Training and accrediting international surgeons.

BACKGROUND: Formal international medical programmes (IMPs) represent an evolution away from traditional medical volunteerism, and are based on the foundation of bidirectional exchange of knowledge, experience and organizational expertise. The intent is to develop multidirectional collaborations and local capacity that is resilient in the face of limited resources. Training and accreditation of surgeons continues to be a challenge to IMPs, including the need for mutual recognition of competencies and professional certification. METHODS: MEDLINE, Embase and Google Scholar™ were searched using the following terms, alone and in combination: 'credentialing', 'education', 'global surgery', 'international medicine', 'international surgery' and 'training'. Secondary references cited by original sources were also included. The authors, all members of the American College of Academic International Medicine group, agreed advice on training and accreditation of international surgeons. RESULTS AND CONCLUSION: The following are key elements of training and accrediting international surgeons: basic framework built upon a bidirectional approach; consideration of both high-income and low- and middle-income country perspectives; sourcing funding from current sources based on existing IMPs and networks of IMPs; emphasis on predetermined cultural competencies and a common set of core surgical skills; a decentralized global system for verification and mutual recognition of medical training and certification. The global medical system of the future will require the assurance of high standards for surgical education, training and accreditation.

Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries.

BACKGROUND: Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management. STUDY DESIGN: This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression. RESULTS: 101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97 ± 47, mean HR 92 ± 47, and mean admission pH 7.22 ± 0.17. Mean RTS 6.25 ± 2.7, mean ISS 36 ± 22. The mean estimated blood loss (EBL) was 5277 ± 4955 mls. Predictors of outcome are: admission pH (p = 0.0014), admission base deficit (p < 0.0001), packed red blood cells (PRBCs) transfused (p = 0.023), whole blood transfused (p < 0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p = 0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p < 0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p = 0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p = 0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p = 0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome. CONCLUSIONS: Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.

Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries.

Mesenteric vessels, including the superior mesenteric artery (SMA) and vein (SMV), provide and drain the rich blood supply of the midgut and hindgut. SMA and SMV injuries are rare and often lethal. Clinical management of these injuries is not well established, but treatment options include operative, non-operative, and endovascular strategies. A narrative review of the literature was conducted using MEDLINE Complete-EBSCO. Relevant studies, specifically those focusing on diagnosis and management of SMA and SMV injuries, were selected. Only original reports and collected series were selected to prevent duplication of cases. A search of the literature for mesenteric arterial injuries yielded 87 studies. Vessel-specific breakdown of the studies yielded 40 with SMA injuries and 41 with SMV injuries. These searches were winnowed to 26 individual studies, which were included in this collective review. Limitations of this study are similar to all narrative literature reviews: the dependence on previously published research and availability of references as outlined in our methodology. Although historically rare, mesenteric vessel injuries are seen with increasing incidence and continue to present a challenge to trauma surgeons due to their daunting mortality rates. Currently, universal treatment guidelines do not exist, but the various options for their management have been extensively reviewed in the literature.

Penetrating cardiac injuries: predictive model for outcomes based on 2016 patients from the National Trauma Data Bank.

BACKGROUND: Penetrating cardiac injuries are uncommon and lethal. The objectives of this study are to examine the national profile of cardiac injuries, identify independent predictors of outcome, generate, compare and validate previous predictive models for outcomes. We hypothesized that National Trauma Data Bank (NTDB) given its large number of patients, would validate these models. METHODS: The NTDB was queried for data on cardiac injuries, using survival as the main outcome measure. Statistical analysis was performed utilizing univariate and stepwise logistic regression. The stepwise logistic regression model was then compared with other predictive models of outcome. RESULTS: There were 2016 patients with penetrating cardiac injuries identified from 1,310,720 patients. Incidence: 0.16%. Mechanism of injury: GSWs-1264 (63%), SWs-716 (36%), Shotgun/impalement-19/16 (1%). Mean RTS 1.75, mean ISS 27 ± 23. Overall survival 675 (33%). 830 patients (41%) underwent ED thoracotomy, 47 survived (6%). Survival stratified by mechanism: GSWs 114/1264 (10%), SWs 564/717 (76%). Predictors of outcome for mortality-univariate analysis: vital signs, RTS, ISS, GCS: Field CPR, ED intubation, ED thoracotomy and aortic cross-clamping (p < 0.001). Stepwise logistic regression identified cardiac GSW's (p < 0.001; AOR 26.85; 95% CI 17.21-41.89), field CPR (p = 0.003; AOR 3.65; 95% CI 1.53-8.69), the absence of spontaneous ventilation (p = 0.008; AOR 1.08, 95% CI 1.02-1.14), the presence of an associated abdominal GSW (p = 0.009; AOR 2.58, 95% CI 1.26-5.26) need for ED airway (p = 0.0003 AOR 1386.30; 95% CI 126.0-15251.71) and aortic cross-clamping (p = 0.0003 AOR 0.18; 95% CI 0.11-0.28) as independent predictors for mortality. Overall predictive power of model-93%. CONCLUSION: Predictors of outcome were identified. Overall survival rates are lower than prospective studies report. Predictive model from NTDB generated larger number of strong independent predictors of outcomes, correlated and validated previous predictive models.

