Large Bowel Injury Research Articles

E-scooter-related imaging: a new emerging high-energy trauma patient.

To quantify the volume and nature of radiological imaging performed for e-scooter related trauma presentations in a tertiary referral centre and to identify common radiological pattern of injuries. Our study received institutional review board approval. We retrospectively reviewed all anonymised radiological imaging studies performed in our institution for the term 'scooter' or 'e-scooter' between July 2020 and July 2021. The patient demographics, number of imaging studies performed and modality type as well as the nature of injuries identified were recorded. Within the study period, 147 patients with e-scooter-related injuries were referred for radiological imaging. Forty-two (29%) of those patients had positive radiological findings. The vast majority of injuries on radiographs were upper limb injuries typical of a fall on outstretched hand (FOOSH) pattern. Thirty-two patients (22%) required advanced diagnostics with CT or MRI with 11 of these patients having positive findings. Four patients suffered significant head injuries including skull fractures and/or intracranial haemorrhage. Five patients suffered facial bone fractures, and 2 suffered spinal fractures. One patient suffered a handlebar abdominal trauma with a resulting large bowel injury ultimately requiring bowel resection. E-scooter-related injuries represent a new and emerging high-energy trauma patient. These patients demonstrate injury patterns similar to other high-energy trauma such as road traffic accidents. Although the most common injuries are musculoskeletal upper limb injuries typical of FOOSH, a large proportion of these require advanced diagnostic imaging (CT, MRI) which were commonly positive for significant injuries.

Pattern of Bowel Injury and the Outcome of their Management in Blunt Abdominal Trauma in a Tertiary Care Hospital

Background: Blunt abdominal injury is common in trauma patients. Evaluation of patients who have sustained blunt abdominal trauma may pose a formidable problem and significant intra abdominal injury is one of the most difficult problems faced by emergency doctors and surgeons in the management of trauma. Traumatic bowel injury is one of the curable traumatic conditions. An accurate and timely diagnosis and treatment giving an excellent outcome in most cases. A delay in diagnosis is associated with significant morbidity and mortality. Objectives: To determine the pattern of bowel injury from blunt abdominal trauma, and outcome of their management of the patient after surgery in a tertiary care hospital. Methods: It was an observational study carried out in the department of surgery, Shaheed Ziaur Rahman Medical College Hospital, Bogura from April '2020 to September '2020. Thereafter, they were scrutinized according to eligibility criteria and 50 patients were finalized. Patients with a history of bowel injury are managed with blunt abdominal trauma after proper counseling, results were tabulated and analyzed. Results: A total of 50 patients were enrolled comprising 42(84%) males and 8(16%) females and male-female ration 21:4. Out of 50 patients, most of 18(35%) patients had 31-40 years age group. The mean age was 33.9±7.2 years. Maximum patients reported within 1-6 hours 28(56%) and next group within about 1 hours 11(22%). The average time lapsed was 5.79 hours. 18(36%) patients had concomitant injuries, like 1(2%) patient had a head injury, 8(16%) had pelvic fracture, 4(8%) patients had long bone fracture, 3(6%) patients had soft tissue injury and 2(4%) patients had blunt chest injury. Features of peritonitis were present at initial evaluation 42(84%) patients abdominal pain and features of paralytic ileus 21(42%). 28(56%) cases sustained injury from motor vehicle accident as passenger. Sites of bowel injury were: duodenum 3(6%), jejunum 24(48%), ileum 8(16%), large gut 8(16%), both small and large gut 2(4%). Conclusion: Traumatic bowel injury is one of the commonest traumatic conditions that are encountered in hospitals, namely in the department of surgery. The management of traumatic bowel injury has a fairly good prognosis in developed countries. The outcome is not as good as expected in the third world countries, like our country, due to certain prevailing adverse conditions. The injury in the small bowel is associated with more morbidity than that in the large bowel injury.

Secondary blast injury: radiological characteristics of shrapnel injuries in children.

