[Show abstract][Hide abstract] ABSTRACT: Severe liver injury in trauma patients still accounts for significant morbidity and mortality. Operative techniques in liver trauma are some of the most challenging. They include the broad and complex area, from damage control to liver resection.
This is a retrospective study of 121 trauma patients with hepatic trauma American Association for Surgery of Trauma (AAST) grade III-V who have undergone surgery. Indications for surgery include refractory hypotension not responding to resuscitation due to uncontrolled hemorrhage from liver trauma; massive hemoperitonem on Focused assessment by ultrasound for trauma (FAST) and/or Diagnostic peritoneal lavage (DPL) as well as Multislice Computed Tomography (MSCT) findings of the severe liver injury and major vascular injuries with active bleeding.
Non-survivors have significantly higher AAST grade of liver injury and higher Injury Severity Score (ISS) (p = 0.000; p = 0.0001). Non-survivors have significant hypotension on arrival and lower Glasgow Coma Scale (GCS) on admission (p = 0.000; p = 0.0001). Definitive hepatic repair was performed in 62(51.2 %) patient. Damage Control, liver packing and planned re-laparotomy after 48 h were used in 59(48.8 %). There was no statistically significant difference in terms of the surgical approach. There was significant difference in the amount of red blood cells (RBC) transfusion in the first 24 h between survivors and non-survivors (p = 0.001). Overall mortality rate was 33.1 %. Regarding complications non-survivors had significantly prolonged bleeding and higher rate of Acute respiratory distress syndrome (ARDS) (p = 0.0001; p = 0.0001), while survivors had significantly higher rate of pleural effusion (p = 0.0001).
All efforts in the treatment of severe liver injuries should be directed to the rapid and effective control of bleeding, because uncontrollable hemorrhage is the cause of early death and it requires massive blood transfusion, all of which contributes to the late fatal complication.
World Journal of Emergency Surgery 08/2015; 10(1):34. DOI:10.1186/s13017-015-0031-8 · 1.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/aims:
The aim of this study was to determine the role of serum Interleukin-12 level as early marker of severity of the SAP and correlation between IL12, SIRS score, APACHE II and Ranson score in prediction of illness severity as well as of outcome of SAP.
We evaluated a total of 234 patients with first onset of SAP, appears in last 24 hours, admitted in surgical Intensive care unit (ICU). Severe Acute Pancreatitis was diagnosed with an APACHE II score of 8 or higher, and/or a Ranson score of 3 or higher, and/or Balthazar scores of 5 or higher. Serum IL-12 concentrations were measured with a commercially aviable IL-12 kit, on admission and days 3, 7, and 14.
IL-12 concentration was significantly higher at 24h compared with IL-12 levels at admission (P = 0.010) and after 72h (P = 0.005). IL-12 concentrations significantly correlated with IL-6 concentrations (r = 0.209, P < 0.001), IL-8 concentrations (r = 0.527, P < 0.001), IL-10 concentrations (r = 0.552, P < 0.001), interpheron-gamma (r = 0.740, P < 0.001), TNF-alpha (r = 0.088, P < 0.05), C-reactive protein (r = -0.097, P < 0.001), in-hospital death (r = -0.171, P < 0.001), APACHE II score (r = 0.140, P < 0.001), and Ranson score (r = -0.319, P < 0.001).
The serum values of the IL-12 can be used as an early marker of severity and course of SAP.
[Show abstract][Hide abstract] ABSTRACT: Endometriosis is a benign condition affecting females of reproductive age. Although intestinal endometriosis is common, it is rarely manifested as an acute bowel obstruction secondary to ileal endometriosis. Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction.
A 41-year-old woman presented with symptoms and signs of an acute small bowel obstruction requiring emergency surgery. A small bowel resection was performed with end-to-end anastomosis. Histological examination demonstrated endometriosis with fibrosis and stricture of the ileal segment. This case is important to report as it highlights the diagnostic difficulty this particular condition pre sents to an emergency surgeon.
In the differential diagnosis, endometriosis should be taken into consideration when assessing females of reproductive age who present with abdominal pain and small bowel obstruction.
