Management of thoracoabdominal gunshot injuries by using minimally invasive surgery at role 2 deployed field hospitals in Ukraine.

The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions.

Surgical management of colorectal injury in war.

The rate of colorectal trauma is 5-10 % in modern war conflicts. The most common causes include gunshots or shrapnel injuries; the contusion-laceration mechanism occurs in sporadic cases in the war zone. Despite modern surgical procedures, however, it is associated with a high rate of morbidity, especially if it is not diagnosed and treated in time. Surgical management is specified by simple scoring schemes - the colon injury scale, rectal injury scale and the Flint grading system. Colonic resection with primary or delayed anastomosis is not associated with a higher risk of complicated healing and is nowadays preferred over the construction of terminal stomas. These are indicated only for cases with severe hemodynamic instability in traumatic-hemorrhagic or septic shock with severe diffuse peritonitis. Trauma to the intraperitoneal segment of the rectum is treated in the same way as trauma to the colon. An extraperitoneal rectal injury without soft tissue devastation can be treated with or without a transanal suture. On the contrary, devastating injuries to the rectum including the pelvic soft tissues should be primarily controlled with a stoma with delayed reconstruction. Presacral drainage or rectal stump lavage are no longer recommended.

Facial defects reconstruction by titanium mesh bending using 3D printing technology: A report of two cases.

Introduction: Facial injuries and deformities have received special attention during the previous decades for their functional, esthetic impairment, surgical challenges related to the location of the intervention, and their relationship to a lower survival rate. Moreover, there have been many surgical reconstructive methods due to the different materials and tools available and thus the final results following the surgical intervention. Case presentation: This study was conducted on two patients with severe war injuries; they both suffered from a significant loss in one or more of the following bones: the zygomatic bone, maxilla, nasal bone, infraorbital rim, and mandible. They were treated using preshaped 3D titanium mesh implants that were made using polylactic acid (PLA) material. The final shape was identified depending on pregenerated multislice 3D modeling using computed tomography (CT) scan. Clinical discussion and conclusion: The patient-specific titanium implants produced using polylactic acid (PLA) have been an important option for reconstructive surgical interventions in facial injuries. It has achieved a better outcome in comparison with manual bent titanium mesh in terms of anatomical symmetry, overall operating time, functional and esthetic impairment. These points helped achieve better care for both civilian and war injuries associated with bone loss.

Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Isolates from Northern Africa and the Middle East.

At the Bundeswehr Hospitals of Hamburg and Westerstede, patients repatriated from subtropical war and crisis zones of Northern Africa and the Middle East were medically treated, including microbiological assessment. Within a six-year interval, 16 Acinetobacter spp. strains, including 14 Acinetobacter baumannii (Ab) isolates with resistance against carbapenems and origins in Afghanistan (n = 4), Iraq (n = 2), Libya (n = 2), and Syria (n = 8) were collected. While clonal relationships of Libyan and Syrian strains had been assessed by superficial next generation sequencing (NGS) and "DiversiLab" repetitive elements sequence-based (rep-)PCR so far, this study provides core genome-based sequence typing and thus more detailed epidemiological information. In detail, sequencing allowed a definitive species identification and comparison with international outbreak-associated Ab strains by core genome multi locus sequence typing (cgMLST) and the identification of MLST lineages, as well as the identification of known resistance genes. The sequence analysis allowed for the confirmation of outbreak-associated clonal clusters among the Syrian and Afghan Ab isolates, indicating likely transmission events. The identified acquired carbapenem resistance genes comprised blaOXA-23, blaOXA-58, blaNDM-1, and blaGES-11, next to other intrinsic and acquired, partly mobile resistance-associated genes. Eleven out of 14 Ab isolates clustered with the previously described international clonal lineages IC1 (4 Afghan strains), IC2 (6 Syrian strains), and IC7 (1 Syrian strain). Identified Pasteur sequence types of the 14 Ab strains comprised ST2 (Syrian), ST25 (Libyan), ST32 (Iraqi), ST81 (Afghan), ST85 (Libyan), and ST1112 (Syrian), respectively. In conclusion, the study revealed a broad spectrum of resistance genes in Ab isolated from war-injured patients from Northern Africa and the Middle East, thereby broadening the scarcely available data on locally abundant clonal lineages and resistance mechanisms.

