Can venous base excess replace arterial base excess as a marker of early shock and a predictor of survival in trauma?

<p><b>INTRODUCTION</b>Arterial base excess is an established marker of shock and predictor of survival in trauma patients. However, venous blood is more quickly and easily obtained. This study aimed to determine if venous base excess could replace arterial base excess as a marker in trauma patients at presentation and if venous base excess is predictive of survival at 24 hours and one week.</p><p><b>METHODS</b>This was a prospective study of 394 trauma patients presenting to the emergency department of a tertiary hospital over a 17-month period. Data on base excess at presentation, vital signs, shock index (SI), injury severity score (ISS), and mortality at 24 hours and one week was collected and analysed.</p><p><b>RESULTS</b>Arterial and venous blood gas tests were performed on 260 and 134 patients, respectively. Patients were stratified into groups based on their SI and ISS for analysis. There was no statistical difference between mean venous blood gas and arterial blood gas levels at presentation when SI > 0.7, regardless of ISS (p > 0.05). The mortality rate was 4.57%. Both venous and arterial base excess was lower in nonsurvivors compared to survivors (p < 0.05). However, at 24 hours and one week, the difference in base excess values at presentation between survivors and nonsurvivors was greater when using venous base excess compared to arterial base excess (11.53 vs. 4.28 and 11.41 vs. 2.66, respectively).</p><p><b>CONCLUSION</b>In conclusion, venous base excess can replace arterial base excess in trauma patients as a means of identifying and prognosticating early shock.</p>

Para-oesophageal and parahiatal hernias in an Asian acute care tertiary hospital: an underappreciated surgical condition

<p><b>INTRODUCTION</b>The prevalence of hiatal hernias and para-oesophageal hernias (PEHs) is lower in Asian populations than in Western populations. Progressive herniation can result in giant PEHs, which are associated with significant morbidity. This article presents the experience of an Asian acute care tertiary hospital in the management of giant PEH and parahiatal hernia.</p><p><b>METHODS</b>Surgical records dated between January 2003 and January 2013 from the Department of Surgery, Changi General Hospital, Singapore, were retrospectively reviewed.</p><p><b>RESULTS</b>Ten patients underwent surgical repair for giant PEH or parahiatal hernia during the study period. Open surgery was performed for four patients with giant PEH who presented emergently, while elective laparoscopic repair was performed for six patients with either giant PEH or parahiatal hernia (which were preoperatively diagnosed as PEH). Anterior 180° partial fundoplication was performed in eight patients, and mesh reinforcement was used in six patients. The electively repaired patients had minimal or no symptoms during presentation. Gastric volvulus was observed in five patients. There were no cases of mortality. The median follow-up duration was 16.3 months. There were no cases of mesh erosion, complaints of dysphagia or recurrence of PEH in all patients.</p><p><b>CONCLUSION</b>Giant PEH and parahiatal hernia are underdiagnosed in Asia. Most patients with giant PEH or parahiatal hernia are asymptomatic; they often present emergently or are incidentally diagnosed. Although surgical outcomes are favourable even with a delayed diagnosis, there should be greater emphasis on early diagnosis and elective repair of these hernias.</p>

Secondary stent-in-stent self-expanding metallic stent placement for early stent occlusion due to mucosal oedema in the gastrojejunal anastomosis after palliative subtotal gastrectomy for locally advanced gastric cancer

Herein, we report a case of early in-stent occlusion due to the ingrowth of soft oedematous mucosal tissue through the lattices of an uncovered stent, which was used for palliation of a postoperative gastrojejunal anastomotic stricture. The in-stent occulsion was treated with the deployment of a second stent, which was covered, within the first stent. This led to successful resolution of the occlusion.