Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota's fascia.

BACKGROUND: Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. METHODS: A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. RESULTS: A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8-99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota's fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. CONCLUSIONS: NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota's fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.

A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management.

BACKGROUND: Global trends of penetrating abdominal trauma (PAT) have seen a shift toward a selectively conservative management strategy. However, its widespread adoption for gunshot injuries has been sluggish. The purpose of this study is to compare the injury mechanisms of gunshot (GSW) and stab wounds (SW) to the abdomen in presentation, management, and outcomes. METHODS: Prospective cohort study, set in Cape Town, South Africa, over 2 years. All patients presenting to the center with PAT during this time were included. Presentation, management, and outcomes were compared by injury mechanism, with a focus on the operative strategy (operative vs nonoperative). RESULTS: During the study period, 805 patients (SW 37.6%; GSW 62.4%) with PAT were managed. Immediate laparotomies were performed in 119 (39.3%) SW and 355 (70.7%) GSW, with a therapeutic laparotomy rate of 85.7% and 91.8% for SW and GSW, respectively. Nonoperative management (NOM) was implemented in 184 SW (60.7%) and 147 GSW (29.3%) (P < 0.001), with a 92.9% and 92.5% success rate for SW and GSW, respectively. The therapeutic laparotomy rate for the delayed laparotomies (DOM) was 69.2% for SW, and 90.9% for GSW. The accuracy of clinical assessment (with adjuncts) in determining the need for laparotomy was: GSW-92% and SW-91%. Univariate analysis revealed the mechanism not to be associated with DOM. The overall mortality rate was 7.2%, and nonfatal morbidities 22.2%. CONCLUSION: Although GSW is a more morbid and often fatal injury, the general principles of selective conservatism hold true for both GSW and SW, equally.

Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center.

BACKGROUND: Global trend has seen management shift towards selective conservatism in penetrating abdominal trauma (PAT). The purpose of this study is to compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively. METHODS: Prospective cohort study of all patients Ùpresenting with PAT to Groote Schuur Hospital, Cape Town from 01 May 2015 to 30 April 2017. Presentation; management; and outcomes of patients were compared. Univariate predictors of delayed operative management (DOM) were explored. RESULTS: Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3 years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05). CONCLUSION: Patients with PAT in the absence of haemodynamic instability; peritonism; organ evisceration; positive radiological findings, or an unreliable clinical examination, can be managed expectantly without increased morbidity or mortality.

The gap in operative exposure in trauma surgery: quantifying the benefits of an international rotation.

BACKGROUND: International rotations with hands-on experience are commonly cited as a potential supplement to the current experience of surgical trainees in trauma; however, quantification of this experience remains unclear. METHODS: A link to an online survey was distributed by electronic mail to physicians who rotated for any period of time at the Trauma Unit of the Groote-Shuur Hospital of the University of Cape Town from January 1, 2006, to December 2016. RESULTS: Of 160 participants, 75 (47%) completed the survey. A high proportion (45%) had performed less than 25 trauma-related surgical procedures during their previous training. Most (56%) performed ≥ 10 trauma laparotomies and sternotomies/thoracotomies during their rotation, whereas 43% performed ≥ 5 vascular procedures. The level of perceived confidence in managing trauma patients increased significantly from a median of 3/10 to 7/10 (P < .05). CONCLUSION: Rotations at large-volume trauma centers abroad offer the opportunity for a hands-on operative experience and may enhance the confidence of surgical trainees. Further standardization of these opportunities may result in a larger-scale participation of graduate residents and fellows.

An Update on Foley Catheter Balloon Tamponade for Penetrating Neck Injuries.

BACKGROUND: Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT. METHODS: Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes. RESULTS: During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9 years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72 h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound. CONCLUSION: This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011.

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Selective nonoperative management of liver gunshot injuries.

PURPOSE: Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. METHODS: A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. RESULTS: During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. CONCLUSION: The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.

Penetrating femoral artery injuries: an urban trauma centre experience.