The aim of this study is to examine the radiological images of child victims suffering from secondary blast injuries, to reveal organ-based injury patterns and their interrelationships, and to record mortality rates that may develop due to injured systems. A total of 65 patients with secondary blast injury due to bomb explosion were included in the study. Injury findings due to shrapnel in radiologic images of the patients were examined. Injured systems and types of injuries were recorded. The most common injuries were intra-abdominal injuries (63%) and fractures (58.5%). Lung injury was observed in 4 (9.8%) of 41 patients with intra-abdominal injury, while 37 (90.2%) did not, and this was statistically significant (p = 0.003). The most common intra-abdominal organ injury was a small bowel injury in 23 (35.4%) patients. The coexistence of small bowel injury and large bowel injury was present in 8 patients (34.8%), and it was statistically significant (p = 0.019). A total of 14 (21.5%) of the patients died. There was no significant relationship between mortality and gender (p = 319). Brain damage was present in 10 (71.4%) of the 14 (21.5%) patients who died, which was statistically significant (p < 0.001). Our results showed that the most common injuries were intra-abdominal injuries, damage to different organs could occur at the same time, and deaths were especially associated with brain injuries. For this reason, it should not be forgotten that CT scans will have an important place in the triage of the patient, especially in victims with shrapnel at the abdominal and cranial levels in radiography examinations.

Evaluation of gastrointestinal tract injury within 1year of surgery for pelvic organ prolapse.

To identify the incidence and risk factors of gastrointestinal injury (GITI) related to pelvic organ prolapse (POP) surgery. Women who underwent POP surgery between 2000 and 2020 were identified in the Premier Healthcare Database. The primary outcome was GITI, defined as small or large bowel injury or repair, and fistula or fistula repair. Differences between patients with and without GITI were evaluated, and a multivariable regression was performed to determine independent predictors of GITI. We identified 563,661 index POP surgeries in female patients aged 18years and older. Of these, 4582 (0.8%) had a bowel injury code within 1year of index POP surgery. Patients who experienced GITI were more likely to be younger (49.9 ± 12.8 vs 50.9 ± 13.7), and receive surgery with a surgeon who performed less than 12 surgeries per year (48% vs 42%). Most GITI was diagnosed in the same month (73.4%) and same hospital encounter (54%) as index POP surgery. After adjusting for confounders, lysis of adhesions (aOR = 2.03, 95% CI: 1.48-2.72) and perioperative hematoma/hemorrhage (aOR = 2.87, 95%C I: 1.70-4.59) were strongly associated with GITI, while having surgery with a surgeon performing > 50 POP surgeries per year (aOR = 0.66, 95%C I: 0.59-0.75 and concomitant obliterative procedures (aOR = 0.48, 95% CI: 0.34-0.65) were associated with a lower probability of GITI. The rate of GITI after POP surgery is less than 1%, and injuries are commonly diagnosed and treated in the same month as index surgery. High-volume surgeons and obliterative procedures may be protective against GITI.

Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program.

To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN. The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach. The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008). Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

Penetrating abdominal trauma: Evaluation in Baghdad during the pandemic Covid-19

Background: Trauma is one of the leading causes of deaths worldwide for all age groups, especially in the younger age group. The purpose of the current study is to assess/analyze the factors for mortality in penetrating abdominal traumas with respect to the total number of intra-abdominal organs injured, related extra-abdominal injuries, gender, type of injury, time of arrival, and amount of blood transfusion needed during the pandemic. Methods: A retrospective study including 523 patients underwent laparotomy in Al-Emamien Al-Kadhimin Medical City from March 2020 to September 2021 for a penetrating abdominal injury due to blast injury, bullet, shrapnel injury, and stab wounds. The study population with penetrating abdominal traumas and indicative abdominal signs was subjected to exploratory laparotomy. Results: In this study, 465 (88.9%) males and 58 (11.1%) females participated; the highest rate was found in small bowel injuries (40.73%) followed by large bowel injuries (21.99%), whereas the lowest rate was found in gallbladder injury (1.34%). Chest injuries represent the highest rate among extra-abdominal injuries (18.36%), whereas head and neck represent the lowest rate (1.34%). Regarding the risk factors affecting the mortality rate, the highest rate of mortality was found in the case of gunshot (13.11%), followed by shrapnel (6.38%) and stab wound injuries (5.26%), which was the lowest. Conclusion: Penetrating abdominal injuries were the most common among males, small bowel injuries are the commonest organs affected by the penetrating abdominal injuries, shrapnel injuries were the commonest causes in our country, and the highest mortality rate was related to gunshot and number of organs affected and delay of arrival to the hospital and number of pints of blood received.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Surgical Complications Requiring Intervention in Open versus Minimally Invasive Radical Prostatectomy

