A prospective reappraisal of primary repair of penetrating duodenal injuries.

Based on a retrospective analysis of 100 penetrating duodenal injuries, the role of primary repair or resection and anastomosis was assessed prospectively in 66 patients (1986-1992). Duodenal exclusion was reserved for extensive combined pancreato-duodenal injuries. Seven of the 66 patients died from extensive abdominal trauma (mean Abdominal Trauma Index, ATI 70) within 48 hours of admission. Fifty-six patients had primary repair, while pyloric exclusion was performed for three patients with extensive pancreatico-duodenal injuries. Three patients (5.1%) developed duodenal fistula, two being in the primary repair group (3.6%). All three patients had associated injury to the head of the pancreas. Four of the 59 patients died, one attributed to the duodenal repair, for a duodenal mortality of 1.7 per cent. Of the anatomic (ATI, duodenal, vascular, and pancreatic injury scores) and physiologic variables (shock, transfusions) analyzed, the ATI, the Duodenal Injury Score, and the Colon Injury Score were significantly higher in the fistula group. We conclude that the vast majority of penetrating duodenal injuries should be managed by primary repair or resection and anastomosis. Complex duodenal decompression or diverticulization rarely are necessary. Complex procedures should be considered for patients with ATI > 40, Duodenal Injury Score > 12, and the presence of injury to the head of the pancreas.

Early management of civilian gunshot wounds to the face.

We analyzed 54 civilian patients (1988-1992) with gunshot wounds (GSWs) of the face to review the management principles and results. Urgent airway control was needed in 18 cases (33%): by orotracheal intubation in 13, cricothyroidotomy in two, tracheostomy in two, and nasotracheal intubation in one. Central nervous system injury was seen in 12 (22%): 40% with orbital, 38% with mid-face, and 0% with lower face injuries. Two patients died of intracranial injuries (mortality, 4%). Vascular injury was present in five patients (9%), all detected by angiography. The local complication rate was 39% in the presence of intra-oral injury and 0% without intra-oral injury (p < 0.001). The maxilla was the most commonly fractured facial bone (41%) followed by the mandible in 28%. All maxillary, orbital, and zygomatic fractures were treated without reduction. One of the seven nasal fractures required open reduction for deformity. Six of the 15 mandible fractures were treated without reduction. Of eight patients treated with closed reduction, one developed nonunion. One patient treated with immediate open reduction developed osteomyelitis of the mandible and nonunion. Five patients (9%) had palate injuries. Two of them later developed intraoral fistulas following conservative treatment. The airway needs immediate attention in GSWs of the face. Computed tomographic scanning of the head or spine should be done when the bullet trajectory is above the lower face (the level of the mandible). Angiography is indicated when the trajectory of the bullet is suggestive. A conservative approach that effectively reduces the fractures is the procedure of choice. Open reductions should not be performed in the initial treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of transperitoneal gunshot wounds of the spine.

To evaluate the results of a conservative approach to gunshot wounds of the spine with a transperitoneal trajectory, we analyzed our 4-year experience with 21 patients. The management protocol consisted of standard treatment of the intra-abdominal injuries, vigorous irrigation of the missile track, and a 48-hour course of antibiotic therapy. The lumbar spine was involved in 14 patients (67%) and the thoracic spine was injured in seven (33%). Eleven patients (52%) were paraplegic on admission and ten patients (48%) had a fixed partial neurologic deficit. One patient with an ISS of 75 died intraoperatively from exsanguination (mortality, 5%). Early morbidity correlated with ISS greater than 40 and spinal AIS greater than 3. Late nonneurologic morbidity was independent of ISS and spinal AIS. One patient required reoperation for a retroperitoneal abscess secondary to a leak from a repaired ureter. Another patient had a retroperitoneal collection on a CT scan which resolved spontaneously. There were no spinal or paraspinal infectious complications in the presence (five cases) or absence of a colonic injury. No change in neurologic status was observed in any patient during a mean follow-up period of 3 months. This preliminary experience suggests that a conservative approach consisting of irrigation of the missile track and short-term antibiotic therapy without laminectomy or removal of fragments from the spinal canal yields optimal results without increasing infectious complications of the spine.

Acute occlusive disease of the brachial artery.

Acute occlusive disease of the brachial artery has been increasing in frequency due to the aging of the population and the developing modalities in the treatment of cardiac patients and in the diagnosis of vascular diseases. In this study, we discussed 54 cases of acute occlusion of the brachial artery that we encountered in the 5 year period between 1982 and 1987. We performed embolectomy or thrombectomy in 49 patients and carried out conservative treatment in 5 patients. Amputation and mortality rates were 13% and 5.6% respectively. The disease was observed to be mode common in women and in the winter months.