High-grade renal trauma in children and adolescents can be successfully managed non-operatively.

BACKGROUND: This paper reviews our experience with management of renal injuries in children and adolescents with a focus on the outcome of non-operative management (NOM). METHODS: Retrospective review of the clinical characteristics, injury grade (I-III, low grade and IV and V high grade), management and outcomes of children ≤ 18 years old with renal trauma presenting to a major trauma centre in South Africa between December 2012 and October 2020. RESULTS: Sixty-one children with a renal injury were identified with a median age of 13 (range 0-18) years. Forty-five were boys; blunt and penetrating mechanisms of trauma were sustained by 55 (90%) and six (10%) children, respectively. The median American Association for the Surgery of Trauma (AAST) grade of renal injury was 3 (range 1-5): this included eight (13%) with grade I, six (10%) with grade II, 17 (28%) with grade III, 20 (46%) with grade IV and 10 (16%) with grade V injuries. Forty children (66%) were successfully managed non-operatively and 21 required a laparotomy; of these six (28%) required nephrectomy. The overall renal salvage rate was 55/61 (90%). Children who required laparotomy were significantly more likely to have sustained a penetrating mechanism of injury (24% vs 2%) and have greater length of hospital stay (median 9 vs 3 days) compared to children managed non-operatively (p < 0.05). Children who underwent a nephrectomy had a significantly greater length of hospital stay (median 9 vs 4 days, p = 0.03); however, their demographics, outcomes developed complications. Two children (3%) died; one managed non-operatively and one with a laparotomy. CONCLUSION: Paediatric renal trauma can be successfully managed non-operatively in over two-thirds of cases in this middle-income country. High grade of renal injury does not absolutely predict need for surgery or nephrectomy and can be managed non-operatively.

The neglected epidemic of trauma from interpersonal violence against the elderly in South Africa.

BACKGROUND: Geriatric injuries comprise a significant burden in the developed world but much less are known in the developing world setting. This study aims to review our experience of geriatric injuries with a focus on interpersonal violence (IPV) managed at a major trauma centre in South Africa. METHODS: This was a retrospective study on all patients who were aged > 65 years admitted to our trauma centre from January 2013 to December 2020, based in Pietermaritzburg, South Africa. RESULTS: Over the 8-year study period, 323 cases were included (62% male, mean age 72 years). Mechanism of injury: 80% blunt, 16% penetrating and 4% others. The median injury severity score (ISS) was 9. The median Charlson comorbidity index (CCI) for all 323 cases was 3. Diabetes (n = 53) was the most prevalent comorbidity which was followed by pulmonary disease (n = 23), cerebral vascular accidents (n = 16) and myocardial infarction (n = 15). Fifteen patients were on antiretroviral therapy (5%). Twenty-four per cent required surgical intervention. Eight per cent of cases experienced one or more complications. Twenty-five per cent (80/323) were related to IPV, 61% (49/80) of these were penetrating injuries and the remaining 31 cases were blunt injuries. Of the 49 cases of penetrating injuries, 33 were gunshot wounds (GSWs) and 16 were stab wounds (SWs) (1 GSW and 2 SWs were self-inflicted and were not included in IPV). Those cases that resulted from IPV were significantly more likely to require operative intervention, experience complications and longer lengths of hospital stay. Geriatric patients had poorer outcomes than non-geriatric patients and rural geriatric patients had worse outcomes than urban geriatric patients. CONCLUSION: Although the burden of geriatric trauma in South Africa appears to be relatively low, it is associated with significant morbidity and mortality. Trauma from interpersonal violence is especially common and is associated with significantly worse outcomes than that of non-interpersonal violence-related trauma. Elderly rural trauma victims have worse outcomes than their urban counterparts.

Transdiaphragmatic pericardial washout post penetrating cardiac injury found incidentally at diagnostic laparoscopy.