Introduction: Injuries to surrounding structures during radical prostatectomy (RP) are rare but serious complications. However, it remains unknown if injuries to intestines, rectum, or vascular structures occur at different rates depending on the surgical approach. Methods: We compared the frequency of these outcomes in open RP (ORP) and minimally invasive RP (MIS-RP) using the national American College of Surgeons National Surgical Quality Improvement Program database (2012–2017). Along with important metrics of clinical and surgical outcomes, patients were identified as undergoing surgical repair of small or large bowel, vascular structures, or hernias based on Current Procedural Terminology codes. Results: In our propensity matched analysis, a total of 13,044 patients were captured. Bowel injury occurred more frequently in ORP than in MIS-RP (0.89 vs. 0.26%, p < 0.01). By intestinal segment, rectal and large bowel injuries were more common in ORP than MIS-RP (0.41 vs. 0.11% and 0.31 vs. 0.05%, both p < 0.01). However, there was no statistically significant difference between the groups for small bowel injury (0.17 vs. 0.11%, p = 0.39). Vascular injury was more common in MIS-RP (0.18 vs. 0.08%, p = 0.08). Hernias requiring repair were only identified in the MIS-RP group (0.12%). Conclusion: When considering surgical approach, rectal and large bowel injuries were more common in ORP, while vascular injuries and hernia repair were more common in MIS-RP. Our findings can be used in counseling patients and identifying risk factors and strategies to reduce these complications.

Abdominal ectopic pregnancy complicated with a large bowel injury: a case report

BackgroundAbdominal pregnancy accounts for 0.6 to 4% of all ectopic pregnancies. Due to delays in diagnosis and difficulties in the management of abdominal pregnancy, the risk of mortality is significantly higher than for uncomplicated ectopic pregnancies.Case summaryA 23 years-old gravida-II, ectopic-I Ethiopian woman was initially managed as a case of missed second trimester abortion. Later on, abdominal ectopic pregnancy was diagnosed with ultrasound and she underwent a laparotomy. Though fetus and placenta was removed successfully without significant hemorrhage, there was inadvertent sigmoid colon injury.ConclusionIn the management of abdominal ectopic pregnancy, the possibility of bowel injury during entry to the abdominal cavity at laparotomy should always be considered and an experienced general surgeon should always be in attendance before opening the abdomen, to prevent it from happening.

Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure

Background: In patients with autosomal dominant polycystic kidney disease (ADPKD) and end-stage kidney disease, bilateral nephrectomy (BN) is currently performed predominantly via the laparoscopic approach. We analysed the results of BN depending on the approach and preoperative and perioperative factors. Patients and Methods: This was a single-centre retrospective study carried out from April 2010 to March 2020, including a total of 142 patients presenting with ADPKD who were treated by BN. Of these, 108 patients meeting the inclusion criteria were selected to analyse the results. We compared therapeutic outcomes depending on the surgical approach (laparotomy or laparoscopy) and the type of the operation (emergent or elective). Results: Of the 108 eligible patients, 36 (group I) underwent laparoscopic BN and the remaining 72 patients (group II) were subjected to midline laparotomy. Sixty-nine patients underwent elective surgery and 39 endured emergent operations. The most frequent indications (87 patients, 80.6%) for surgical treatment were urinary tract infection and infected cysts. The median length of hospital stay for group I and group II patients amounted to 8 days (IQR: 7.5–9) and 12.5 days (IQR: 9–16.5), respectively (p < 0.001). However, comparing the patients operated on electively, the actual difference in the length of hospital stay was inconsiderable: median 8 days (IQR: 7–9) in group I and 9 days (IQR: 9–11.5) in group II. The median duration of the operation was significantly (p < 0.001) longer in group I amounting to 217.5 min (IQR: 197.5–305) than in group II equalling 115 min (IQR: 107.5–145). The frequency of postoperative complications, lethal outcomes, and blood loss volume did not statistically significantly differ depending on the surgical approach. Only patients operated on emergency underwent releparotomy due to intraoperative large bowel injury. Lethal outcomes (n = 18, 16.7%) after surgery were observed only in emergent patients. Sepsis prior to surgery, systemic inflammation response syndrome (SIRS) with the CRP level above 173 mg/mL, prolonged preoperative antibacterial therapy, and undiagnosed large bowel injury were associated with a lethal outcome after BN. Conclusion: The results of open and laparoscopic BN in elective surgery were comparable. Emergency operations for infected renal cysts and SIRS were associated with increased incidence of large bowel injury and lethal outcomes.

Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy.

Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.

More medications, more problems: results from the Sedation Level after Emergent Exlap with Packing for TRAUMA (SLEEP-TRAUMA) study.

PurposeSedation management of trauma patients after damage control laparotomy (DCL) has not been optimized. We evaluated if shorter sedation exposure was associated with increased proportion of delirium-free/coma-free (DF/CF-ICU) days and change in time to definitive fascial closure (DFC).MethodsWe reviewed trauma DCL patients at an ACS-verified level I center over 5 years as shorter (SE) or longer than median (LE) sedation exposure. We compared demographics, injury patterns, hemodynamic parameters, and injury severity between groups. We calculated the propensity for each patient to achieve DFC using age, gender, ISS, red blood cell transfusion, bowel discontinuity, abdominal vascular injury, and time to first takeback; we then determined the effect of sedation exposure on rate of DFC by multivariate Cox regression, adjusted for propensity to achieve DFC. We used linear regression adjusted for age, ISS, head-AIS, bowel discontinuity, and vascular injury to determine the effect of sedation exposure on the proportion of DF/CF-ICU days.Results65 patients (33.8% penetrating) had mean age 41.8 ± 16.0, ISS 27.1 ± 14.2, Head-AIS 1.2 ± 1.6 and median sedation exposure of 2.2 [IQR 0.78, 7.3] days (35 SE and 30 LE). Pattern and severity of solid organ injuries and proportion of small and large bowel and vascular injuries were similar between groups. LE had more abdominal sepsis (23.3% vs 0%, p = 0.003) and enterocutaneous fistula (16.7% vs 0%, p = 0.016), and more ventilator (17.3 ± 12.7 vs 6.1 ± 6.8, p < 0.001), ICU (20.8 ± 14.2 vs 7.2 ± 7.6, p < 0.001), and hospital days (29.6 ± 19.6 vs 13.9 ± 9.0, p < 0.001). DFC was achieved more rapidly in the SE group (2.0 ± 1.5 days vs 3.9 ± 3.7 days [unadjusted], p = 0.023) and SE had a higher proportion of unadjusted DF/CF-ICU days (33.0 ± 32.0% vs 18.1 ± 16.4%, p = 0.020).SE was associated with an increased proportion of adjusted DF/CF-ICU days by multivariate linear regression (13.1% [95% CI 1.4–24.8%], p = 0.029) and with faster adjusted rate of DFC by multivariate Cox regression (RR 2.28 [95% CI 1.25–4.15, p = 0.007]).ConclusionsShorter sedation exposure is associated with increased proportion of DF/CF-ICU days and more rapid DFC after DCL for trauma.Electronic supplementary materialThe online version of this article (10.1007/s00068-020-01524-9) contains supplementary material, which is available to authorized users.

Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan

BackgroundManagement of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients’ care.MethodsWe reviewed the records of all patients admitted at the Lashkargah “Emergency” hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death.ResultsWe treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries.ConclusionsEpidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.

Management of intra-abdominal vascular injury in trauma laparotomy: a South African experience.

