World Journal of Emergency Surgery - Latest Articles

Thoracic hyperextension injury with complete "bony disruption" of the thoracic cage: Case report of a potentially life-threatening injury.

James Bailey — 2012-05-15T00:00:00Z

Background: Severe chest wall injuries are potentially life-threatening injuries which require astandardized multidisciplinary management strategy for prevention of posttraumaticcomplications and adverse outcome.Case presentationWe report the successful management of a 55-year old man who sustained a complete "bonydisruption" of the thoracic cage secondary to an "all-terrain vehicle" roll-over accident. Theinjury pattern consisted of a bilateral "flail chest" with serial segmental rib fractures, bilateralhemo-pneumothoraces and pulmonary contusions, bilateral midshaft clavicle fractures, adisplaced transverse sternum fracture with significant diastasis, and an unstable T9hyperextension injury. After initial life-saving procedures, the chest wall injuries weresequentially stabilized by surgical fixation of bilateral clavicle fractures, locked plating of thedisplaced sternal fracture, and a two-level anterior spine fixation of the T9 hyperextensioninjury. The patient had an excellent radiological and physiological outcome at 6 months postinjury. Conclusion: Severe chest wall trauma with a complete "bony disruption" of the thoracic cage represents arare, but detrimental injury pattern. Multidisciplinary management with a staged timing foraddressing each of the critical injuries, represents the ideal approach for an excellent longtermoutcome.

Treatment of burns in the first 24 hours: simple and practical guide by answering 10 questions in a stepby- step form

Ziyad Alharbi — 2012-05-14T00:00:00Z

Residents in training, medical students and other staff in surgical sector, emergency room(ER) and intensive care unit (ICU) or Burn Unit face a multitude of questions regarding burncare. Treatment of burns is not always straightforward. Furthermore, National andInternational guidelines differ from one region to another. On one hand, it is important tounderstand pathophysiology, classification of burns, surgical treatment, and the latest updatesin burn science. On the other hand, the clinical situation for treating these cases needs clearguidelines to cover every single aspect during the treatment procedure. Thus, 10 questionshave been organised and discussed in a step-by-step form in order to achieve the excellenceof education and the optimal treatment of burn injuries in the first 24 hours. These 10questions will clearly discuss referral criteria to the burn unit, primary and secondary survey,estimation of the total burned surface area (%TBSA) and the degree of burns as well asresuscitation process, routine interventions, laboratory tests, indications of Bronchoscopy andspecial considerations for Inhalation trauma, immediate consultations and referrals,emergency surgery and admission orders. Understanding and answering the 10 questions willnot only cover the management process of Burns during the first 24 hours but also seems tobe an interactive clear guide for education purpose.

Factors predicting mortality in emergency abdominal surgery in the elderly

Naoto Fukuda — 2012-05-11T00:00:00Z

ObjectiveThis study aimed to investigate clinical features of abdominal emergency surgery in elderlypatients, and to determine factors predicting mortality in these patients. Methods: The study population included 94 patients aged 80 years or older who underwent emergencysurgery for acute abdominal diseases between 2000 and 2010. Thirty-six patients (38.3%)were male and fifty-eight patients (61.7%) were female (mean age, 85.6 years). Mainoutcome measures included background of the patient's physical condition (concomitantmedical disease, and performance status), cause of disease, morbidity and mortality, anddisease scoring system (APACHE II, and POSSUM). Prognostic factors affecting mortalityof the patient were also evaluated by univariate analysis using Fisher's exact test and Mann-Whitney U-test, and by multivariate analysis using multiple logistic regression analysis. Results: Of the 94 patients, 71 (75.5%) had a co-existing medical disease; most patients hadhypertension (46.8%). The most frequent surgical indications were acute cholecystitis in 23patients (24.5%), followed by intestinal obstruction in 18 patients (19.1%). Forty-one patients(43.6%) had complications during hospital stay; the most frequent were surgical site infection(SSI) in 21 patients (22.3%) and pneumonia in 12 patients (12.8%). Fifteen patients died(overall mortality, 16%) within 1 month after operation. The most common causes of deathwere sepsis related to pan-peritonitis in 5 patients (5.3%), and pneumonia in 4 patients(4.3%). Multiple logistic regression analysis showed that time from onset of symptoms tohospital admission and the POSSUM scoring system could be prognostic factors formortality. Conclusions: Mortality in elderly patients who underwent emergency surgery for acute abdominal diseasecan be predicted using the disease scoring system (POSSUM) and on the basis of delay inhospital admission.Keywords