SUMMARY: A 22-year-old male presented following a precordial stab. He was haemodynamically and metabolically normal. Initial investigations did not reveal pericardial fluid or haemothorax. At diagnostic laparoscopy, we encountered haemoperitoneum and a diaphragmatic injury through which the heart was visible. After pericardial washout, laparoscopic repair was effected. This case highlights a potential problem with extended focused assessment with sonography in trauma (eFAST) in that it will only be positive if there is an accumulation of pericardial fluid. It also confirms the utility of diagnostic laparoscopy for penetrating left thoracoabdominal injuries and shows that principles of open surgery can be safely applied laparoscopically in select patients.

An audit of trauma laparotomy in children and adolescents highlights the role of damage control surgery and the need for a trauma systems approach to injury in this vulnerable population.

BACKGROUND: This study reviews the indications and outcome of emergency laparotomy for paediatric trauma in a South African trauma centre. METHODS: This was a retrospective study of all children less than 18 years of age who underwent an emergency laparotomy for trauma between December 2012 and October 2020 at Grey's Hospital in Pietermaritzburg. RESULTS: During the eight-year period under review, a total of 136 children of which 107 were male underwent a laparotomy for trauma. The median age was 14 years. There were 80 (57.1%) blunt mechanisms, and the rest were penetrating mechanisms. A total of 46 (33%) patients required ICU admission. Thirty-four patients developed a complication. These included nine cases of pneumonia, one case of renal failure, two patients developed abdominal collections, three woundrelated complications, three neurological complications and one miscellaneous complication. There were seven (5%) deaths. The penetrating cohort were older than the blunt cohort. Solid viscera were more likely to be injured in the blunt cohort and hollow viscera more likely in the penetrating cohort. A total of 16 (11%) patients underwent damage control surgery (DCS). Of this cohort, there were three female children. Six sustained blunt trauma and ten penetrating trauma. A total of six (37%) of these children died. CONCLUSION: Emergency laparotomy for trauma in children is not infrequent in Pietermaritzburg and there is a high incidence of penetrating trauma in this cohort. The response to increased degrees of physiological derangement is the application of DCS. Ongoing efforts to develop and strengthen a paediatric trauma service appear to be justified.

Childhood and adolescent trauma in Pietermaritzburg is a neglected sub-epidemic within a larger epidemic and warrants a dedicated service.

BACKGROUND: This study reviews our experience with paediatric trauma to help plan and strengthen ongoing strategies to deal with trauma in our region. METHODS: All children and adolescents less than 18 years of age who were admitted to our centre following trauma between December 2012 and October 2020 were reviewed. RESULTS: Over the 8-year period, 2 091 children were admitted with trauma to Grey's Hospital. There were 1 479 (71%) male patients, median age: 10 years. One thousand four hundred and fifty-eight (70%) patients were referral from rural regions. In 1 597 (76%) patients, the mechanism of injury was blunt trauma. A total of 387 (19%) patients underwent a surgical intervention, whilst 1 641 (78%) patients were managed non-operatively. In 63 patients, management records were missing. Multiple patients required multiple surgical procedures. A total of 144 patients had a laparotomy, 70 a soft tissue debridement procedure, 40 an orthopaedic procedure, 53 a neurosurgical procedure, which included 37 patients who underwent craniotomy, and 18 patients underwent a fasciotomy for compartment syndrome. There were 82 patients who required miscellaneous procedures. A total of 213 (10%) patients required ICU admission. There were 48 (2.3%) deaths. CONCLUSION: The volume of child and adolescent trauma managed is significant and suggests that a dedicated paediatric trauma service in the region is warranted. It is hoped that future partnering with appropriate stakeholders will allow this service to continue to mature and provide leadership in all aspects of care of injured children in the region.

Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach.

BACKGROUND: Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a 'no-zone' approach to PNI is valid. METHODS: Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared. RESULTS: In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination. CONCLUSION: An approach to PNI based on zones is questionable, and this study supports a no-zone approach based on imaging guided by clinical examination.