Trauma to the bladder and ureter: a review of diagnosis, management, and prognosis.

BACKGROUND: Injuries to the ureter or bladder are relatively rare. Therefore, a high level of clinical suspicion and knowledge of operative anatomy is of utmost importance for their management. Herein, a review of the literature related to the modern diagnosis, management, and prognosis for bladder and ureteral injuries is presented. METHODS: A literature search was conducted through PubMed. A thorough search of the world's literature published in English was completed. Search terms included "injury, diagnosis, prognosis, and management for ureter and bladder". All years, both genders, as well as penetrating, blunt, and iatrogenic mechanisms were evaluated for inclusion. Following PRISMA guidelines, studies were selected based on relevance and then categorized. RESULTS: 172 potentially relevant studies were identified. Given our focus on modern diagnosis and treatment, we then narrowed the studies in each category to those published within the last 30 years, resulting in a total of 26 studies largely consisting of Level IV retrospective case series. Our review found that bladder ruptures occur from penetrating, blunt, or iatrogenic mechanisms, and most are extraperitoneal (63%). Ureteral injuries are incurred from penetrating mechanisms in 77% of cases. The overall mortality rates for bladder rupture and ureteral injury were 8 and 7%, respectively. LIMITATIONS: Limitations of this article are similar to all PRISMA-guided review articles: the dependence on previously published research and availability of references. CONCLUSION: The bladder is injured far more often than the ureter but ureteral injuries have higher injury severity. Both of these organs can be damaged by penetrating, blunt, or iatrogenic mechanisms and surgical intervention is often required for severe ureter or bladder injuries. Since symptoms of these injuries may not always be apparent, a high level of suspicion is required for appropriate diagnosis and treatment.

Traumatic pulmonary pseudocyst: An underreported entity.

BACKGROUND: Traumatic pulmonary pseudocysts (TPP) are underreported cavitary lesions of the pulmonary parenchyma that can develop following blunt chest trauma. Although the occurrence of traumatic pulmonary pseudocyst is rare, this condition should be considered in the differential diagnosis of any cavitary lesion. Awareness of this injury and its clinical significance is important for successful management in order to avoid medical errors in the course of treatment. METHODS: A literature search was conducted through Medline using the key phrases "traumatic pulmonary pseudocyst" and "traumatic pneumatocele." Relevant articles, especially those with focus on diagnosis and management of traumatic pneumatocele in adults, were selected. Due to the scarcity of literature and lack of Level I evidence on this subject, studies published in any year were considered. RESULTS: A search of "traumatic pulmonary pseudocyst" and "traumatic pneumatocele" yielded 114 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were reviewed. The majority of these were individual case studies; only eight articles were considered large case studies (greater than eight patients). CONCLUSION: Traumatic pulmonary pseudocysts are lesions that occur secondary to blunt chest trauma. Diagnosis is based on a history of trauma and appearance of a cystic lesion on CT. Accurate diagnosis of traumatic pulmonary pseudocyst is imperative to achieve successful outcomes. Failure to do so may lead to unnecessary procedures and complications.

Contemporary wars and their contributions to vascular injury management.