Depression, Anxiety, and Post-Traumatic Stress Disorder Following Orthopedic War Injuries.

Introduction There are ongoing wars worldwide, during which significant numbers of people are injured. Several studies have indicated that high rates of depression and anxiety are seen in war-injured patients. Methods Eighty-one male patients treated between November 2019 and January 2021 far from home in a Turkish hospital due to war injuries that happened in the Libyan Civil War were investigated. Demographic characteristics and injury data of the patients were evaluated regarding age, Injury Severity Score (ISS), location of injuries, type and mechanism of injuries, operations, and accompanying traumas. The psychological statuses of the patients were evaluated with the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and post-traumatic stress disorder (PTSD) records filled out at the first admission to the hospital. Results The mean age of the patients was 29.8±7.7 (19-56) years. While 59 patients had fractures, 22 patients had only soft tissue injuries. Eighteen patients suffered from other accompanying injuries. While 85.2% of the patients showed symptoms of depression, 82.7% of the patients suffered from anxiety and PTSD symptoms were seen in 86.4% of the patients. Statistical analysis was performed to investigate the effects of injury severity, duration of hospitalization, number of operations, and age on depression, anxiety, and PTSD among these patients with war injuries. The results did not indicate any significant effect of injury severity, hospitalization duration, or operations. Conclusion Depression, anxiety, and PTSD are common in patients injured in wars. Injury severity does not seem to affect depression, anxiety, or PTSD in these patients.

Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Isolated from War-Injured Patients from the Eastern Ukraine.

Recently, a total of 32 carbapenem- and fluoroquinolone-resistant Acinetobacter baumannii (Ab) isolates was isolated from war-injured patients who were treated at German Bundeswehr Hospitals, and preliminarily typed by "DiversiLab" repetitive elements sequence-based (rep-) PCR. Core genome-based sequence typing was also used to provide more detailed epidemiological information. From the clusters observed by rep-PCR, selected Ab strains were subjected to Next Generation Sequencing (NGS) in order to compare them with international outbreak-associated Ab strains and to identify MLST (multi-locus sequence type) lineages, as well as to identify known resistance genes. Accordingly, NGS indicated higher diversity than rep-PCR, but also confirmed likely transmission events. The identified acquired carbapenem-resistant genes comprised blaOXA-23, blaOXA-72 and blaGES-12, as well as various other intrinsic and acquired resistance-associated genetic elements. All isolates clustered with the previously identified international clonal lineages IC1, IC2, IC6 and IC7, with corresponding Pasteur sequence types ST1, ST2, ST78 and ST25, respectively. In conclusion, the assessment confirmed a broad spectrum of resistance-associated genes in Ab isolated from war-injured patients from the Eastern Ukraine, and provided the first insights into locally abundant clonal lineages.

Management of upper extremity war injuries in the subacute period: A review of 62 cases.

OBJECTIVE: In this study, we aimed to describe the relationship between the localization of rarely seen upper extremity war injuries and their complications in the subacute period, and define our preferences for surgery and antibiotic use. METHODS: Patients with an upper extremity war injury who presented to our institution between 2015 and 2018 were retrospectively evaluated. Data regarding demographics, time between injury and presentation, location of injury, type of damage, complications, treatment methods, infection rates and antibiotic use were recorded. Tissue defects, fracture fixation, neurovascular damage, infection development and treatment approaches were analyzed. RESULTS: Sixty-two male patients with isolated upper extremity injuries (mean age: 31.66 ± 8.28 years) were included in the study. The average time between trauma and hospitalization was 14 days. The mean hematocrit (Hct) level at presentation was 36.3 ± 6.8%. Patients had been followed up for an average period of 95.6 ± 32.1 days. Twenty-nine patients (46.8%) had nerve injury, eight (12.9%) had arterial injury that required repair, and 23 had infection (37.1%), of which five developed osteomyelitis. Infection was polymicrobial in nine cases and monobacterial in 14. A positive correlation was found between the presence of fracture and nerve injury (p = 0.013). The frequency of nerve injuries due to gunshot wounds was higher in the mid-section and lower part of the arms and in the proximal forearm when compared to other regions (p = 0.011). The infection rates were significantly higher in patients with fractures (p = 0.033). The mean hematocrit (Hct) level at presentation of the patients with infection (32.1 ± 6.3%) was significantly lower than that of those who did not have infection (38.8 ± 5.9%) (p<0.001). CONCLUSION: Upper extremity war injuries require case-specific solutions. Microbiological samples should be taken prior to empirical antibiotic treatment for infection management and rational antibiotic use principles should be applied according to the culture and antibiogram results. The holistic and ambiguous character of nerve injuries often requires early exploration and combined reconstructive interventions. Arterial injuries can be overlooked by physical examination alone and thus routine angiography should be performed. Completion of the bone and soft tissue reconstructions in the same session using a holistic approach minimizes the possible risks.