AIM: This study reviews a single centre experience with penetrating femoral artery injuries. PATIENTS AND METHODS: The records of all patients with femoral artery injuries admitted to the Trauma Centre at Groote Schuur Hospital from January 2002 to December 2012 were reviewed. These were analysed for demographics, injury mechanism, perioperative, and surgical management. Outcome was categorised by limb salvage. RESULTS: One-hundred and fifty-eight (158) patients with femoral artery injuries were identified. There were 144 (91%) men and 14 women with a mean age of 28 years. Ninety-five percent (N = 150) sustained penetrating injuries. The superficial femoral artery (87%) was most commonly injured. The most common type of arterial injury was a laceration (39%) and transection (37%). Eighty-one (51%) patients had a primary repair, 53 (33%) patients had a vein interposition graft, and 16 patients (10%) had a prosthetic graft. There were 78 (51%) concomitant venous injuries, 11 were repaired, and 1 vein patch repair was performed (15.4%). There were 4 (2.5%) primary amputations and 10 (6.5%) secondary amputations. There were no deaths. Statistically significant risk factors for secondary amputation derived by univariate analysis were: ischaemia (p < 0.0001), neurological deficit due to ischemia (p < 0.001), temporary vascular shunting (p < 0.001), and the absence of a palpable pulse post-repair (p < 0.01). CONCLUSION: This study has a primary and secondary amputation rate of 2.5 and 6.5%, respectively. There was greater than 90% limb salvage rate. The outcome of threatened limbs due to femoral artery injury is good, provided that there is no delay to surgery.

The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis.

BACKGROUND: The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status. METHODS: This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days. RESULTS: A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days. CONCLUSIONS: Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.

Penetrating trauma to the kidney and Meckel's Diverticulum in a patient with unilateral renal agenesis.

INTRODUCTION: Emergency laparotomy for abdominal gunshot wounds is frequently performed in South Africa and remains associated with significant morbidity and mortality. The occurrence of congenital anomalies during surgery is an unexpected finding and presents a major challenge. PRESENTATION OF CASE: The successful management of a haemodynamically unstable 26-year-old man with unilateral renal agenesis, concomitant right renal and hepatic injuries, and a transected Meckel's Diverticulum following an abdominal gunshot wound is presented. DISCUSSION: Intraoperative decision-making is difficult when congenital visceral anomalies form part of the injury complex in trauma. Basic principles of damage control surgery that include initial exploration, secondary resuscitation and definite operation must be adhered to. Repair of complex injuries are delayed until the definitive laparotomy. The presence of one congenital anomaly should alert the surgeon to the possibility of further anomalies. CONCLUSION: Although congenital visceral anomalies are spectacular findings at laparotomy, they should not distract the trauma surgeon. Adhering to damage control surgery principles and careful inspection of the peritoneal cavity for further abnormalities remain the mainstay of successful management.

Time since injury is the major factor in preventing tranexamic acid use in the trauma setting: An observational cohort study from a major trauma centre in a middle-income country.

BACKGROUND: Haemorrhage is responsible for about a third of in-hospital trauma deaths. The CRASH-2 trial demonstrated that early administration of tranexamic acid, ideally within 3 hours, can reduce mortality from trauma-associated bleeding by up to 32%. OBJECTIVE: To explore whether, in our trauma network in a middle-income country, patients arrived at hospital soon enough after injury for tranexamic acid administration to be effective and safe. METHODS: A prospective cohort study of 50 consecutive patients admitted to our trauma unit was undertaken. Inclusion criteria were as for the CRASH-2 study: systolic blood pressure <90 mmHg and/or heart rate >110 beats per minute, with injuries suggestive of a risk of haemorrhage. Patients with isolated head injuries were excluded. The mechanisms of injury, time since injury and any reasons for delay were recorded. RESULTS: Thirteen (26%) patients presented early enough for tranexamic acid administration. Of these, only three patients presented within the 1st hour. Eleven patients had a documented time of injury >3 hours prior to presentation. We were unsure of the time of injury for 26 patients, although for most of these it was likely to be >3 hours before presentation. CONCLUSIONS: The majority (74%) of bleeding trauma patients did not present within the timeframe allowed for safe administration of tranexamic therapy. Of those who did, most would have benefited from even earlier commencement of therapy. This raises the possibility that tranexamic acid may be more effective on a population basis if incorporated into prehospital rather than in-hospital protocols; future studies should explore the benefits and risks of this approach.

Selective nonoperative management in 1106 patients with abdominal gunshot wounds: conclusions on safety, efficacy, and the role of selective CT imaging in a prospective single-center study.