INTRODUCTION: Man's inhumanity for man still knows no boundaries, as we continue as a species as a whole to engage in war. According to Kohn's Dictionary of Wars [1], of over 3,700 years of recorded history, there have been a total of 3,010 wars. One is hard pressed to actually find a period of time in which here has not been an active conflict in the globe. The world has experienced two world wars: WWI (1914-1918) and WWII (1939-1945). The total number of military casualties in WWI was over 37 million, while WWII so far, has been the deadliest military conflict in history with over 60 million people killed accounting for slightly over 2.5% of the world's population. MATERIAL AND METHODS: The purpose of this study is to review contemporary wars and their contributions to vascular injury management. It is precisely wartime contributions that have led to the more precise identification and management of these injuries resulting in countless lives and extremities saved. However, surgeons dealing with vascular injuries have faced a tough and arduous road. Their journey was initiated by surgical mavericks which undaunted, pressed on against all odds guided by William Stewart Halsted's classic statement in 1912: "One of the chief fascinations in surgery is the management of wounded vessels." CONCLUSION: Contemporary wars of the XX-XXI centuries gave birth, defined and advanced the field of vascular injury management.

Vascular complications and special problems in vascular trauma.

The evaluation and management of patients with vascular trauma or injury often involve rapid decision making in less than ideal circumstances. Immediate consequences such as hemorrhage, ischemia, compartment syndrome, thrombosis, and embolization may be life threatening and require immediate intervention. In addition, a number of regional and systemic complications of the initial vascular pathology are possible, such as shock, acute renal failure, myocardial infarction, or stroke. Understanding the disease process, as well as the optimal diagnostic and therapeutic interventions, is critically important to minimize the risk of these highly morbid or potentially mortal complications. The managing physician must be adept and well versed at both the initial management of the specific vascular injury and the many potential complications that may subsequently arise. This article will review a number of vascular-specific complications and provide details of strategies for their prevention or optimal management. These problems include traumatic injuries to the arterial or venous system, failure of vascular repairs or reconstructions, surgical site and graft infections, anastomotic complications, and compartment syndromes. In addition, arterial and venous complications secondary to the use of illicit intravenous drug use and cocaine-related vascular injury will be discussed. Finally, the increasingly important topic of iatrogenic or procedure-related vascular injuries and complications will be reviewed.

Iliac vessel injuries: difficult injuries and difficult management problems.

INTRODUCTION: Injury to the iliac vessels poses a serious and frustrating treatment dilemma for all trauma surgeons. Generally, patients present in profound shock secondary to severe hemorrhage from either iliac arterial, venous, or combined injuries. Despite improvements in our emergency medical services (EMS), rapid transport, standard training of trauma surgeons, and improved technology, the morbidity and mortality from iliac vessel injuries remain high, ranging from 25 to 40 %. MATERIALS AND METHODS: A systematic review of the literature, with emphasis placed on the diagnosis, treatment, and outcomes of these injuries, incorporating the author's experience. CONCLUSIONS: Injuries to the iliac vessel remain a daunting task, even after great advances in anatomic injury grading and damage control as well as advances in surgical techniques and critical care. Despite all the advances in treatment and appropriate management strategies, the morbidity and mortality from iliac vessel injuries remain high, demonstrating the complex challenge their treatment presents to even the modern-day trauma surgeon.

Shank vessel injuries: the forgotten vascular injuries.

INTRODUCTION: Vascular injuries in branch vessels of the popliteal artery, such as the tibioperoneal trunk, and shank vessels, such as anterior, posterior tibial, and peroneal vessels, occur in both blunt and penetrating trauma. Their management has evolved significantly in the past few decades. While their incidence is variable, limb loss and morbidity remain significant. MATERIAL AND METHODS: Physical examination, along with measuring an Ankle-Brachial Index (ABI), is still sometimes all that is required for diagnosis and can expeditiously triage those that require urgent operation. Despite our technological advancements and newer algorithms for lower extremity vascular trauma, operative intervention and exposure still remain difficult and pose a great challenge for surgeons that normally do not operate on this area. CONCLUSIONS: Shank vessel injuries still comprise a significant proportion of combat and civilian vascular injuries, and modern advances have led to a dramatic decrease in amputation rates.

Penetrating carotid artery: uncommon complex and lethal injuries.

Carotid arterial injuries are the most difficult and certainly the most immediately life-threatening injuries found in penetrating neck trauma. Their propensity to bleed actively and potentially occludes the airway and makes surgical intervention very challenging. Their potential for causing fatal neurological outcomes demands that trauma surgeons exercise excellent judgment in the approach to their definitive management. The purpose of this article is to review the diagnosis and management of these injuries.