Intra-abdominal vascular injury (IAVI) is uncommon but continues to be associated with high mortality rates despite technological advances in the past decades. In light of these ongoing developments, we reviewed our contemporary experience with IAVI in an attempt to clarify and refine our management strategies and the outcome of these patients. We retrospectively reviewed the charts of all patients admitted between January 2011 and December 2014 at a major trauma centre in South Africa who were found to have an IAVI during laparotomy for trauma. We collected demographic and clinical data including mechanism of injury, location and severity of the injury, concurrent injuries, physiologic parameters and clinical outcome. We identified 110 patients with IAVIs, of whom 98 had sustained penetrating injuries (55 gunshot wounds and 43 stab wounds). There were 84 arterial injuries (including 21 renal and 17 mesenteric) and 74 venous injuries (including 21 renal and 17 inferior vena caval). Combined venous and arterial injuries were found in almost one-third of patients (34 [30.9%]). Fifty-seven patients (51.8%) required intensive care admission. The overall mortality rate was 28.2% (31 patients); the rate was 62% for aortic injuries and 47% for inferior vena cava injuries. Liver injury, large bowel injury, splenic injury and elevated lactate level were all associated with a statistically significantly higher mortality rate. The mortality rate for IAVI remains high despite decades of operative experience in high-volume centres. Open operative techniques alone are unlikely to achieve further reduction in mortality rates. Integration of endovascular techniques may provide an alternative strategy to improve outcomes.

Characteristics of Combat-Associated Small Bowel Injuries.

Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries. The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications. One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively). We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion.

Practice Patterns for the Use of Antibiotic Agents in Damage Control Laparotomy and Its Impact on Outcomes.

The purpose of this study was to identify practice patterns associated with the use of antimicrobial agents with damage control laparotomy (DCL) and the relationship with post-operative intra-abdominal infection (IAI) rates. The study was a retrospective review of trauma patients undergoing laparotomy at a Level 1 trauma center in 2010. Patients undergoing DCL versus those primarily closed (PCL) were compared for antimicrobial use (ABX) and its correlation with IAI rates (p < 0.05). Deaths with length of stay <5 days were excluded. A total of 121 patients were identified (28 DCL, 93 PCL). The DCL group was more severely injured (Injury Severity Score [ISS]: 31.4 ± 15 DCL vs. 18 ± 12.7 PCL, p < 0.001) with more small and large bowel injuries (SLBI), although not statistically significant (53.6% DCL vs. 35.5% PCL, p = 0.12). Practice patterns of ABX administration in terms of pre-operative (94.6% PCL vs. 69.2% DCL, p = 0.0012) and post-operative administration (PCL: 50.5% none, 21.5% one day, 28% long term >1 d; DCL: 21.4% none, 25.0% one day, 53.6% long term >1 day, p = 0.0130) were significant. Regression analyses demonstrated that neither ISS nor DCL was an independent predictor of infection, but pre-operative ABX was a negative predictor (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.05-0.91, p = 0.037), while post-operative ABX (OR 6.7, 95%CI 1.33-33.8, p = 0.044) and SLBI (OR 3.45, CI 1.03-11.5, p = 0.02) were positive predictors of infection with an receiver operating characteristic of 0.81. Significant variations exist in the use of ABX in DCL and PCL. These variations may lead to deleterious results from both lack of initial pre-operative coverage and prolonged ABX use. The decrease in infection rates with pre-operative ABX yet significant increase with continued post-operative use even in the presence of SLBI suggests the need for a more standardized approach. With the increase in DCL and the open abdomen, more research is needed to clearly establish ABX protocols in this patient population.

Can multidetector CT detect the site of gastrointestinal tract injury in trauma? - A retrospective study.

We aimed to assess the performance of computed tomography (CT) in localizing site of traumatic gastrointestinal tract (GIT) injury and determine the diagnostic value of CT signs in site localization. CT scans of 97 patients with surgically proven GIT or mesenteric injuries were retrospectively reviewed by radiologists blinded to surgical findings. Diagnosis of either GIT or mesenteric injuries was made. In patients with GIT injuries, site of injury and presence of CT signs such as focal bowel wall hyperenhancement, hypoenhancement, wall discontinuity, wall thickening, extramural air, intramural air, perivisceral infiltration, and active vascular contrast leak were evaluated. Out of 97 patients, 90 had GIT injuries (70 single site injuries and 20 multiple site injuries) and seven had isolated mesenteric injury. The overall concordance between CT and operative findings for exact site localization was 67.8% (61/90), partial concordance rate was 11.1% (10/90), and discordance rate was 21.1% (19/90). For single site localization, concordance rate was 77.1% (54/70), discordance rate was 21.4% (15/70), and partial concordance rate was 1.4% (1/70). In multiple site injury, concordance rate for all sites of injury was 35% (7/20), partial concordance rate was 45% (9/20), and discordance rate was 20% (4/20). For upper GIT injuries, wall discontinuity was the most accurate sign for localization. For small bowel injury, intramural air and hyperenhancement were the most specific signs for site localization, while for large bowel injury, wall discontinuity and hypoenhancement were the most specific signs. CT performs better in diagnosing small bowel injury compared with large bowel injury. CT can well predict the presence of multiple site injury but has limited performance in exact localization of all injury sites.

