Iatrogenic and non-iatrogenic vascular trauma in a district general hospital: a 21-year review.

BACKGROUND: Vascular trauma is associated with significant mortality and severe complications. Vascular injuries in the UK are infrequent, although the exact incidence remains unknown. The objective of this article is to describe patients presenting with vascular trauma to one surgeon over 21 years in a British hospital. METHODS: A retrospective review of prospectively collected data was performed and supplemented by case notes retrieval. Patients' details, including cause and nature of vascular injury, intervention, and long-term survival, were recorded. Statistical analysis was performed by comparison of survival curves using a log-rank test. RESULTS: Eighty-nine patients presented, including 44 men (49%). Iatrogenic trauma accounted for 63 cases (71%) with a median age of 63 years (range = 33-91), and 51 of these cases (81%) occurred either following peripheral angioplasty (n = 40) or after cardiac catheterisation (n = 11). Within the non-iatrogenic group (n = 26), median age was 35 years (range = 15-71), with 19 cases (58%) situated in the lower limb. There were no amputations. Median survival of patients following peripheral vascular intervention was 83 months, compared with 180 months following coronary procedures. No patient died following non-iatrogenic trauma. CONCLUSION: Vascular trauma remains a serious although uncommon phenomenon, with a trend in the UK of increasing iatrogenic trauma. To ensure the best possible outcomes, future rotas and designation of services will need to guarantee the consistent availability of a vascular surgeon. A British national registry on vascular trauma is currently lacking and would assist in identifying national trends and comparing international outcomes and epidemiology.

A large ventricular septal defect complicating resuscitation after blunt trauma.

A young adult pedestrian was admitted to hospital after being hit by a car. On arrival to the Accident and Emergency Department, the patient was tachycardic, hypotensive, hypoxic, and acidotic with a Glasgow Coma Scale of 3. Despite initial interventions, the patient remained persistently hypotensive. An echocardiogram demonstrated a traumatic ventricular septal defect (VSD) with right ventricular strain and increased pulmonary artery pressure. Following a period of stabilization, open cardiothoracic surgery was performed and revealed an aneurysmal septum with a single large defect. This was repaired with a bovine patch, resulting in normalization of right ventricular function. This case provides a vivid depiction of a large VSD in a patient following blunt chest trauma with hemodynamic compromise. In all thoracic trauma patients, and particularly those poorly responsive to resuscitation, VSDs should be considered. Relevant investigations and management strategies are discussed.

An assessment of between-recti distance and divarication in patients with and without abdominal aortic aneurysm.

INTRODUCTION: The study assessed whether there is a greater incidence of divarication of the recti and whether between-recti distance is greater in patients with abdominal aortic aneurysm (AAA). PATIENTS AND METHODS: The study consisted of two parts: a radiological and a clinical assessment. All patients with a confirmed AAA on computerised tomography were included and compared with patients in whom AAA was excluded with imaging. Between-recti distance was measured using a computerised image viewer and clinical divarication was assessed by a surgical registrar or consultant. RESULTS: In the radiological part of the study, 108 patients with AAA were compared with 84 with colorectal cancer. Median between-recti distance was 38 mm (range, 25-59 mm) in the AAA group and 27 mm (range, 20-44.5 mm) in the non-AAA group (P=0.006). AAA diameter did not correlate with between-recti distance. The clinical study included 50 patients (25 AAA). The groups were well matched, with only a greater incidence of diabetes in the AAA group (20% vs 0%; P=0.018). AAA patients were more likely to have clinically detected divarication of the recti (76% vs 36%; P=0.004). CONCLUSIONS: Patients with AAA have greater radiological and clinical evidence of divarication. It is suggested that patients with divarication be screened for AAA.

Perforation of a sigmoid diverticulum presenting with a pneumoscrotum and surgical emphysema.

A case of a sigmoid perforation presenting as a pneumoscrotum with progressive surgical emphysema is reported. An elderly patient presented with a grossly swollen scrotum and a distended abdomen. A computed tomography (CT) scan demonstrated sigmoid diverticulitis in conjunction with air and a subdiaphragmatic collection. A laparotomy was performed and revealed a perforated sigmoid diverticulum (Hinchey III). Sadly the patient died on the operating table. Intra-abdominal pathology manifesting as a pneumoscrotum and surgical emphysema is a rare yet reported phenomenon most often associated with colonoscopy, but also described with appendicitis and perforated colonic carcinoma. In previous reports, in contrast to this patient, the individual's scrotum was inflamed but not erythematous and tender, and the rapid progression of surgical emphysema is not reported.