Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines

Liver trauma: WSES 2020 guidelines.

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines

Liver trauma: WSES 2020 guidelines.

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines

Liver trauma: WSES 2020 guidelines

Abstract: Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines

Cold modified Del Nido cardioplegia in adults undergoing elective cardiac coronary surgery

Introduction: The cardioplegic solution of Kirklin (Kn) is frequently used in adult cardiosurgical patients. It requires reinfusion at short intervals, which causes further difficulty during surgery and the quality of myocardial protection is often called into question. Aim: To demonstrate whether the modified cardioplegia of del Nido (MDN) with a longer period of cardiac arrest provides sufficiently effective and reliable myocardial protection when compared to the classic cardioplegia of Kirklin we use in our institution. Materials and methods: This ambispective clinical-epidemiological study was conducted in the Department of Heart Surgery at St Anna University Hospital in Sofia between January 2017 and September 2021. Using a random number generator, а hundred and twenty patients were selected and divided into two cohorts of 60 patients each. After further data processing, an additional five patients dropped out of the Kirklin group due to a ‘beating heart’ operative technique. As a result, the groups were divided as follows: 1) intermittent cardioplegia Kirklin (Kn, n=55) used in patients between January 2017 and June 2019, and 2) modified del Nido cardioplegia (MDN, n=60) used from June 2019 to September 2021. Results: In this study, we present our experience with MDN cardioplegia in patients undergoing isolated CABG and compare it with a group of patients who received Kn cardioplegia. The difference in cross-clamp and CPB times is due to the individual qualities and experience of surgeons. When using MDN, the longer intraoperative times not only showed no deterioration in postoperative results, did not increase the need of using an additional dose of cardioplegia, but also did not materialize in a statistically significant difference. The MDN cardioplegia showed significantly less usage of inotropic support (p<0.001) and IABP (p=0.029). Creatinine phosphokinase MB fraction when patients are admitted to intensive care was significantly less in the Kirklin group (p=0.045). Conclusions: Results suggest that the routine use of modified cardioplegic protection of del Nido in adult patients may be safe, leads to comparable clinical outcomes and could accelerate the surgical process. The reduced incidence in intra- and postoperative complications like DC shocks, arrhythmia, myocardial infarction, multiorgan failure and in-hospital mortality should be further studied, as it may imply superiority of myocardial protection with the modified solution

Therapy with L-thyroxine and Omnadren after Cardiac Surgery. A Case Report

Background: Cardiopulmonary bypass in cardiac surgery produces systemic inflammatory response and catabolic state. Severe stress frequently causes abnormalities in thyroid hormones in the absence of primary thyroid disease, defined as sick euthyroid syndrome (SES).Materials and methods: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support has been used to improve outcome in critically ill patient after cardiac surgery.Results: Administration of thyroid and anabolic hormones significantly improved patient’s condition.Conclusions: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support could be used to improve hemodynamics, achieve transition to anabolic metabolism and enhance recovery, which could eventually help for a reduction in post-operative morbidity and mortality

Therapy with L-thyroxine and Omnadren after Cardiac Surgery. A Case Report

Background: Cardiopulmonary bypass in cardiac surgery produces systemic inflammatory response and catabolic state. Severe stress frequently causes abnormalities in thyroid hormones in the absence of primary thyroid disease, defined as sick euthyroid syndrome (SES).Materials and methods: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support has been used to improve outcome in critically ill patient after cardiac surgery.Results: Administration of thyroid and anabolic hormones significantly improved patient’s condition.Conclusions: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support could be used to improve hemodynamics, achieve transition to anabolic metabolism and enhance recovery, which could eventually help for a reduction in post-operative morbidity and mortality

Damage control or definitive repair? a retrospective review of abdominal trauma at a major trauma center in South Africa

CITATION: Weale, R., et al. 2019. Damage control or definitive repair? a retrospective review of abdominal trauma at a major trauma center in South Africa. Trauma Surgery and Acute Care Open, 4(1):e000235, doi:10.1136/tsaco-2018-000235.The original publication is available at https://tsaco.bmj.comBackground: This study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS. Methods: All patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These Methods All patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest. Results: A total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS. Conclusion: DCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS.https://tsaco.bmj.com/content/4/1/e000235Publisher's versio

Developing a blueprint for a civilian-military collaborative program in trauma training for Northern European countries: A South African experience

Background: Recent terrorist attacks and mass shooting incidents in major European and North American cities have shown the unexpected influx of large volumes of patients with complex multi-system injuries. The rise of subspecialisation and the low violence-related penetrating injuries among European cities, show the reality that most surgical programs are unable to provide sufficient exposure to penetrating and blast injuries. The aim of this study is to describe and create a collaborative program between a major South African trauma service and a NATO country military medical service, with synergistic effect on both partners. This program includes comprehensive cross-disciplinary training & teaching, and scientific research. Methods: This is a retrospective descriptive study. The Pietermaritzburg hospital and Netherlands military trauma register databases were used for analysing patient data: Pietermaritzburg between September 2015 and August 2016, Iraq between May and July 2018 and Afghanistan from 2006 to 2010. Interviews were held to analyse the mutual benefits of the program. Results: From the Pietermaritzburg study, mutual benefits focus on social responsibility, exchange of knowledge and experience and further mutual exploration. The comparison showed the numbers of surgical procedures over a one-month period performed in Iraq 12.7, in Afghanistan 68.8 and in Pietermaritzburg 152. Conclusion: This study has shown a significant volume of penetrating trauma in South Africa, that can provide substantial exposure over a relatively short period. This help to prepare civilian and military surgeons and deployable military medical personnel for casualties with blast – and/or penetrating injuries. The aforementioned findings and the willingness to shape the mutual benefits, create a platform for trauma electives, research, education and training

In-Hospital Mortality Following Traumatic Injury in South Africa

Objectives:. Trauma is a leading cause of death worldwide and in South Africa. We aimed to quantify the in-hospital trauma mortality rate in Pietermaritzburg, South Africa. Background:. The in-hospital trauma mortality rate in South Africa remains unknown, and it is unclear whether deficits in hospital care are contributing to the high level of trauma-related mortality. Methods:. All patients hospitalized because of trauma at the Department of Surgery at Grey’s Hospital, Pietermaritzburg Metropolitan Trauma Service, were prospectively entered in an electronic database starting in 2013 and the data were retrospectively analyzed. The trauma service adheres to Advanced Trauma Life Support and the doctors have attended basic and advanced courses in trauma care. The primary outcome was in-hospital mortality. Results:. Of 9795 trauma admissions, 412 (4.2%) patients died during hospital care between January 2013 and January 2019. Forty-six percent died after road traffic accidents, 19% after gunshot wounds, 13% after stab wounds, and 10% after assaults. Sixteen percent were classified as avoidable deaths due to inappropriate care and resource limitations. Fifty percent died because of traumatic brain injury and 80% of them were unavoidable. Conclusions:. In conclusion, the in-hospital trauma mortality rate at a South African trauma center using systematic trauma care is lower than that reported from other trauma centers in the world during the past 20 years. Nevertheless, 16% of death cases were assessed as avoidable if there had been better access to intensive care, dialysis, advanced respiratory care, blood for transfusion, and improvements in surgery and medical care