Srpski arhiv za celokupno lekarstvo 03/2012; 140(3-4):225-8. DOI:10.2298/SARH1204225G · 0.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Development of abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) has a strong impact on the course of disease. Number of patients with this complication increases during the years due more aggressive fluid resuscitation, much bigger proportion of patients who is treated conservatively or by minimal invasive approach, and efforts to delay open surgery. There have not been standard recommendations for a surgical or some other interventional treatment of patients who develop ACS during the SAP. The aim of DECOMPRESS study was to compare decompresive laparotomy with temporary abdominal closure and percutaneus puncture with placement of abdominal catheter in these patients.
One hundred patients with ACS will be randomly allocated to two groups: I) decompresive laparotomy with temporary abdominal closure or II) percutaneus puncture with placement of abdominal catheter. Patients will be recruited from five hospitals in Belgrade during two years period. The primary endpoint is the mortality rate within hospitalization. Secondary endpoints are time interval between intervention and resolving of organ failure and multi organ dysfunction syndrome, incidence of infectious complications and duration of hospital and ICU stay. A total sample size of 100 patients was calculated to demonstrate that decompresive laparotomy with temporary abdominal closure can reduce mortality rate from 60% to 40% with 80% power at 5% alfa.
DECOMPRESS study is designed to reveal a reduction in mortality and major morbidity by using decompresive laparotomy with temporary abdominal closure in comparison with percutaneus puncture with placement of abdominal catheter in patients with ACS during SAP.
ClinicalTrials.gov Identifier: NTC00793715.
BMC Surgery 07/2010; 10(1):22. DOI:10.1186/1471-2482-10-22 · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Early recognition of severe form of acute pancreatitis is important because these patients need more agressive diagnostic and therapeutical approach an can develope systemic complications such as: sepsis, coagulopathy, Acute Lung Injury (ALI), Acute Respiratory Distress Syndrome (ARDS), Multiple Organ Dysfunction Syndrome (MODS), Multiple Organ Failure (MOF). To determine role of the combination of Systemic Inflammatory Response Syndrome (SIRS) score and serum Interleukin-6 (IL-6) level on admission as predictor of illness severity and outcome of Severe Acute Pancreatitis (SAP).
We evaluated 234 patients with first onset of SAP appears in last twenty four hours. A total of 77 (33%) patients died. SIRS score and serum IL-6 concentration were measured in first hour after admission.
In 105 patients with SIRS score 3 and higher, initial measured IL-6 levels were significantly higher than in the group of remaining 129 patients (72 +/- 67 pg/mL, vs 18 +/- 15 pg/mL). All nonsurvivals were in the first group, with SIRS score 3 and 4 and initial IL-6 concentration 113 +/- 27 pg/mL. The values of C-reactive Protein (CRP) measured after 48h, Acute Physiology and Chronic Health Evaluation (APACHE II) score on admission and Ranson score showed the similar correlation, but serum amylase level did not correlate significantly with Ranson score, IL-6 concentration and APACHE II score.
The combination of SIRS score on admission and IL-6 serum concentration can be early, predictor of illness severity and outcome in SAP.
[Show abstract][Hide abstract] ABSTRACT: The phylosophy of aggressive surgical approach, its complete implementation in liver trauma surgery did not appear efficient. No matter of permanenent development of diagnostic imaging methods, anesthesia, intensive therapy, medical technology and suture materials, operational theater and operative tchniques, major liver resections in trauma had mortality rate up to 60%. With introduction of computerized tomography (CT, 1981) in everyday clinical praxis and with better evaluation of trauma patients, the whole approach to liver trauma patient has been redesigned. Based on AAST-OIS classification, almost 70% of traumatized with grade I, II and III sholud be treated non-operatively, hospitally, with repeating FAST (focused abdominal ultrasound in trauma) and abdominal CT scans. The rest of traumatized patients, with grade IV and V injuries of juxtahepatic structures demand complexive surgical treatment. The modalities of surgical treatment depend on trauma mechanisms, extensivity, anatomical localisation and affection of vascular structures. Hanging Manuevr--the Method of French surgeon Belghiti bases on anterior approach in liver resection is a try for fast solution for fatal bleeding in liver trauma. It consists of placing the elastic cord throughout the anterior surface of VCI or ligamentum venosusm, of upper end of the cord is located in superior part of VCI where hepatic veins are emerging. Lower end of the cord is located in subhepatic part of VCI between 3 Glisonian pedicles. Concerning hepatic veins liver is divided in 3 sections, which derives blood in right hepatic vein RHV, middle hepatic vein MHV and left hepatic vein LHV. Belghiti proposed the usage of hanging maneuver when resecting the right liver, while the cord is placed throughout retrohepatic VCI, lower end between elements of Glisonian pedicle and upper end between hepatic veins. Complications like bleeding from caudal veins are minimal, then speed in liver resection in hemodynamic unstable and ishemic patient, defects like bleeding because compressing tapes or lesions IVC tile mobilazion of liver for conventional resection.
