Operative management of liver trauma. A 10-year experience in Riyadh, Saudi Arabia.

OBJECTIVE: To analyze our experience and the outcome of operative management of liver trauma, and to suggest ways to improve the management of such patients. METHODS: This retrospective study was conducted on patients admitted with liver trauma to King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia between January 1997 and December 2006. Only patients who underwent operative management were included in this study. RESULTS: Sixty-four out of 138 patients with liver injury were treated surgically. Most of the patients were young (mean 29.4 years), and male (84%). Fifty-six patients sustained blunt trauma. Eight patients had grade I, 17 had grade II, 21 had grade III, 12 had grade IV, and 6 patients had grade V liver injuries. Hepatorrhaphy (n=28) was the most common surgical technique used followed by peri-hepatic packing (n=12), simple hemostatic measures (n=9), and non-anatomical hepatic resections (n=8). Laparotomy was non-therapeutic in 7 patients (11%). Liver injury related morbidity was 19%, and mortality was 11%. CONCLUSION: Hepatorrhaphy was the most common surgical modality employed to control bleeding. Peri-hepatic packing was used in unstable patients. In 25% of patients, bleeding had either stopped from the injured liver or needed only simple hemostatic measures.

Necrotizing fasciitis. Role of early surgical intervention.

OBJECTIVE: To evaluate our experience of management of necrotizing fasciitis (NF) particularly the role of early and aggressive surgical intervention. METHODS: This is a retrospective review of the cases affected by this disease and managed at Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia, during 5 calendar years from 1996 through to 2000 (1416-1420 A.H). The preoperative and operative data was collected, and postoperative morbidity and mortality were analyzed. RESULTS: A total of 25 cases of NF were treated during the 5-year period, 18 were males and 7 female. The majority of patients had perianal suppuration as the primary lesion, followed by groin area in drug addicts and only 2 cases were primarily in the upper limbs. Diabetes and drug addiction were the main predisposing factors. All but 3 infections were polymicrobial, with streptococci and acinobacter being the most frequent organisms. The mainstay of treatment depends on a high index of suspicion, aggressive early and repeated debridements and adequate antibiotic coverage. The overall mortality was 24% but the drastic reduction in mortality was observed with early surgical intervention. CONCLUSION: The results highlight the role of early diagnosis; prompt and aggressive surgical debridements are critical for improved survival.

Initial factors predicting rebleeding and death in bleeding peptic ulcer disease.

OBJECTIVE: Bleeding peptic ulcer constitutes approximately half of the cases admitted with upper gastrointestinal bleeding. Although the bleeding episode stops spontaneously in most of them, rebleeding occurs in as much as 10-30% of them and has a mortality rate of 5-10%. In this study, we have evaluated the possible significant predictors associated with this adverse outcome. METHODS: The records of 205 patients admitted to gastrointestinal bleeding unit (GIBU) in Riyadh Central Hospital, during the period May 1996 through to April 1999, with endoscopic confirmed diagnosis of bleeding peptic ulcer disease were reviewed for demography, clinical presentation, hematology, biochemistry, initial blood pressure, nasogastric lavage color, co-morbid disease and endoscopic findings. All the significant factors found initially (P<0.05) were entered into odds ratio and its 95% confidence interval and finally the unconditioned logistic regression model was used to find out the significant independent predictors for both rebleeding and mortality in these patients. RESULTS: The majority of patients (85%) were males and below the age of 60 (73%). Duodenal ulcer was the source of bleeding in 84%. Endoscopy was performed in all patients within 24 hours of admission. Only 15% were actively bleeding at the time of initial endoscopy. Thirty-six patients (17%) rebelled, majority within 72 hours of initial hemostasis. Overall, 11 patients (5%) died, 6 of them were rebleeders. Initial presentation of systolic blood pressure <100 mm Hg, blood in nasogastric tube and visible vessel within the ulcer in endoscopy were independent predictors of rebleeding while initial systolic blood pressure <100 mm Hg and age >60-years were independent predictors of mortality. CONCLUSION: Improvement of outcome in patients with bleeding peptic ulcer disease can be achieved by early detection of those patients who are at risk of adverse outcome. Patients with the above mentioned independent predictors of rebleeding and mortality are best managed in the intensive care unit with endoscopic hemostasis and proton pump inhibitor (PPI) therapy for a minimum of 5-days of admission.

Outcome of nonoperative management of blunt liver trauma.

OBJECTIVE: To evaluate our experience with the management of blunt liver trauma at Riyadh Central Hospital, Kingdom of Saudi Arabia. METHODS: The hospital records of 68 patients treated for blunt liver trauma at Riyadh Medical Complex over a 5-year period (1997 through to 2002) were reviewed retrospectively. Patients who were hemodynamically unstable or had peritonitis were treated by urgent laparotomy (operative group). The other group of patients were treated conservatively as they were hemodynamically stable (nonoperative group) in the intensive care unit (ICU). All patients had computed tomogram of the abdomen with oral and intravenous contrast. Injuries grades were classified according to American Association for the Surgery of Trauma (AAST). Follow up computed tomogram of the abdomen was performed in 1-2 weeks time. RESULTS: A total of 68 patients were treated over a 5-year period. Thirty-three patients (49%) were treated by immediate surgery. Hepatorraphy was performed in 22 patients, non anatomical resection in 3 patients and liver packing in 2 patients to control bleeding. No active bleeding was found in 8 patients. Nonoperative group (n=35, 51%) were managed in the ICU for close monitoring. Surgically treated group had more patients with complex liver injury (30% versus 11%), required more units of blood (3.2 versus 2.1) but had a shorter hospital stay (9 days versus 12 days). Two patients for nonoperated group develop complications (biloma: one patient, infected hematoma: one patient), the nonoperative treatment failed in one patient who required laparotomy due to rebleeding from grade IV liver injury with failure rate of 3%. The only mortality (one patient) was in the operated group. CONCLUSION: The nonoperative treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The nonoperative treatment should be the treatment of choice in such patients whenever computed tomogram and ICU facilities are available. However, further studies with larger number of patients are needed to support our results.

Management of foot lesions in 310 diabetics.

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