ANTECEDENTES: Muchos protocolos actuales para el manejo de lesiones penetrantes en el cuello (penetrating neck injury, PNI) aún proponen un enfoque zonal. Este estudio se llevó a cabo para determinar la correlación entre la zona de la herida externa y el nivel de la lesión interna y para comprobar si sería válido un enfoque "sin zonas" para la PNI. MÉTODOS: Los pacientes con PNI ingresados en un centro terciario de traumatología entre enero de 2011 y mayo de 2018 fueron identificados a partir de la base de datos del centro. Se incluyeron pacientes con lesión confirmada vascular o lesión del tracto aero-digestivo (aero-digestive tract injury, ADTI). Se revisaron las historias clínicas de cada paciente con respecto a la zona de la herida externa y el nivel de lesión interna, comparándose dichos hallazgos. RESULTADOS: En el período de estudio, 1.075 pacientes fueron tratados por una PNI. De estos, 298 (27,7%) tenían una lesión vascular o una ADTI confirmadas y se incluyeron en la cohorte. En 176 pacientes (59,1%), la lesión interna estaba localizada en la misma zona de la herida externa. En otros 70 pacientes (23,5%), no hubo correlación entre la localización de la lesión interna y la herida externa y en los 52 pacientes restantes (17,4%) no se pudo determinar dicha correlación. En esta cohorte, todos los pacientes clínicamente evaluables con lesiones significativas presentaban signos físicos sugestivos de lesión o enfisema profundo con indicación quirúrgica en el examen radiológico. CONCLUSIÓN: El enfoque de la PNI basado en zonas es cuestionable y este estudio apoya un enfoque de "sin zonas" basado en pruebas de imágen basadas en los hallazgos clíncos.

Penetrating trauma in children and adolescents in Pietermaritzburg.

BACKGROUND: This project aims to review the spectrum and outcome of penetrating trauma in children and adolescents with the objective of defining the extent of the problem and of developing strategies to reduce the incidence and severity of this form of trauma. METHODS: All patients less than eighteen years of age who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) following penetrating trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR). RESULTS: During the five-year period under review, a total of 164 patients less than eighteen years of age sustained penetrating trauma and were admitted to the PMTS. There were 138 males and 26 females. The mean age was 13.29 years and the median age 15 years. There were 70 stab wounds (SW) and 73 gunshot wounds (GSW). There were 21 non-intentional impalement injuries. The mean ISS was 9.04 and the median was 9. A total of 155 plain X-rays were performed, 50 CT scans and 51 CT angiograms in this cohort of patients. Only two ultrasound examinations were performed. A total of 76 patients required an operation, which included 50 laparotomies. Of the patients who underwent a laparotomy, 18 required a repeat laparotomy. There were 46 other procedures undertaken in this cohort of patients, which included two thoracotomies, three laparoscopies and two thoracotomies. The median hospital stay was 2 days and 17 (10%) patients required ICU admission and 7 (4%) died. CONCLUSION: Penetrating trauma in children and adolescents is associated with significant mortality and morbidity. There are similarities with the management of these injuries in adults, but further work is required to ensure that paediatric management algorithms are evidence based.

A comparison of blunt and penetrating pancreatic trauma.

BACKGROUND: This project reviews our experience with managing pancreatic trauma from 2012 to 2018. METHODS: All patients over the age of 15 years with a pancreatic injury during the period December 2012-December 2018 were retrieved from the Hybrid Electronic Medical Registry at Grey's Hospital and reviewed. RESULTS: During the study period 161 patients sustained a pancreatic injury. The mechanism of trauma was penetrating in 86 patients (53%) and blunt in 75 (47%). The blunt mechanisms included MVA in 27, PVA in 15, falls in four and assaults in the remaining 29. There were 52 stab wounds and 34 gunshot wounds of the pancreas. A total of 26 patients (16%) were shocked on presentation with a systolic blood pressure of 90 mm Hg or less. The median injury severity score was 16. There were 90 patients with American Association for the Surgery of Trauma (AAST) grade I injury to the pancreas, 36 AAST grade II, 27 AAST grade III, 7 AAST grade IV and a single AAST grade V. Fifty-four patients (34%) were initially treated non-operatively of which three eventually required surgery. Of the patients who required surgery, 26 (16%) underwent a distal pancreatectomy. The remainder simply underwent pancreatic drainage. The overall mortality rate was 13% (21/161). The operative mortality was 11% (18/161). Thirteen patients (8%) with penetrating injuries and eight patients (5%) with blunt injuries died. Of the 21 patients who died, 14 had multiple injuries. Five patients died due to overwhelming sepsis. One patient died due to hypovolemic shock and another due to a traumatic brain injury. CONCLUSION: Our centre not infrequently deals with pancreatic trauma secondary to both blunt and penetrating trauma. We follow the general principles outlined in the literature. Despite this, pancreatic trauma is still associated with significant morbidity and mortality.