Subclavian vessel injuries: difficult anatomy and difficult territory.

INTRODUCTION: Thoracic and thoracic related vascular injuries represent complex challenges to the trauma surgeon. Subclavian vessel injuries, in particular, are uncommon and highly lethal. Regardless of the mechanism, such injuries can result in significant morbidity and mortality. MATERIALS AND METHODS: Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience. CONCLUSIONS: These injuries are associated with significant morbidity and mortality. Patients who survive transport are subject to potentially debilitating injury and possibly death. Management of these injuries varies, depending on hemodynamic stability, mechanism of injury, and associated injuries. Despite significant advancements, mortality due to subclavian vessel injury remains high.

Operative exposure and management of axillary vessel injuries.

INTRODUCTION: Axillary vessel injuries are uncommon and challenging injuries encountered by trauma surgeons. Proximity of this vessel to other adjacent veins including the axillary vein, brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of associated injuries. MATERIALS AND METHODS: Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience. CONCLUSIONS: Although uncommon, axillary arterial injuries can result in significant morbidity, limb loss and mortality. Early diagnosis and timely repair of the artery leads to good outcomes.

Brachial vessel injuries: high morbidity and low mortality injuries.

INTRODUCTION: Reports of arterial injuries from both the civilian and military arenas report the brachial artery as the most frequently injured vessel, accounting for approximately 25-33% of all peripheral arterial injuries. The brachial artery is surrounded by important peripheral nerves -the median, ulnar and radial, and also parallels the humerus and associated veins. Due to its close proximity to these structures, associated nerve and osseous injuries are frequent with residual neuropathy from such nerve injuries, often the main sources of permanent disability. MATERIALS AND METHODS: Systematic review of the literature, with emphasis in the diagnosis, treatment and outcomes of these injuries, incorporating the authors experience. CONCLUSIONS: The morbidity and mortality rates associated with brachial artery injuries depend on the cause of the injury itself, which vein or tendon is injured, and whether musculoskeletal and nerve injuries are also present. During the last 20 years, amputation associated with upper extremity arterial injuries has decreased to a rate of 3% because of advances in the treatment of shock, the use of antibiotic therapy, and increased surgical experience.

Preliminary study comparing the effects of locally and systemically applied L-carnitine on the healing of full-thickness skin defects.

BACKGROUND AND AIMS: L-carnitine as an endogenous cofactor has a role in the regulation of energy flow between different oxidative sources. The purpose of this study is to investigate that the clinical and histopathologic effects of L-carnitine locally and systemically on secondary healing in wounds of full thickness defects. We also measured the effects of L-carnitine on wound tensile strength as mechanical. MATERIAL AND METHODS: sixty adult male Sprague-Dawley rats were divided into three groups randomly; group 1 (control group, n = 20), group 2 (local experimental group, n = 20), group 3 (systemic experimental group, n = 20). Group 1 was not given any pharmacologic agents. L-carnitine was administered locally in the group 2, and systemically in group 3 for a total of 14 days. The healing days of all groups were recorded. On the 7th, 10th,14th and 21st postoperative days, biopsy specimens, including tissue samples both from healing wound sites and sur-rounding healthy skin were evaluated for neovascularization, inflammation, the amount of collagen deposit, fibroblast migration and re-epithelization. Tensile strength was measured in the samples which completed healing on the 30th day. The results were evaluated by nonparametric Kruskall-Wallis test followed by Mann Whitney-U test. RESULTS: the mean clinical healing days were 18.25 days, 16.5 days, 15 days for the control group, local experimental and systemic group, respectively. The differences between groups were statistically significant (p < 0.005). Mean tensile strength values were 762.10 centinewton (cN), 801.69 cN and 786.13 cN for the control group, local experimental group and systemic experimental group, respectively. There were no statistically significant differences between groups (p > 0.05). There was no statistically significant difference in the histopathologic ex-amination on the 7th, 10th, 14th and 21st days in the neovascularization, inflammation and fibroblast migration. Collagen deposit was most prevalent in the systemic experimental group and was least in the control group. Complete wound closure rate was observed on the 7th day in the systemic administration group, on the 10th day in local administration group and on the 14th day in the control group. Re-epithelization thickness in the systemic carnitine group was more than the other groups. CONCLUSIONS: L-carnitine administered locally or systemically has positive effects on wound healing rate and tensile strength in rats.