Perceptions of Non-Communicable Disease and War Injury Management in the Palestinian Health System: A Qualitative Study of Healthcare Providers Perspectives.

BACKGROUND: Palestine, like other low-income countries, is confronting an increasing epidemic of non-communicable disease (NCD) and trend of war injury. The management of health problems often presents a critical challenge to the Palestinian health system (PHS). Understanding the perceptions of healthcare providers is essential in exploring the gaps in the health system to develop an effective healthcare intervention. Unfortunately, health research on management of NCD and war injury has largely been neglected and received little attention. Therefore, the study aimed to explore the perspectives of healthcare providers regarding NCD and war injury management in the PHS in the Gaza Strip. METHODS: A qualitative study approach was used, based on four focus group discussions (FGDs) involving a purposive sampling strategy of 30 healthcare providers from three main public hospitals in Gaza Strip. A semi-structured topic guide was used, and the focus group interviews data were analyzed using manifest content analysis. The study was approved by the Palestinian Health Research Council (PHRC) for ethics approval. RESULTS: From the healthcare providers perspective, four main themes and several sub-themes have emerged from the descriptive manifest content analysis: functioning of healthcare system; system-related challenges; patients-related challenges; strategies and actions to navigating the challenges and improving care. Informants frequently discussed that despite some positive aspects in the system, fundamental changes and significant improvements are needed. Some expressed serious concerns that the healthcare system needs complete rebuilding to facilitate the management of NCD and war-related injury. They perceived important barriers to effective management of NCD and war injury such as poor hospital infrastructure and logistics, shortage of micro and sub-specialities and essential resources. Participants also expressed a dilemma and troubles in communication and interactions, especially during emergencies or crises. The informants stressed the unused of updated clinical management guidelines. There was a consensus regarding poor shared-care/task sharing, partnership, and cooperation among healthcare facilities. CONCLUSION: Our findings suggest that fundamental changes and significant reforms are needed in the health system to make healthcare services more effective, timely, and efficient. The study disclosed the non-use of clinical guidelines as well as suboptimal sectorial task-sharing among different stakeholders and healthcare providers. A clear and comprehensive healthcare policy considering the gaps in the system must be adopted for the improvement and development of care in the PHS.

Reconstruction of composite leg defects post-war injury.

BACKGROUND: In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap. METHODS: Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage. RESULTS: There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing. CONCLUSION: A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions.

Assessment of the Forearm Tendon Transfer with Irreparable Radial Nerve Injuries Caused by War Projectiles.