An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa.

BACKGROUND: There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact. OBJECTIVES: To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error. METHODS: The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed. RESULTS: During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang's taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114. CONCLUSIONS: Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan.

The spectrum of animal related injuries managed at a major trauma centre in South Africa.

BACKGROUND: Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South Africa. METHOD: All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMR). RESULTS: There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients died. CONCLUSION: Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions.

Isolated free fluid on computed tomography for blunt abdominal trauma.

INTRODUCTION: The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit's experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma. MATERIALS AND METHODS: All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study. RESULTS: During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%. DISCUSSION: In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.

Trauma electives in South Africa provide valuable training for international surgeons.

BACKGROUND: Trauma electives in South Africa (SA) are common and many foreign-based surgeons have undertaken such electives over the past 3 decades. Despite this, little academic attention has been paid to these electives, which remain largely informal and unstructured. This project aims to redress this deficit. OBJECTIVES: To investigate and document the extent of trauma clinical electives and to assess their impact on the careers of foreign surgeons who have undertaken such electives. METHODS: A mixed methods-style questionnaire was compiled, which sought to document the demographics of surgeons undertaking an SA trauma clinical elective, the trauma clinical experience they had prior to the elective, as well as the volume of experience they acquired during the elective. RESULTS: Sixty questionnaires were sent out and 21 were completed. There were 16 male and 5 female respondents. Only 17 had undertaken a formal trauma rotation before their elective in SA. The mean number of major resuscitations managed prior to rotating through surgery departments in SA was 15, and the mean number managed during a 12-month rotation in SA was 204. It would take each respondent 14 years in their country of origin to acquire an equivalent level of exposure to major resuscitation. During the year before their elective, each surgeon had been exposed to a mean number of the following: 0.5 gunshot wounds (GSWs), 2 stab wounds (SWs), 0.1 blast injuries and 19 road traffic accidents (RTAs). The equivalent mean number for their year in SA was 106 GSWs, 153 SWs, 4 blast injuries and 123 RTAs. The time necessary to achieve a similar level of exposure to their SA experience if they had remained in their country of origin was 213 years for GSWs, 73 years for SWs, 41 years for blast injuries and 7 years for RTAs. Compared with their SA elective, it would take each respondent 3 years to insert as many central venous lines, 9 years to perform the same number of tube thoracostomies, 9 years to manage as many surgical airways, 18 years to explore as many SWs of the neck and 93 years to explore as many GSWs of the neck. Furthermore, it would take 33 years to see and perform as many laparotomies for SWs to the abdomen, 374 years to perform an equivalent number of GSWs to the abdomen and 34 years of experience to perform as many damage-control laparotomies in their countries of origin. In terms of vascular trauma, it would take 23 years to see as many vascular injuries secondary to SWs and 77 years to see an equivalent number of vascular injuries secondary to GSWs. CONCLUSIONS: A trauma clinical elective in SA provides an unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support programme. Formalising these trauma electives might allow for the development of exchange programmes for SA trainees who wish to acquire international exposure to advanced general surgical training.

The Hybrid Electronic Medical Registry Allows Benchmarking of Quality of Trauma Care: A Five-Year Temporal Overview of the Trauma Burden at a Major Trauma Centre in South Africa.