[Show abstract][Hide abstract] ABSTRACT: Anemia is common in critically ill patients and carries risk of reduced oxygen carriage and worse outcomes. Transfusion, however, carry their own risk, and the physician must balance the risks of anemia with the risk of transfusion in each patient. Some recent studies compared a liberal with a restrictive approach to transfusion, and a clinical practice guidelines were made. This protocols consider that acute hemorrhage has been controlled, the initial resuscitation has been completed, and the patient is stabile in the intensive care unit without ongoing bleeding. The trigger for PRBC transfusion in patients without severe cardiovascular disease is hemoglobin g/dL (or a hematocrit %).
[Show abstract][Hide abstract] ABSTRACT: The liver is the most commonly injured abdominal organ. Severe hepatic trauma continue to be associated with high mortality. Management of liver injuries has changed significantly over the last two decades. Nonoperative management of hemodynamically stable patients has become the first treatment of choice. In unstable patients immediate control of bleeding is critical. In the management of severe injuries of the liver, particularly for patients who had developed a metabolic insult (hypothermia, coagulopathy, and acidosis), perihepatic packing has emerged as the key to effective damage control (DCS). The surgical aim is control of hemorrhage, preservation of sufficient hepatic function and prevention of secondary complications. Currently available surgical methods include hepatorrhaphy, resectional debridement, anatomical/nonanatomical resection, selective hepatic artery ligation, Pringle maneuver, total vascular exclusion, liver transplatation. This review discusses available diagnostic modalities and the best management options for liver injury, based on literature search and authors experience.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic diagnostics provides fast, reliable, clear, and obvious information on extent and depth of abdominal organs injury with minimizing additional trauma to the patient. It is performed without any specific preparations and, if needed, it may be promptly converted into conventional laparotomy. Through use of optical equipment with various refraction angles and through variable patient positioning, laparoscopic technique enables visualization of whole abdominal cavity. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Abdominal surgeons are familiar with this method, making interpretaion of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy.
[Show abstract][Hide abstract] ABSTRACT: Due to improved methods of treatment and management of hemorrhage, the mortality from liver injuries has decreased significantly over the past few decades. In spite of that, liver injuries still represent diagnostic and therapeutic challenge. This retrospective study included 197 patients surgically treated because of trauma of the liver at The Clinic for Emergency Surgery, during the period 2004-2009. The results showed significant difference in mortality rates in cases of penetrating wounds compared to blunt trauma and gunshot wounds. The severity of injury evaluated by Organ Injury Scale was significantly higher in gunshot wounds compared to blunt and penetrating trauma. The correlation of severity of injuries and mortality rates showed that the mortality is significantly lower in patients with grade 1, 2, and 3 injuries compared to grades 4 and 5 (p=0.016). Specific complication rate was 28.4%, while mortality rate was 21.8%. The results reflect diagnostic and treatment problems, as well as the importance of multidisciplinary approach to the patients with liver trauma.
[Show abstract][Hide abstract] ABSTRACT: Originally the main idea was to obtain a stable patella, i.e., to stabilize the "slipping patella". In the past many conditions like patella alta, ligamentous laxity, PF bone hypoplasia, weakness of the quadriceps muscle, genu valgum or genu recurvatum were thought to predispose to patellar instability. For a long period muscle exercises were instituted to strengthen the weak m.vastus medialis and to make vastus lateralis stronger. This pulls the patella laterally, especially during running or jumping, when lateral luxation of the patella occurs. Muscle imbalance as well as anatomical abnormalities are the basis both for patellar instabilities and reasonable surgical procedures were: proximal extensor mechanism realignment, proximal capsular reefing, patellar tendon splitting and its medial transfer. On the other hand bone procedures on the hypoplastic lateral femoral condyle were also performed by Albee, as well as tibial tubercle transfer and trochleoplasty by deepening of the trochlea (Dejour). An understanding of the pathoanatomic basis is the corner stone for
[Show abstract][Hide abstract] ABSTRACT: Acutelunginjury (ALI) and its more severe form acute respiratory distress syndrome (ARDS) are syndromes with a spectrum of increasing severity of lung injury defined by physiologic and radiographic criteria. There are many clinical disorders as sociated with the development of ALI/ARDS and can be divided into those associated with direct or indirect lung injury. Early detection and protective lung ventilation strategy contribute to lowering the mortality rate.