INTRODUCTION: Injuries to the radial nerve can occur at any point along its anatomical route, and the etiology quite varies. A particular entity are war injuries of the extremities, which have high morbidity but low mortality. After irreparable radial nerve injury, the only treatment is tendon transfer (if we neglect arthrodesis) with over then 40 methods. Four tendon transfers are considered as better than the other and two of them are the subject of our article flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU). AIM: To evaluate the ultimate functional results of forearm tendon transfers for irreparable radial nerve damage caused by war injuries and indicate the better operative treatment choice in accordance with the evaluation schemes. METHODS: This retrospective research included 40 patients with isolated irreparable radial nerve damage. Patients were operated from 1993 to 1996. The follow-up period is from 3.5 to 11.5 years (until 2007). Twenty patients were operated using FCR tendon transfer method and twenty patients were operated using FCU tendon transfer method. The surgery was performed at the Clinic for Reconstructive and Plastic Surgery, Clinical Center University of Sarajevo. Three score evaluation schemes were used: Zachary, Neumann Pertecke and Tajima scheme, along with subjective evaluation of treatment. RESULTS: Measured by the Zachary Evaluation Scheme, the overall score in patients undergoing FCR tendon transfer is 92.25%. In patients undergoing FCU tendon transfer, the total score was 82.20%. The total result of all 40 operated patients was 87.25%. The Zachary evaluation scheme showed a significant difference between FCR and FCU results by tendon transfer (p <0.05) in favor of the FCR tendon transfer. Tajima scheme proved a statistically significant difference between the two tendon transfers (p = 0.024), also in favor of FCR tendon transfers. CONCLUSION: Forearm tendon transfer is a relevant method to compensate for the loss of function of the wrist, fingers and thumb extensions as a result of irreparable damage to the radial nerve. FCR tendon transfer provides better functional results than FCU tendon transfer in irreparable radial nerve damage. The time elapsed from the injury to the performed surgery of the tendon transfer has no effect on the final functional result. There is no surgical tendon transfer procedure that can be recommended as a standard for any patient. Practically, the surgeon must tailor the surgery to the patient's needs. It is necessary to develop a unique and generally accepted evaluation scheme for the results of tendon transfers that will enable comparisons of results achieved. Both methods can be used for irreparable damage of radial nerve due to any etiology.

A contemporary, 7-year analysis of vascular injury from the war in Afghanistan.

OBJECTIVE: Vascular injury is a leading cause of death and disability in military and civilian trauma. Although a previous interim study defined the distribution of vascular injury during the wars in Iraq and Afghanistan, a contemporary epidemiologic assessment has not been performed. The objective of this study was to provide a current analysis of vascular injury during the final 7 years of the war in Afghanistan, including characterization of anatomic injury patterns, mechanisms of injury, and methods of acute management. METHODS: The Department of Defense Trauma Registry was analyzed to identify U.S. military service members who sustained a battle-related vascular injury and survived to be treated at a surgical facility in Afghanistan between January 1, 2009, and December 31, 2015. All battle-related injuries (nonreturn to duty) were used as a denominator to establish the injury rate. Mechanism and anatomic distribution of injury as well as the acute management strategies of revascularization, ligation, and use of endovascular techniques were defined. RESULTS: Of 3900 service members who sustained a battle-related injury, 685 patients (17.6%) had 1105 vascular injuries (1.6 vascular injuries per patient). Extremity trauma accounted for 72% (n = 796) of vascular injuries, followed by the torso (17%; n = 188) and cervical (11%; n = 118) regions. Lower extremity vascular injury was the most prevalent anatomic location (45%; 501/1105). Explosion with fragment penetration accounted for 70% (477/685) of injuries, whereas gunshot wounds accounted for 30% (205/685). Open repair was performed in 559 cases (57%; 554/981), whereas ligation was the initial management strategy in 40% (395/981) of cases. In addition, 374 diagnostic endovascular procedures were completed, 27 therapeutic endovascular interventions to include stent placement and angioplasty were performed and 55 inferior vena cava filters were placed. Mortality of the vascular injury cohort was 5%. CONCLUSIONS: The rate of vascular injury in modern combat is higher than that reported in previous wars. Open reconstruction is performed in half of cases, although ligation is an important damage control option, especially for minor or distal vessel injuries. Angiographic techniques are increasingly being used and documented within wartime registries more than ever. Proficiency with open and endovascular methods of vascular injury management remains a critical need for the U.S. military and will require partnership with civilian institutions to attain and maintain.

Phacoemulsification After Penetrating Keratoplasty Due War Injury at Young Adult.

