Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre.

INTRODUCTION: Selective non-operative management (SNOM) of penetrating abdominal injuries has increasingly been applied in North America in the last decade. However, there is less acceptance of SNOM among UK surgeons and there are limited data on UK practice. We aimed to review our management of penetrating liver injuries and, specifically, the application of SNOM. METHODS: A retrospective review was performed of patients presenting with penetrating liver injuries between June 2005 and November 2013. RESULTS: Thirty-one patients sustained liver injuries due to penetrating trauma. The vast majority (97%) were due to stab wounds. The median injury severity score was 14 and a quarter of patients had concomitant thoracic injuries. Twelve patients (39%) underwent immediate surgery owing to haemodynamic instability, evisceration, retained weapon or diffuse peritonism. Nineteen patients were stable to undergo computed tomography (CT), ten of whom were selected subsequently for SNOM. SNOM was successful in eight cases. Both patients who failed SNOM had arterial phase contrast extravasation evident on their initial CT. Angioembolisation was not employed in either case. All major complications and the only death occurred in the operatively managed group. No significant complications of SNOM were identified and there were no transfusions in the non-operated group. Those undergoing operative management had longer lengths of stay than those undergoing SNOM (median stay 6.5 vs 3.0 days, p<0.05). CONCLUSIONS: SNOM is a safe strategy for patients with penetrating liver injuries in a UK setting. Patient selection is critical and CT is a vital triage tool. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolisation should be considered for this group.

Damage control surgery in the era of damage control resuscitation.

Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Over the last 10 yr, a new addition to the damage control paradigm has emerged, referred to as damage control resuscitation (DCR). This focuses on initial hypotensive resuscitation and early use of blood products to prevent the lethal triad of acidosis, coagulopathy, and hypothermia. This review aims to present the evidence behind DCR and its current application, and also to present a strategy of overall damage control to include DCR and DCS in conjunction. The use of DCR and DCS have been associated with improved outcomes for the severely injured and wider adoption of these principles where appropriate may allow this trend of improved survival to continue. In particular, DCR may allow borderline patients, who would previously have required DCS, to undergo early definitive surgery as their physiological derangement is corrected earlier.

A multi-centre analysis of the impact of updated risk stratification on follow-up of gastric gastro-intestinal stromal tumours in the post-imatinib era.

BACKGROUND: Previously Gastro-Intestinal Stromal Tumours (GISTs) have been risk stratified histologically according to their size and mitotic index. However, gastric GISTs have a lower likelihood of recurrence and so the Miettinen criteria are now used to risk stratify patients. Records were reviewed from multiple centres to determine if these changes altered patients' clinical care and also to determine the survival of patients following the introduction of imatinib therapy. METHODS: Prospective databases of GISTs undergoing surgical resection and those reviewed by the regional sarcoma MDT were cross-referenced and added to by searching a variety of clinical and pathology coding datasets, to identify patients diagnosed between January 2000 and March 2010. Patients undergoing resection for localised disease were re-scored using Miettinen criteria and Kaplan-Meier analysis was used to determine survival outcomes. RESULTS: The search identified 203 patients; including 132 gastric GISTs, 89 of which had resections of untreated localised disease. These were reassessed, of which approximately one third were scored as intermediate risk. Following reclassification, 26 of 29 of intermediate risk cases moved to low risk groups, representing 27.7% of all those remaining in follow-up at the time of audit. Median survival was not reached after a median follow-up of 3.85 years and 4-year survival was estimated at 72%. CONCLUSIONS: Clinicians involved in the follow-up of gastric GISTs should reassess the pathology of all intermediate and high risk patients in order to decrease patient exposure to stressful interventions, as well as hospital workload, and expenditure on unnecessary observation.