Proposal for a recovery prediction method for patients affected by acute mediastinitis

Slawomir Jablonski — 2012-05-10T00:00:00Z

Background: An attempt to find a prediction method of death risk in patients affected by acute mediastinitis. There is not such a tool described in available literature for that serious disease. Methods: The study comprised 44 consecutive cases of acute mediastinitis. General anamnesis and biochemical data were included. Factor analysis was used to extract the risk characteristic for the patients. The most valuable results were obtained for 8 parameters which were selected for further statistical analysis (all collected during few hours after admission). Three factors reached Eigenvalue >1. Clinical explanations of these combined statistical factors are: Factor1 - proteinic status (serum total protein, albumin, and hemoglobin level), Factor2 - inflammatory status (white blood cells, CRP, procalcitonin), and Factor3 - general risk (age, number of coexisting diseases). Threshold values of prediction factors were estimated by means of statistical analysis (factor analysis, Statgraphics Centurion XVI). Results: The final prediction result for the patients is constructed as simultaneous evaluation of all factor scores. High probability of death should be predicted if factor 1 value decreases with simultaneous increase of factors 2 and 3. The diagnostic power of the proposed method was revealed to be high [sensitivity =90%, specificity =64%], for Factor1 [SNC = 87%, SPC = 79%]; for Factor2 [SNC = 87%, SPC = 50%] and for Factor3 [SNC = 73%, SPC = 71%]. Conclusion: The proposed prediction method seems a useful emergency signal during acute mediastinitis control in affected patients.

Sigmoid volvulus in pregnancy and puerperium: a surgical and obstetric catastrophe. Report of a case and review of the world literature

Muhammad Khan — 2012-05-02T00:00:00Z

Sigmoid volvulus is a rare surgical complication occurring in pregnancy and puerperium.Only 84 cases of sigmoid volvulus in pregnancy have been reported in the English literatureso far. We have reviewed the available literature on this subject and present another caserecently managed at our institution. The available literature suggests that over the years, therehas been an improvement in the maternal and fetal outcome for this critical condition, butdelay in presentation and a further delay in diagnosis remain a challenge for the treatingphysicians. Our patient was a 30-week pregnant lady, who presented late with 6 days historyof abdominal pain, distension and absolute constipation. She had evidence of multi-organdysfunction at presentation due to complicated sigmoid volvulus. She was resuscitated andsurgical exploration revealed gangrenous large bowel. Bowel resection with divertingileostomy was performed, but she succumbed to the septic shock due to late presentation.Acute surgical pathology may be overlooked in pregnant patients due to reluctance inradiological workup and a high index of suspicion is essential for enhanced outcome. There isa need to increase the awareness amongst the obstetricians and general practitioners. Earlydiagnosis and referral and timely surgical intervention could significantly improve theoutcome of this surgical and obstetric catastrophe.

Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

Mario Testini — 2012-04-11T00:00:00Z

Background: Acute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature. Methods: During 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260). Results: In 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality. Conclusion: On the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.