INTRODUCTION: It is known that phacoemulsification of cataracts after penetrating keratoplasty there are always some difficulties and of course a higher rate of different intraoperative complications. Phacoemulsification after PK may cause significant endothelial injury and affect long term graft survival. AIM: The aim of this report is to describe one of these cases and the possible ways to manage them. CASE REPORT: We report a case o of a 31-year-old female patient, with a cataract on her left eye. She reported that when she was 10 years old, she was admitted to regional hospital in Bosnia and Herzegovina due perforative corneal war injury. At the age of 11 years at Germany on her left eye corneal transplantation was performed. She reported that she wasn't ever seeing quite good, due high myopia. Twenty years after war injury she was admitted to hospital. At that moment patient has been ophthalmologicaly examined (visual acuity testing, biomicroscopy, tonometry, ultrasound of both eyes with biometry and ophthalmoscopy). At the day of admission to the hospital on slit lamp we found occlusion of pupil and complicated cataract. Her only wish was to get operated due cosmetic reasons. Before surgery her visual acuity on her left eye was light perception. Thirty days after surgery her visual acuity was 0,1 without correction. CONCLUSION: It is concluded that cataract surgery in patients after keratoplasty is more complicated. Therefore, these patients should be managed with utmost care and operated by an experienced surgeon.

Management of War-Related Ballistic Craniocerebral Injuries in a French Role 3 Hospital During the Afghan Campaign.

INTRODUCTION: France deployed to Afghanistan from 2001 to 2014 within the International Security and Assistance Force. A French role 3 hospital was built in 2009 in the vicinity of Kabul International Airport (KaIA). The objectives of this study were to describe the epidemiology, management, and outcome of war-related craniocerebral injuries during the Afghan campaign in a French role 3 hospital. METHODS: From March 1, 2010 to September 30, 2012, we conducted a retrospective descriptive study in Kabul, Afghanistan. All patients presenting with a ballistic craniocerebral injury to the KaIA role 3 hospital were included. RESULTS: We analyzed 48 records. Mean age was 21.9 years (1-46 years) with a 37:11 (male:female) sex ratio and a majority Afghan population (n = 41). Civilians represented 64.6% (n = 31) of casualties. On the battlefield, mean Glasgow Coma Scale score was 9.4 [3-15]. On arrival at the KaIA field hospital, 20 of the 48 patients were hemodynamically unstable. All patients underwent a full-body computed tomography scan. The majority of our casualties had associated injuries. Neurosurgery was indicated for 42 (87.5%) patients. The surgery consisted of wound debridement plane by plane associated with decompressive craniectomy (n = 11), debridement craniectomy (n = 19), and craniotomy (n = 12). A total of 32.4% wounded died at the point of injury, 8.4% at the emergency department, and 16.9% after surgery. CONCLUSIONS: War casualties with ballistic head injuries were predominantly multitraumatized patients with hemodynamic compromise requiring neurosurgical damage control management and multidisciplinary care. The neurosurgeon has thus an essential role to play.

Limb reconstructive surgery in austere settings: use of flaps in French forward surgical facilities.

INTRODUCTION: Military surgeons deployed abroad must achieve soft tissue coverage under austere conditions. HYPOTHESIS: A non-specialized surgeon can achieve soft tissue coverage with good results. MATERIAL AND METHOD: This is a retrospective study of all patients who underwent soft tissue coverage in French forward surgical units between 2003 and 2013. RESULTS: In all, 81 flaps were constructed. Open fractures (39%) were the leading indication, followed by osseous infections (35%). Most flaps were for legs (70%) and hands (25%). Only pedicle flaps were used. The success rate was 91%. DISCUSSION: Flaps can be constructed by orthopedic surgeons who are not specialized in reconstructive surgery, in austere settings and with good results. This procedure must be part of a global strategy of limb reconstruction, especially in cases of bone and joint infection. Pedicle flaps, especially muscular, appear more reliable and are to be preferred. The training of the surgeons deployed abroad must include flap surgery.

[Assessment of the perioperative period in civilians injured in the Syrian Civil War]. / Avaliação do período perioperatório em civis feridos na Guerra Civil Síria.

