[Surgical treatment of liver injury--5-year experience].

Due to improved methods of treatment and management of hemorrhage, the mortality from liver injuries has decreased significantly over the past few decades. In spite of that, liver injuries still represent diagnostic and therapeutic challenge. This retrospective study included 197 patients surgically treated because of trauma of the liver at The Clinic for Emergency Surgery, during the period 2004-2009. The results showed significant difference in mortality rates in cases of penetrating wounds compared to blunt trauma and gunshot wounds. The severity of injury evaluated by Organ Injury Scale was significantly higher in gunshot wounds compared to blunt and penetrating trauma. The correlation of severity of injuries and mortality rates showed that the mortality is significantly lower in patients with grade 1, 2, and 3 injuries compared to grades 4 and 5 (p = 0.016). Specific complication rate was 28.4%, while mortality rate was 21.8%. The results reflect diagnostic and treatment problems, as well as the importance of multidisciplinary approach to the patients with liver trauma.

[Surgical treatment of pancreatic injuries in severe abdominal trauma].

In spite of its low incidence, pancreatic injuries hold important place in abdominal trauma because of diagnostic difficulties, severe potential complications, therapeutic challenges, and high mortality rates. These injuries are related with specific morbidity and are very often accompanied with injuries of other organs. This retrospective study included 31 patients treated at The Clinic for Emergency Surgery of Clinical Center of Serbia during the period of 2004-2009 with intraoperativelly confirmed diagnosis of pancreatic trauma. The most common mechanism of injury was blunt trauma (83.9%). Among available diagnostic methods, abdominal ultrasound was characterized with high incidence of false-negative findings (33.3%) while for CT it was at 16.6%. The type of surgical procedure was related to degree and severity of injury. Specific complications occurred in 22.6% of patients, while mortality rate was 25.8%. The creation of unambiguous algorithms for optimal treatment of patients with pancreatic trauma require multi-centric prospective studies.

[Laparoscopy in the evaluation of blunt abdominal trauma].

Laparoscopic diagnostics provides fast, reliable, clear, and obvious information on extent and depth of abdominal organs injury with minimizing additional trauma to the patient. It is performed without any specific preparations and, if needed, it may be promptly converted into conventional laparotomy. Through use of optical equipment with various refraction angles and through variable patient positioning, laparoscopic technique enables visualization of whole abdominal cavity. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Abdominal surgeons are familiar with this method, making interpretaion of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy.

[Surgical treatment of injuries of the stomach and duodenum in abdominal trauma].

Injuries of the stomach and duodenum have an important place in abdominal trauma, even though that the isolated injuries are rare. This kind of injury is most commonly associated with injuries of other abdominal organs. This retrospective study has been done at the Department of Emergency Surgery, Clinical Centre of Serbia, during the period from January 2004. until January 2009. The study included 36 patients diagnosed intraoperatively with the injury of the stomach and duodenum. The most common mechanism of harming were injuries due to blunt trauma (41.7%), the ones followed by gunshot wounds (30.5%), and the least were stab injuries (27.8%). With the majority of patients has been conducted sutures (46.3%) and serosation (30.6%) of the stomach and duodenum. In 24 (66.7%) patients on admission have been done ultrasound of the abdomen, in 6 (16.7%) abdominal CT was done, in 4 (11.1%) peritoneal lavage have been done and the x-ray of the abdomen was performed in 3 (8.3%) patients. Specific complications had 1 (2.8%) patient, while 14 (29.9%) patients have had non-specific complications. Total mortality has been 33.3%

[Hanging manuever in liver trauma].

The phylosophy of aggressive surgical approach, its complete implementation in liver trauma surgery did not appear efficient. No matter of permanenent development of diagnostic imaging methods, anesthesia, intensive therapy, medical technology and suture materials, operational theater and operative tchniques, major liver resections in trauma had mortality rate up to 60%. With introduction of computerized tomography (CT, 1981) in everyday clinical praxis and with better evaluation of trauma patients, the whole approach to liver trauma patient has been redesigned. Based on AAST-OIS classification, almost 70% of traumatized with grade I, II and III sholud be treated non-operatively, hospitally, with repeating FAST (focused abdominal ultrasound in trauma) and abdominal CT scans. The rest of traumatized patients, with grade IV and V injuries of juxtahepatic structures demand complexive surgical treatment. The modalities of surgical treatment depend on trauma mechanisms, extensivity, anatomical localisation and affection of vascular structures. Hanging Manuevr--the Method of French surgeon Belghiti bases on anterior approach in liver resection is a try for fast solution for fatal bleeding in liver trauma. It consists of placing the elastic cord throughout the anterior surface of VCI or ligamentum venosusm, of upper end of the cord is located in superior part of VCI where hepatic veins are emerging. Lower end of the cord is located in subhepatic part of VCI between 3 Glisonian pedicles. Concerning hepatic veins liver is divided in 3 sections, which derives blood in right hepatic vein RHV, middle hepatic vein MHV and left hepatic vein LHV. Belghiti proposed the usage of hanging maneuver when resecting the right liver, while the cord is placed throughout retrohepatic VCI, lower end between elements of Glisonian pedicle and upper end between hepatic veins. Complications like bleeding from caudal veins are minimal, then speed in liver resection in hemodynamic unstable and ishemic patient, defects like bleeding because compressing tapes or lesions IVC tile mobilazion of liver for conventional resection.

[Relation between cytokine IL-6 levels and the occurrence of systemic complications in patients with multiple injuries and blunt abdominal trauma]. / Odnos nivoa citokina IL6 i ucestalosti sistemskih komplikacija kod politraumatizovanih sa tupom abdominalnom traumom.

Severe trauma is the third cause of death and the first one in the most vital and young population. In USA more children die of trauma then of all other causes. Blunt abdominal trauma takes 56% cases of multiple traumas of all etiologies. Among multiple injured patients, near to 50% have some system-complications, more of 60% in the group of critically injured (ISS > 35). Cytokines play the main role in the inflammatory reaction during the early phase response on trauma. Their secretion predicts system-complications as ARDS, SIRS, even MODS. Hypothetically, level of concentration of Interleukin-6 (IL 6) can improve methods of early diagnostic procedures for detecting SIRS and MODS, when scores are still low (preclinical level), at which stages therapy is more powerful and also cheaper. This prospective study includes 35 multiple injured persons with blunt abdominal trauma (75 > ISS > 18). We have used standard diagnostic procedures. Concentration of IL 6 was detected with ELISA-test. Levels of IL 6 were significantly higher in correlation with SIRS score groups. Correlation with MODS score was not significant for the lowest scores, but IL 6 showed significant higher levels in the second and the third MODS score group.