with intravenous sedation and local anesthesia. In 150 cases, no hemoperitoneum was found in 53% of these cases. Except for 1 (see text for details), none of these patients needed further exploration. In 21%, severe hemoperitoneum was discovered; these patients were transferred to the operating room, and this was confirmed by surgery. In 26%, a small amount of blood was found in the gutters. These patients were observed in the intensive care unit and an unnecessary exploration was avoided. Laparoscopy gives a wider range of decision making by observing the abdominal cavity. It can be completed in 10–20 min at the bedside. No serious complications were encountered. This procedure should be taught and practiced in trauma centers. Partially based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Postoperative CD4 counts predict anastomotic leaks in patients with penetrating abdominal trauma

Introduction

The influence of trauma- and surgical stress-induced decrease of CD4 count on anastomotic leaks after penetrating abdominal trauma has to date not been investigated. A prospective study was performed to explore the effect of CD4 count 24?h after surgery on the anastomotic leak rate and to identify risk factors for anastomotic leaks.

Abdominal aortic injuries associated with chance fractures in pediatric patients

Injury to the abdominal aortic artery from blunt trauma is an infrequent event with few cases reported in either the adult or the pediatric literature. Injury to the thoracic aorta after blunt abdominal trauma is more common. It has been estimated that 95% to 99% of all aortic disruptions are in the thoracic region. Injury to the abdominal aorta is rarely seen in association with fractures of the lumbar spine secondary to seat belt use in motor vehicle accidents; there are few cases in the literature of these injuries in pediatric patients. Nevertheless, the overall mortality rate of this injury has been reported to be between 18% and 37%. It is therefore important to be aware of the possible association to allow prompt diagnosis and management of multitraumatized patients because extensive injuries to the abdominal viscera may mask aortic dissection and prognosis is significantly improved with early intervention.     

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre

Introduction

The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms.

Methodology

A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study.

Results

A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries.

Conclusion

We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.