OBJECTIVE: The primary aim of this study was to delineate the role of computed tomography (CT) in patients undergoing NOM for AGSW. BACKGROUND: Nonoperative management (NOM) of abdominal gunshot wounds (AGSWs) remains controversial. METHODS: This prospective study included all patients with abdominal gunshot injuries admitted to our trauma center from April 1, 2004 to September 30, 2009. Exclusion criteria included patients with peritonitis, hemodynamic instability, unreliable physical examination, head and spinal cord injury with an AGSW underwent immediate laparotomy. The remaining patients were selected for NOM. Nonperitonitic stable patients with right-sided thoracoabdominal/right upper quadrant gunshots and/or hematuria underwent mandatory CT with intravenous contrast. CT to detect missile trajectory was optional. The primary outcome measure was failure of NOM. Secondary outcomes were unnecessary laparotomy rates and mortality. RESULTS: A total of 1106 patients with abdominal gunshot injuries were admitted. Of these, 834 (75.4%) underwent immediate laparotomy, whereas 272 (24.6%) were selected for NOM. In the former group, there were 56 (6.7%) deaths and 29 (3.5%) unnecessary laparotomies, whereas in the latter NOM group, 82 (30.1%) patients were managed by serial clinical examination alone, whereas 190 (69.9%) patients underwent abdominal CT scanning, in addition to serial clinical examination. The overall NOM success rate was 95.2%. Of the 13 patients undergoing delayed laparotomy, there were 10 therapeutic, 2 nontherapeutic, and 1 negative laparotomy. CONCLUSIONS: The NOM of appropriately selected patients with AGSW with selective use of CT scanning is feasible, safe, and effective, but largely based on findings from serial clinical examinations.

Management of biliary complications in 412 patients with liver injuries.

BACKGROUND: Bile leaks occur in 4% to 23% of patients after major liver injuries. The role of conservative management versus internal biliary drainage has not been clearly defined. The safety and efficacy of nonoperative management of bile leaks were studied. METHODS: Four hundred twelve patients with liver injuries were assessed in a prospective study between 2008 and 2013. All patients with clinically significant injuries to the intrahepatic biliary tract were evaluated. Bile leaks were classified as minor or major (>400 mL/d or persistent drainage >14 days). Minor leaks were managed conservatively, and major leaks underwent endoscopic retrograde cholangiogram and endoscopic biliary stenting. RESULTS: Fifty-one patients (12%) developed a bile leak after liver trauma. Eleven patients (22%) with an extrahepatic duct injury underwent open surgery. Forty patients (78%) had an intrahepatic bile leak. Twenty-six patients (65%) with minor bile leaks were treated conservatively, and 14 patients (35%) with major leaks underwent endoscopic retrograde cholangiogram and internal drainage. All bile leaks resolved. There was no significant difference in the two groups with respect to septic complications (p = 0.125), intensive care unit stay (p = 0.534), hospital stay (p = 0.164), or mortality (p = 1.000). CONCLUSION: Sixty-five percent of the intrahepatic bile leaks following trauma are minor and easily managed conservatively. Endoscopic retrograde cholangiogram and internal drainage should be reserved for major leaks. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Management of a pneumopericardium due to penetrating trauma.

INTRODUCTION: A pneumopericardium presenting after penetrating chest trauma is a rare event. The surgical management of this clinical problem has not been clearly defined. The aim of this study was to document the mode of presentation and to suggest a protocol for management. PATIENT AND METHODS: A review of a prospectively collected cardiac database of patients presenting to Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 with a pneumopericardium on chest X-ray after penetrating trauma. RESULTS: There were 27 patients with a pneumopericardium (mean age 25 years, range 17-36). The mechanism of injury was a stab wound to the chest in 26 patients and a single patient with multiple low velocity gunshot wounds. Six patients (22%) were unstable and required emergency surgery. One of these patients presented with a tension pneumopericardium. Twenty-one patients were initially stable. Two of these (10%) patients later developed a tension pneumopericardium within 24-h and were taken to theatre. The remaining 19 patients were managed with a subxiphoid pericardial window (SPW) at between 24 and 48h post admission. Ten of these 19 patients (52%) were positive for a haemopericardium. Only 4 of the 19 underwent a sternotomy and only two of these had cardiac injuries that had sealed. There were no deaths in this series. CONCLUSION: Patients with a penetrating chest injury with a pneumopericardium who are unstable require emergency surgery. A delayed tension pneumopericardium developed in 10% of patients who were initially stable. It is our recommendation that all stable patients with a pneumopericardium after penetrating chest trauma should undergo a SPW. A sternotomy is not required in stable patients.

Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial.

OBJECTIVE: To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone. BACKGROUND: The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed. METHODS: A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay. RESULTS: Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3). CONCLUSIONS: SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).