[Show abstract][Hide abstract] ABSTRACT: In spite of its low incidence, pancreatic injuries hold important place in abdominal trauma because of diagnostic difficulties, severe potential complications, therapeutic challenges, and high mortality rates. These injuries are related with specific morbidity and are very often accompanied with injuries of other organs. This retrospective study included 31 patients treated at The Clinic for Emergency Surgery of Clinical Center of Serbia during the period of 2004-2009 with intraoperativelly confirmed diagnosis of pancreatic trauma. The most common mechanism of injury was blunt trauma (83,9%). Among available diagnostic methods, abdominal ultrasound was characterized with high incidence of false-negative findings (33,3%) while for CT it was at 16,6%. The type of surgical procedure was related to degree and severity of injury. Specific complications occurred in 22,6% of patients, while mortality rate was 25,8%. The creation of unambiguous algorithms for optimal treatment of patients with pancreatic trauma require multi-centric prospective studies.
[Show abstract][Hide abstract] ABSTRACT: Helicobacter pylori infection is accepted to be associated with two mutually exclusive diseases duodenal ulcer and gastric cancer. The aim of this study was to explore the relationship and prevalence of Helicobacter pylori infection in different surgical diseases.
With use of simple serologic assays for detecting IgA and IgG antibodies to HP antigen, we studied the association of infection with HP and 15 surgical diseases.
The prevalence of HP was 68.60% (results of assays were positive for 142 patients out of 207). This study confirmed statistically significant correlation between HP seropositivity and pancreatic cancer (p = 0.02), hepatocellular cancer (p = 0.000), gastric cancer (p = 0.01), colon cancer (p = 0.002), rectal cancer (p = 0.001), intestinal cancer (p = 0.026), stenosis pylori (p = 0.01), ulcer diseases (p = 0.004), jaundice (p = 0.002); statistically significant inverse association between HP seropositivity and the acute appendicitis (p = 0.013) and no correlation with HP infection and cholecystitis (p = 0.716), cholelithiasis (p = 0.06), and ulcer hemorrhage (p = 0.064).
The use of simple serological tests to identify patients with HP infection could help to calculate the risk of development of severe gastrointestinal diseases.
[Show abstract][Hide abstract] ABSTRACT: Question of missed injuries is more often a question of human errors: task execution errors, procedural errors, communication errors, decision errors and noncompliance. Missed injuries are those which are not idetified in the first three days of hospitalisaation. This theme is not popular among physicians. Literature data mention percent from 3-29% missed injuries overall. The underlying causes errors are: false attributin, false negative prediction and false lebeling. False attribution involves a tendency to incorrectly link a clinical observation with an arroneous cause. This tendency also ignores one of the fundamental principles of the management of traumatic injury: that the index of suspicion should proceed on the basis of assumed wors resonable case scenario. Weaknesses of trauma systems: high patients volume, high-risk patients, long hours, changing set of resources, and problems sush bad admission planing, defficite anamnesis, defficite diagnostic procedures, bad communication, improvisation etc.
[Show abstract][Hide abstract] ABSTRACT: Patellofemoral (PF) disorders are a common cause of knee pain and sometimes it can be quite difficult to make a diagnosis, because, besides PF disorders due to lateral compression or instability, the pain may be caused by a parapatellar postraumatic disorder, overuse syndrome, sympathetic algodystrophy or internal knee derangement. Thus, a thorough history and careful physical examination are essential for accurate diagnosis. Besides conventional radiographic views, axial Computerized Tomography (CT), Magnetic Resonance Imaging (MRI) or arthroscopy could sometimes be important. If physical therapy for at least 6 months fails, lateral release is performed in the lateral patellar compressive syndrome (lateral tilt), while either proximal or distal realignment of the extensor mechanism is done in the case of subluxation due to the altered Q angle or patellar height abnormality. In cases of dysplastic and shallowflat trochlea the trochleoplasty could be performed. In the presence of cartilage destruction, tibial tubercle elevation and medialisation are accompanied by arthroscopic debridement or shaving, which could diminish further cartilage symptomatology. In any case, the treatment must be addressed to the primary cause.