INTRODUCTION: This study is a five-year follow-up of previously published review of the trauma workload at our institution. It aims to provide evidence about the quality of trauma care delivered by a major academic trauma service in South Africa to provide a temporal analysis of trauma trends in the city of Pietermaritzburg. MATERIALS AND METHODS: All trauma patients admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS) for the period December 2012-April 2018 were retrieved from the Hybrid Electronic Medical Registry (HEMR) for analysis. RESULTS: Over the five-year period, a total of 8722 trauma patients were admitted to Grey's Hospital. There were 7242 (83.0%) males. The average age was 29.66 years. A total of 1719 (19.7%) patients less than 19 years of age, 377 (4.3%) older than 60 years of age and 1480 (17.0%) female patients were admitted following trauma. Table 3 breaks down the mechanism of trauma. A total of 5027 patients sustained blunt trauma (57.6%), and 3334 (38.5%) sustained penetrating trauma. A total of 4808 patients sustained intentional trauma implying that 55.1% of all trauma was secondary to grievous bodily harm or assault either in the form of a stab wound or GSW or of an assault. There was a total of 2232 road traffic-related incidents, of which 37.9% (845) were pedestrian victims. The mortality rate for all trauma admissions was 4.5% (396). Of these 396 deaths, 64 (16.2%) were classified at the morbidity and mortality conference as being avoidable. CONCLUSIONS: The HEMR has allowed us to track the burden of trauma presenting to our institution over a five-year period. This confirms previous studies over shorter time periods from our institution. The pattern of trauma has remained consistent, and the previously described high levels show no sign of decreasing. Interventions to try and reduce this burden are urgently required.

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma.

INTRODUCTION: The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience. METHODS: All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0. RESULTS: A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high. CONCLUSION: Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.

The spectrum and outcome of blunt trauma related enteric hollow visceral injury.

Introduction This audit focused on patients who sustained enteric injury following blunt abdominal trauma. Methods Our prospectively maintained electronic registry was interrogated retrospectively, and all patients who had sustained blunt abdominal trauma between December 2011 and January 2016 were identified. Results Overall, 2,045 patients had sustained blunt abdominal trauma during the period under review. Seventy per cent were male. The median age was 28 years. Sixty patients (2.9%) sustained a small bowel injury (SBI). Thirty-five of these were peritonitic on presentation. All patients with a SBI had a chest x-ray and free air was present in seven. In 18 patients with a SBI, computed tomography (CT) was performed, which revealed isolated free fluid in 12 and free intraperitoneal air in 5. In five cases, the CT was normal. A total of 32 patients (1.5%) sustained blunt duodenal trauma (BDT). All patients with BDT had a chest x-ray on presentation. Free intraperitoneal air was not present in any. CT was performed on 17 patients with BDT. This revealed isolated free fluid or retroperitoneal air in 12. The median delay between injury and presentation for these enteric injures was 15.5 hours (interquartile range [IQR]: 8-25 hours) while between presentation at hospital and operation, the median delay was 6 hours (IQR: 3-13 hours). Conclusions Blunt trauma related enteric hollow visceral injury remains associated with delayed diagnosis and significant morbidity. It can be caused by a disparate array of mechanisms and is difficult to diagnose even with modern imaging strategies.

The effect of systematic factors on the outcome of trauma laparotomy at a major trauma centre in South Africa.

Introduction The aim of this study was to examine and interrogate outcomes in trauma laparotomy in a South African trauma centre to determine whether systematic factors were associated with any discrepancies in outcome. Methods This was a retrospective review of a prospectively entered trauma registry undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. The service has developed a hybrid electronic medical record system (HEMR) where clinical data were captured in real time, which were incorporated this into a database. Results During the period from December 2012 to July 2016, 562 patients underwent emergency laparotomy for trauma and the time and date of surgery was recorded in the HEMR. The mean age of all patients was 29.5 years. There were 256 operations during the weekend or over a public holiday, with a mortality of 8% (n = 21) compared with 306 during the week (mortality of 10%, n = 31). This difference was not statistically significant (P = 0.237). A total of 327 operations were performed at night (18:00 - 08:00) and 235 operations were performed during the day (08:00-18:00 Hours). This was a significant difference in mortality (10% (33) vs 7 % (16), P=0.013) These differences persisted if weekends and public holidays were separated out from normal working days. A total of 188 operations were performed on a week night, with a mortality of 11% (n = 20) and 121 operations were performed during a week day, with a mortality of 8% (n = 10). There were 139 operations on a weekend or public holiday night, with a mortality of 9% (n = 13). A total of 114 operations were performed on a weekend or public holiday day with a mortality of 7% (n = 8). A total of 208 procedures were performed with an consultant present. Of these, 32 patients (15%) died. A total of 368 procedures were performed without a consultant present and 8 (2%) died. Conclusions This study demonstrated a discrepancy in outcome for trauma laparotomy, depending on whether the operation was performed at night or during the day. The reasons for this are unclear, although the lack of consultant presence at night in comparison to during the day appears to be implicated.