Blunt trauma induced splenic blushes are not created equal

Clay Cothren Burlew — 2012-03-30T00:00:00Z

Background: Currently, evidence of contrast extravasation on computed tomography (CT) scan is regarded as an indication for intervention in splenic injuries. In our experience, patients transferred from other institutions for angioembolization have often resolved the blush upon repeat imaging at our hospital. We hypothesized that not all splenic blushes require intervention. Methods: During a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan. Results: During the study period, 241 patients were referred for splenic injuries, of whom 16 had a contrast blush on initial CT imaging (88% men, mean age 35 ± 5, mean ISS 26 ± 3). Eight (50%) patients were managed without angioembolization or operation. Comparing patients with and without intervention, there was a significant difference in admission heart rate (106 ± 9 vs 83 ± 6) and decline in hematocrit following transfer (5.3 ± 2.0 vs 1.0 ± 0.3), but not in injury grade (3.9 ± 0.2 vs 3.5 ± 0.3), systolic blood pressure (125 ± 10 vs 115 ± 6), or age (38.5 ± 8.2 vs 30.9 ± 4.7). Of the 8 observed patients, 3 underwent repeat imaging immediately upon arrival with resolution of the blush. In the intervention group, 4 patients had ongoing extravasation on repeat imaging, 2 patients underwent empiric embolization, and 2 patients underwent splenectomy for physiologic indications. Conclusions: For blunt splenic trauma, evidence of contrast extravasation on initial CT imaging is not an absolute indication for intervention. A period of observation with repeat imaging could avoid costly, invasive interventions and their associated sequelae.

Acute pancreatitis due to pancreatic hydatid cyst: a case report and review of the literature

Amin Makni — 2012-03-24T00:00:00Z

Hydatid disease is a major health problem worldwide. Primary hydatid disease of the pancreas is very rare and acute pancreatitis secondary to hydatid cyst has rarely been reported. We report the case of a 38-year-old man who presented acute pancreatitis. A diagnosis of hydatid cyst of the pancreas, measuring 10 cm, was established by abdominal computed tomography before surgery. The treatment consisted of a distal pancreatectomy. The postoperative period was uneventful. Additionally, a review of the literature regarding case reports of acute pancreatitis due to pancreatic hydatid cyst is presented.

An audit of secondary peritonitis at a tertiary care university hospital of Sindh, Pakistan

Ahmer Memon — 2012-03-16T00:00:00Z

ObjectivePeritonitis is the most common life threatening surgical emergency, which requires urgent surgical intervention and is a significant cause of morbidity and mortality. The objective of this study was to highlight the frequency of secondary peritonitis and to analyze the site and causes of perforation, in our tertiary care setup. Methods: A retrospective analysis of 311 patients of secondary peritonitis was done from July 2008 to June 2010 at Liaquat University Hospital Jamshoro, Hyderabad, Sindh, Pakistan. All cases found to have peritonitis as a result of perforation of any part of gastrointestinal tract at the time of surgery were included in the study. All cases with either primary peritonitis or that due to anastomotic dehiscence were excluded. Results: A total of 311 patients were studied. Most of the patients were males (77%) and (89%) were in the third and fourth decades of life. Majority of the patients presented with pain (97%) associated with bowel symptoms. Most common site of perforation was small bowel (ileal 59%, jujenal 2%). In this series, most common risk factor of perforation was typhoid (43%). Ileostomy was the most commonly performed procedure. Overall morbidity was 48.5% and mortality was 17%. Conclusion: Considering the relatively higher rate of typhoid perforation quoted in this study, it is vital that typhoid fever ought to be eliminated by improved sanitation and immunizing programmes, otherwise surgeons will be confronted with its complications.

Ex-vivo porcine organs with a circulation pump are effective for teaching hemostatic skills

Yoshimitsu Izawa — 2012-03-09T00:00:00Z

Surgical residents have insufficient opportunites to learn basic hemostatic skills from clinical experience alone. We designed an ex-vivo training system using porcine organs and a circulation pump to teach hemostatic skills. Residents were surveyed before and after the training and showed significant improvement in their self-confidence (1.83 ± 1.05 vs 3.33 ± 0.87, P < 0.01) on a 5 point Likert scale. This training may be effective to educate residents in basic hemostatic skills.