Multidetector computed tomography evaluation of post cholecystectomy complications: A tertiary care center experience.

To evaluate the role of multidetector computed tomography (CT) and CT angiography (CTA) in post cholecystectomy complications. A retrospective analysis of data from December 2012 to August 2014 was performed. Eight hundred sixty consecutive patients with history of cholecystectomy (laparoscopic or open) were evaluated. After exclusion of 645 patients with normal imaging, analysis for post cholecystectomy complications was performed in 215 patients. A contrast enhanced CT/CTA was performed. Mean interval to imaging was 10 months (range 3 days to 15 months). A complication rate of 25% was noted in patients undergoing imaging following cholecystectomy. Gallbladder bed or perihepatic collections were seen in 11.9% cases (n = 103). Intrahepatic biliary radicle dilatation (IHBRD) was seen in 7% patients (n = 60). Isolated right or left ductal dilatation was seen in 9 patients; rest of the patients had bilateral IHBRD. Cholangitic abscesses and mild acute pancreatitis were seen in 11 (1.2%) and 12 (1.3%) patients respectively. These comprised biliary complications. Venous thrombosis involving the portal vein was the most frequently encountered vascular complication (n = 12). Right hepatic artery pseudoaneurysm was seen in two patients. Less common complications were abdominal wall hematoma (n = 2), incisional hernia (n = 6), port site hernia (n = 2), large bowel injury (n = 1), biliocutaneous fistula (n = 1) and enterocutaneous fistula (n = 1). CT allows classification of post cholecystectomy complications and guides further management. CTA provides an efficient road map for management of vascular complications.

No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients.

Digital rectal exams (DRE) are routinely used on trauma patients during the secondary survey as recommended by current Advanced Trauma Life Support (ATLS) protocols. However, recent literature has called the blanket use of the DRE on each trauma patient into question. The purpose of this study was to evaluate the efficacy of the DRE as a diagnostic tool in the setting of urethral, spinal cord, small bowel, colon, and rectal injuries and determine if it can be eliminated from routine use in the trauma setting. Trauma patients with small bowel, colon, rectal, urethral, and spinal cord injuries, age of 18years or older, and a noted DRE were included. Exclusion criteria included an age less than 18, patients who received paralytics, a Glasgow Coma Scale (GCS) of 3, and a history of paraplegia or quadriplegia. One-hundred eleven patient records were retrospectively reviewed. Ninety-two male (82.9%) and 19 (17.1%) females with a GCS of 13.7 were evaluated. Sixty-two (55.9%) injuries were penetrating with 49 (44.1) being blunt. The DRE missed 100% of urethral, 91.7% of spinal cord, 93.1% of small bowel, 100% of colon, and 66.7% of rectal injuries. For injuries confirmed with radiologic modalities, the DRE missed 93.3%. For injuries confirmed on exploratory laparotomy, the DRE missed 94.9%. The DRE has poor sensitivity for the diagnosis of urethral, spinal cord, small bowel, and large bowel injury. The DRE was found to be themost sensitive in the setting of rectal injuries. The DRE offers no benefit or predictive value when compared to other imaging modalities.

Uterine Perforation and Extensive Large Bowel Injury

ABSTRACT Unsafe abortion represents a preventable yet major cause for maternal mortality in India. Complications may occur in these cases and ultimately require tertiary care. Large bowel injury is a rare complication and can occur when the uterus is perforated, allowing the instrument to pierce the underlying structures. Here, we discuss a case of a woman who sustained injury to large bowel during second trimester medical termination of pregnancy (MTP) and had to undergo complete large bowel resection. How to cite this article Chandran JR. Uterine Perforation and Extensive Large Bowel Injury. J South Asian Feder Obst Gynae 2015;7(3):225-226.