The incidence, spectrum and outcome of paediatric trauma managed by the Pietermaritzburg Metropolitan Trauma Service.

INTRODUCTION: The Pietermaritzburg Metropolitan Trauma Service (PMTS) has run a systematic quality improvement programme since 2006. A key component included the development and implementation of an effective surveillance system in the form of an electronic surgical registry (ESR). This study used data from the ESR to review the incidence, spectrum and outcome of paediatric trauma in Pietermaritzburg, South Africa. METHODS: The ESR was reviewed, and all cases of paediatric trauma managed between 1 January 2012 and 30 July 2014 were retrieved for analysis. RESULTS: During the study period, 1,041 paediatric trauma patients (724 male, 69.5%) were managed by the PMTS, averaging a monthly admission of 36. The mean age was 10.9 years (standard deviation: 5.4 years). The mechanism of injury (MOI) was blunt trauma in 753 patients (72.3%) and penetrating trauma in 170 (16.3%). Pedestrian vehicle collisions accounted for 21% of cases and motor vehicle collisions for a further 11%. Intentional trauma accounted for 282 patients (27.1%) and self-inflicted trauma for 14 cases (1.3%). Ninety patients admitted to the intensive care unit and fifty-one required high dependency unit admission. There were 17 deaths, equating to an in-hospital mortality rate of 1.7%. A total of 172 children died on the scene of an incident. There were 35 road traffic related deaths, 26 suicides by hanging, 27 deaths from blunt assault and 23 deaths from penetrating assault. The overall mortality rate for paediatric trauma was 18.2%. CONCLUSIONS: The ESR has proved to be an effective surveillance system and has enabled the accurate quantification of the burden of paediatric trauma in Pietermaritzburg. This has improved our understanding of the mechanisms and patterns of injury, and has identified a high incidence of intentional and penetrating trauma as well as road traffic collisions. These data can be used to guide strategies to reduce the burden of paediatric trauma in our environment.

Lentiviral protein delivery of meganucleases in human cells mediates gene targeting and alleviates toxicity.

Site-specific endonucleases can be engineered for custom recognition of any genetic locus and used for gene targeting. Yet, the prolonged expression and accumulation of these nucleases in cells lead to toxic effect. Here we describe an efficient and quantitative method for introducing nucleases into cells as proteins packaged within lentiviral vector particles. I-CreI-derived meganucleases, which can be engineered as single-chain proteins, were incorporated into lentiviral vector particles either without modification or as fusions with cyclophilin A. The small amount of nuclease delivered by the viral particles is sufficient to induce efficient targeted mutagenesis in human HEK293H and primary T cells. When a repair template sequence was packaged in the lentiviral vector, high levels of homologous gene targeting were obtained and toxicity was markedly reduced.

Haemobilia following blunt liver injury.

Blunt liver trauma is commonly managed by non-operative measures. We report a case of an American Association for the Surgery of Trauma grade III liver injury and its complications, successfully managed by a combination of minimally invasive interventions.

[Conjoined twins--rare biological phenomenon. Case report].

Authors are discussing a rear case of multiple pregnancy--conjoined twins. The case is personal by exact antenatal diagnosis and delivering is made by the author. It is proposed a classification of conjoined twins and theoretical interpretation of pathological mechanism of fusion.