BACKGROUND: Wars and its challenges have historically afflicted humanity. In Syria, severe injuries occurred due to firearms and explosives used in the war between government forces and civilians for a period of over 2 years. MATERIALS AND METHODS: The study included 364 cases, who were admitted to Mustafa Kemal University Hospital, Medicine School (Hatay, Turkey), and underwent surgery. Survivors and non-survivors were compared regarding injury site, injury type and number of transfusions given. The mortality rate found in this study was also compared to those reported in other civil wars. RESULTS: The mean age was 29 (3-68) years. Major sites of injury included extremities (56.0%), head (20.1%), abdomen (16.2%), vascular structures (4.4%) and thorax (3.3%). Injury types included firearm injury (64.4%), blast injury (34.4%) and miscellaneous injuries (1.2%). Survival rate was 89.6% while mortality rate was 10.4%. A significant difference was observed between mortality rates in this study and those reported for the Bosnia and Lebanon civil wars; and the difference became extremely prominent when compared to mortality rates reported for Vietnam and Afghanistan civil wars. CONCLUSION: Among injuries related to war, the highest rate of mortality was observed in head-neck, abdomen and vascular injuries. We believe that the higher mortality rate in the Syrian Civil War, compared to the Bosnia, Vietnam, Lebanon and Afghanistan wars, is due to seeing civilians as a direct target during war.

Assessment of the perioperative period in civilians injured in the Syrian Civil War / Avaliação do período perioperatório em civis feridos na Guerra Civil Síria

BACKGROUND: wars and its challenges have historically afflicted humanity. In Syria, severe injuries occurred due to firearms and explosives used in the war between government forces and civilians for a period of over 2 years. MATERIALS AND METHODS: the study included 364 cases, who were admitted to Mustafa Kemal University Hospital, Medicine School (Hatay, Turkey), and underwent surgery. Survivors and non-survivors were compared regarding injury site, injury type and number of transfusions given. The mortality rate found in this study was also compared to those reported in other civil wars. RESULTS: the mean age was 29 (3-68) years. Major sites of injury included extremities (56.0%), head (20.1%), abdomen (16.2%), vascular structures (4.4%) and thorax (3.3%). Injury types included firearm injury (64.4%), blast injury (34.4%) and miscellaneous injuries (1.2%). Survival rate was 89.6% while mortality rate was 10.4%. A significant difference was observed between mortality rates in this study and those reported for the Bosnia and Lebanon civil wars; and the difference became extremely prominent when compared to mortality rates reported for Vietnam and Afghanistan civil wars. CONCLUSION: among injuries related to war, the highest rate of mortality was observed in head-neck, abdomen and vascular injuries. We believe that the higher mortality rate in the Syrian Civil War, compared to the Bosnia, Vietnam, Lebanon and Afghanistan wars, is due to seeing civilians as a direct target during war.

JUSTIFICATIVA: Historicamente, as guerras e seus desafios afligem a humanidade. Na Síria, lesões graves ocorreram devido às armas de fogo e explosivos usados na guerra entre as forças governamentais e civis durante um período de mais de dois anos. MATERIAIS E MÉTODOS: O estudo incluiu 364 pacientes, admitidos no Hospital da Universidade Mustafa Kemal da Faculdade de Medicina (Hatay, Turquia) e submetidos à cirurgia. Os sobreviventes e não sobreviventes foram comparados quanto ao local e tipo da lesão e número de transfusões administradas. A taxa de mortalidade encontrada neste estudo também foi comparada àquelas relatadas em outras guerras civis. RESULTADOS: A média de idade foi de 29 (3-68) anos. Os principais locais de lesão incluíram extremidades (56,0%), cabeça (20,1%), abdome (16,2%), estruturas vasculares (4,4%) e tórax (3,3%). Os tipos de lesões incluíram ferimento de arma de fogo (64,4%), lesão causada por explosão (34,4%) e ferimentos diversos (1,2%). A taxa de sobrevivência foi de 89,6%, enquanto a taxa de mortalidade foi de 10,4%. Observou-se uma diferença significativa entre as taxas de mortalidade neste estudo e aquelas relatadas para as guerras civis da Bósnia e Líbano; e a diferença ficou extremamente significativa quando comparada com as taxas de mortalidade relatadas para as guerras civis do Vietnã e do Afeganistão. CONCLUSÃO: Dentre as lesões relacionadas à guerra, a maior taxa de mortalidade foi observada em lesões de cabeça-pescoço, abdome e vasculares. Acreditamos que a maior taxa de mortalidade na Guerra Civil da Síria, em comparação com as guerras da Bósnia, Vietnã, Líbano Afeganistão, se deva ao fato de os civis terem sido vistos como alvo direto durante a guerra.

