Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

Background/purpose

Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high.

Methods

The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed.

Results

In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team.

Conclusions

Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.     

Brain-stem relays mediating stimulation-produced antinociception from the lateral hypothalamus in the rat

Several lines of evidence have demonstrated a role for the lateral hypothalamus (LH) in an endogenous system of descending inhibition. The present study, in rats lightly anesthetized with pentobarbital, was undertaken to examine systematically the organization in the brain stem of pathways mediating descending inhibition of the nociceptive tail flick (TF) reflex produced by focal electrical stimulation in the LH. The microinjection of lidocaine into the midbrain, dorsolateral pons, or medial medulla resulted in significant increases in stimulation thresholds in the LH for inhibition of the TF reflex (89.1, 67.4, and 73.6%, respectively). Selective lesions of cell bodies in the midbrain or medulla by the neurotoxin ibotenic acid also produced significant increases in stimulation thresholds in the LH for inhibition of the TF reflex (31.6 and 131.6%, respectively), thus revealing relays in the periaqueductal gray and the nucleus raphe magnus located between the LH and the lumbar spinal cord. The failure of ibotenic acid to affect LH-produced descending inhibition when microinjected into the dorsolateral pons, and the significant effect produced by lidocaine microinjected into the same area, implicates fibers of passage in the dorsolateral pons in descending inhibition of the TF reflex produced by focal electrical stimulation in the LH. The fluorescent dye Fast blue and HRP conjugated to wheat germ agglutinin were used to confirm that the area stimulated in the LH has reciprocal connections with the periaqueductal gray and nucleus raphe magnus.     

Mediterranean Diet and Lifestyle Habits during Pregnancy: Is There an Association with Small for Gestational Age Infants? An Italian Single Centre Experience

Background. The small-for-gestational-age (SGA) in infants is related to an increased risk of developing Non-Communicable Diseases later in life. The Mediterranean diet (MD) is related to lower odds of being SGA. The study explored retrospectively the association between SGA, maternal MD adherence, lifestyle habits and other SGA risk factors during pregnancy. Methods. One hundred women (16–44 years) with a pregnancy at term were enrolled. Demographic data, parity, pre-gestational BMI, gestational weight gain, pregnancy-related diseases, and type of delivery were collected. The MD adherence (MEDI-LITE score ≥ 9), physical activity level, and smoking/alcohol consumption were registered. SGA neonates were diagnosed according to the neonatal growth curves. Results. Women were divided into “SGA group” vs. “non-SGA group”. The MD was adopted by 71% of women and its adherence was higher in the “non-SGA group” (p = 0.02). The prevalence of pregnancy-related diseases (gestational diabetes/pregnancy-induced hypertension) was higher in the “SGA group” (p = 0.01). The logistic regression showed that pregnancy-related diseases were the only independent risk factor for SGA. Conclusions. MD may indirectly reduce the risk of SGA since it prevents and exerts a positive effect on pregnancy-related diseases (e.g., gestational diabetes and hypertension). The small sample size of women in the SGA group of the study imposes a major limitation to the results and conclusions of this research, suggesting however that it is worthy of further investigation.     

Prevalence of muscle relaxant sensitivity in a general population: implications for a preoperative screening.

BACKGROUND: Muscle relaxants (MR) are responsible for 59% of peroperative anaphylactic reactions. A major issue would be to determine whether a systematic preoperative screening in the general population should be recommended. OBJECTIVE: The purpose of the study was to evaluate the prevalence of muscle relaxant sensitivity in a sample of the general population and to assess the role of possible risk factors. METHODS: Two hundred and fifty-eight subjects, aged 20-40 years, visiting a health care centre for a check-up were evaluated. Protocol included a questionnaire (occupation, symptoms of atopy, previous surgery, history of drug allergy), skin-prick tests to four commercial muscle relaxants and measurement of specific IgE against quaternary ammonium ions. Atopy was evaluated by skin-prick tests to common inhalant allergens and by a Phadiatop test. RESULTS: Of the study group, 9.3% had either a positive skin test to one or more muscle relaxant or a presence of specific IgE to quaternary ammonium ions. No risk factor was identified in the studied group. CONCLUSION: Since the rate of MR sensitivity is much higher than the anticipated rate of peroperative reactions due to allergy, a systematic preoperative screening for MR allergy should not be recommended for adults in a general population.     

Predictive factors of renal involvement or relapsing disease in children with Henoch-Schönlein purpura

Predictive factors of renal involvement or relapsing disease in children with Henoch-Schönlein purpura (HSP) are poorly known. We examined clinical and laboratory variables concerning HSP evolution in children hospitalized in the last decade to predict the possibility of renal complications or relapse occurrence. Periodic clinical evaluations with urinalysis were performed for 6±3.6 years. Simple logistic regression showed that persistent rash and severe abdominal pain at the onset of HSP are significantly related to renal involvement, while persistent rash is significantly related to relapsing disease. Multiple logistic regression showed that persistent rash remains related to renal involvement when adjusted for sex, age, and severe abdominal pain and conversely that severe abdominal pain is not related to renal involvement when adjusted for sex, age, and persistent rash. In conclusion, persistent rash over a period longer than 1 month seems to represent a significant predictor of renal sequelae and disease relapse in children with HSP.     

Is systematic preoperative screening for muscle relaxant and latex allergy advisable?

We investigated a female population prior to general anaesthesia, using skin prick tests with latex and muscle relaxants to appraise the validity and feasibility of a systematic preoperative screening for these substances. Anaesthetists performed skin tests, and positive and doubtful tests were checked in our allergy department. Of 114 patients, 42 had uninterpretable tests because of dermographism (28 patients) or suppression of skin reactivity (14 patients). Among the other 72, nine had a positive or doubtful test to latex, and seven a positive or doubtful test to one or more muscle relaxants. After checking, only four sensitizations to latex and one to muscle relaxant were confirmed. In conclusion, a systematic screening for latex and muscle relaxant allergy is not advisable. In contrast, screening for latex allergy in selected high-risk groups (spina bifida, health-care workers) is necessary.