Civilian popliteal artery injuries.

BACKGROUND: Civilian popliteal artery injuries are associated with significant amputation rates. AIM: The aim of this study was to identify factors associated with limb loss in patients with popliteal artery injuries. PATIENTS AND METHODS: We performed a retrospective chart review of prospectively collected data on patients with popliteal artery injuries presenting to the Trauma Centre at Groote Schuur Hospital, Cape Town, from 1 January 1999 to 31 December 2008. Demographic data, mechanism of injury, haemodynamic status, limb viability, special investigations, associated injuries, ischaemic time, surgical treatment and amputation rates were analysed. RESULTS: One hundred and thirty-six patients with popliteal artery injuries were identified. Penetrating and blunt trauma accounted for 81 (59.6%) and 55 (40.4%) injuries, respectively. Associated injuries included fractures in 66 patients (48.6%), knee dislocations in 29 (21.3%) and popliteal vein injuries in 59 (43.4%). Fifty-seven patients (41.9%) presented with a compartment syndrome. Arterial injuries were treated with reversed vein grafting in 68 patients, primary anastomosis in 33, prosthetic graft insertion in 11, and primary amputation in 7. Thirty-two patients underwent delayed amputation, giving an overall amputation rate of 37.5%. A delay of more than 7 hours of ischaemic time between injury and definitive repair (p=0.0236) and the presence of a compartment syndrome (p=0.003) were significantly associated with an increased amputation rate. CONCLUSION: The most significant factors associated with the high amputation rate of 37.5% were an ischaemic time longer than 7 hours, and the presence of a compartment syndrome.

Civilian penetrating axillary artery injuries.

BACKGROUND: The surgical management and outcome of penetrating axillary artery (AA) injuries is presented. PATIENTS AND METHODS: Patients presenting to Groote Schuur Hospital with penetrating AA injuries from January 2003 to December 2009 were reviewed. Demographic data, mechanism of injury, associated injuries, angiographic findings, surgical treatment, complications, and mortality were noted. RESULTS: Sixty-eight patients with AA injuries were identified from an operating trauma database. Stab and gunshot wounds accounted for 54 (79.4%) and 14 injuries, respectively. The mean Revised Trauma Score was 7.5 (range: 3.8-7.8). Angiography was done in 49 patients; false aneurysms (32) and total occlusions (15) were the two commonest findings. Primary repair of the injured AA was possible in 41 (60.3%) patients. Five AA (7.4%) injuries were ligated. Morbidity was restricted to associated brachial plexus injuries. The limb salvage rate was 100%. CONCLUSIONS: Primary repair of AA injuries was possible in 60% of patients, and ligation was life-saving in critically ill patients. The associated brachial plexus injury was the cause of major long-term morbidity.

Nonoperative management of pelvic gunshot wounds.

BACKGROUND: The nonoperative management (NOM) of abdominal gunshot injuries is gradually becoming the standard of care. Patients with pelvic gunshot injuries constitute a subgroup of patients at high risk of visceral injury. The aim of this study was to assess the feasibility and safety of the selective NOM of pelvic gunshot injuries. PATIENTS AND METHODS: This prospective study was performed from April 1, 2004, to November 30, 2008. Patients with pelvic gunshot injuries underwent laparotomy for peritonitis, hemodynamic instability, rectal bleeding, and urologic injuries. Patients with benign abdominal findings with hematuria underwent computed tomography scanning with intravenous contrast. Stable patients with no tenderness or minimal tenderness confined to the wound or wound tract underwent serial abdominal examination. Outcome parameters included need for delayed laparotomy, complications, length of hospital stay, and survival. RESULTS: During the 54-month study period, 239 patients with pelvic gunshot injuries were treated. One hundred seventy-six (73.6%) patients underwent immediate laparotomy, whereas 63 (26.4%) were selected for NOM. The nontherapeutic laparotomy rate was 4.5% in the former group, and no patient required delayed laparotomy in the latter group. Also, 3 patients with minor extraperitoneal bladder injuries were successfully managed nonoperatively. Associated injuries included mostly fractures to the bony pelvis including the iliac blade (19), pubic ramii (3), and acetabulum (3). The mean hospital stay was 2.2 (range 1-8) days in the nonoperative group of patients. There were no deaths. CONCLUSIONS: Selective NOM of pelvic gunshot injuries is a feasible, safe, and effective alternative to routine laparotomy.