Assessment of the perioperative period in civilians injured in the Syrian Civil War.

BACKGROUND: wars and its challenges have historically afflicted humanity. In Syria, severe injuries occurred due to firearms and explosives used in the war between government forces and civilians for a period of over 2 years. MATERIALS AND METHODS: the study included 364 cases, who were admitted to Mustafa Kemal University Hospital, Medicine School (Hatay, Turkey), and underwent surgery. Survivors and non-survivors were compared regarding injury site, injury type and number of transfusions given. The mortality rate found in this study was also compared to those reported in other civil wars. RESULTS: the mean age was 29 (3-68) years. Major sites of injury included extremities (56.0%), head (20.1%), abdomen (16.2%), vascular structures (4.4%) and thorax (3.3%). Injury types included firearm injury (64.4%), blast injury (34.4%) and miscellaneous injuries (1.2%). Survival rate was 89.6% while mortality rate was 10.4%. A significant difference was observed between mortality rates in this study and those reported for the Bosnia and Lebanon civil wars; and the difference became extremely prominent when compared to mortality rates reported for Vietnam and Afghanistan civil wars. CONCLUSION: among injuries related to war, the highest rate of mortality was observed in head-neck, abdomen and vascular injuries. We believe that the higher mortality rate in the Syrian Civil War, compared to the Bosnia, Vietnam, Lebanon and Afghanistan wars, is due to seeing civilians as a direct target during war.

Definition of polytrauma: Discussion on the objective definition based on quantitative estimation of multiply injured patients during wartime.

AIM: There is a clear lack of consensus on a validated definition of the term "polytrauma". This study presents and classifies the extent of injuries during wartime in Croatia using the Revised Trauma Score and Injury Severity Score (TRISS) and compares the scores with a clinical estimation based on subjective assessments of polytraumatised and non-polytraumatised patients. METHODS: We analysed the data from 426 war victims who sustained multiple injuries and were managed at Osijek University Hospital from September 1st 1991 to December 31st 1991. The victims were divided into polytraumatised (n=149) and multitraumatised (n=277) patients according to the initial clinical estimation of the extent of injury. Patients classified as monotraumatised were excluded from this study. The assessment was based on the following definition of polytrauma: simultaneous injury of two or more body regions or anatomical systems with at least one injury being life-threatening. All data were scored retrospectively using TRISS methodology. RESULTS: Two patients classified as polytraumatised had an ISS of less than 16, and one patient classified as multitraumatised had an ISS of more than 16. The difference between the actual (29.5%) and expected (40.44%) postoperative mortality in the polytraumatised group was statistically significant (p=0.0016), whereas in the multitraumatised group, the difference between the actual (3.2%) and expected (3.04%) postoperative mortality was not significant (p=0.6103). CONCLUSIONS: The data show that clinical and subjective assessment of polytraumatised patients can be useful in the management of such cases and can be tested retrospectively using TRISS methodology.

A simple method of skin mapping for planning the operative approach in peripheral nerve injuries.

BACKGROUND: The operative treatment of post-traumatic neuromas includes open exploration, excision of adhesions and/or neurectomy. Apart from the anatomical variations of the peripheral nerves and their branches' routes, nerves may be further deviated from their expected anatomical locations due to scar tissue formation. We describe a simple and reproducible method of preoperative skin marking which aids the development of an accurate surgical exposure for the localisation of a lesion. METHOD: Skin marking is based on clinical assessment and is performed by the bedside on the day of the operation. It consists of mapping the skin with permanent marker by repeatedly using three symbols, namely √, O or X. These refer respectively to areas of normal sensation, numbness (decreased or no sensation without paraesthesia) and pain/dysaesthesia. Points with a positive Tinel sign were marked with an "X in a square". Fourteen patients, aged 21-55 years old, with post-traumatic neuromas, were marked with the method. A total of 18 neuromas were successfully located in the upper and lower limbs. RESULTS: In all cases the preoperative skin marking corresponded to the course of the nerve and/or its branches. All patients were improved with a good to excellent clinical outcome. CONCLUSIONS: Planning the surgical approach according to the skin marking enabled limited operative exposures and corresponded to atypical locations and branching of the peripheral nerves.