The rate of success of the conservative management of liver trauma in a developing country.

BACKGROUND: The conservative treatment of liver trauma has made important progress over the last 10 years at the Trauma University Hospital in Tirana, Albania. The percentage of success was 58.7%. The aims of this study were to analyze the conservative treatment of liver trauma and to compare the results with those in the literature. METHODS: This study was conducted prospectively from January 2009 to December 2012. We analyzed 173 patients admitted to our hospital with liver trauma. Liver injuries were evaluated according to the American Association for the Surgery of Trauma and the World Society of Emergency Surgery classification, while the anatomic gravity of the associated injuries was defined using the Injury Severity Score system. The potential mortality was estimated with the Revised Trauma Score. RESULTS: Out of the 173 patients with liver trauma, 83.2% were male. The main cause of liver trauma was motor vehicle crashes (50.9%). Blunt trauma was the cause of liver injury in 129 cases (74.6%), and penetrating trauma occurred in 44 cases (25.4%). Initially, the decision was to manage 88 cases (50.9%) via the conservative approach. Of these, 73 cases (42.2%) were successfully treated with conservative treatment, while in 15 cases (17.2%), this approach failed. The success rate of conservative treatment by grade of injuries was as follows: grade I (38.4%), grade II (30.1%), grade III (28.8%), and grade IV (2.7%). The likelihood of the success of conservative treatment had a significant correlation with the grade of the liver injury (p < 0.00001), associated intra-abdominal injuries (p = 0.00051), and complications (z = 2.3169, p = 0.02051). The overall mortality rate of liver trauma was 13.2%. CONCLUSIONS: The likelihood of success in using conservative treatment had a significant correlation with the grade of liver injury and associated intra-abdominal injuries. The limited hospital resources and low level of consensus on conservative treatment had a negative impact on the level of success.

The influence of the risk factor on the abdominal complications in colon injury management.

INTRODUCTION: The management of colon injuries has distinctly evolved over the last three decades. However, trauma surgeons often find themselves in a dilemma, whether to perform a diversion or to perform a primary repair. The purpose of this study is to evaluate risk factors in colon injury management and their influence on abdominal complications. PATIENTS AND METHODS: This is a prospective study conducted at a national level I trauma center in Tirana, Albania from January 2009 to December 2012. The data with respect to demographics, physiological risk factors, intraoperative findings, and surgical procedures were collected. Colonic injury-related morbidity and mortality were analyzed. Multivariate logistic regression analysis was performed by assessing the influence of risk factors on abdominal complications. RESULTS: Of the 157 patients treated with colon injury, was performed a primary repair in 107 (68.15%) of the patients and a diversion in the remaining 50 (31.85%). The mean PATI was 18.6, while 37 (23.6%) of patients had PATI greater than 25. The complications and their frequencies according to the surgical technique used (primay repair vs diversion respectively) includes: wound infections (9.3% vs 50%), anastomotic leak (1.8% vs 8.7%), and intra-abdominal abscess (1.8% vs 6.5%). The multivariate analysis identified two independent risk factors for abdominal complications: transfusions of 4 units of blood within the first 24 hours (OR = 1.2 95% CI (1.03 - 1.57) p =0.02), and diversion (OR = 9.6, 95% CI 4.4 - 21.3, p<0.001). CONCLUSION: Blood transfusions of more than 4 units within the first 24 hours and diversion during the management of destructive colon injuries are both independent risk factors for abdominal complications. The socioeconomic impact and the need for a subsequent operation in colostomy patients are strong reasons to consider primary repair in the management of colon injuries.

Seat belt syndrome, a new pattern of injury in developing countries. Case report and review of literature*.

BACKGROUND: Classically, seat belt syndrome appears with seat belt marks on the body, bowel perforations, and lumbar spine fractures. However the symptoms are not limited to those previously mentioned, and organ damage can vary greatly. CASE REPORT: A 34-year-old female passenger, was admitted to our hospital after a motor vehicle crash. The physical examination revealed an ecchymosis across the chest, a transverse abdominal abrasion, and fractures of the left humerus, the left femur, and the right tibia. The laparotomy revealed multiple jejunal perforations, such as a seromuscular tear of the hepatic and splenic flexure of the colon and a defect of the abdominal wall. The primary suture of jejunum, resection with end to end anastomosis of jejunum, suture of a seromuscular tear of the colon, and primary repair of the abdominal wall defect procedures were performed. On the fifth day, the patient underwent osteosynthesis. CONCLUSION: The abdominal pain in the polytraumatized patients with seat belt syndrome may be dominated by the pain caused by extra-abdominal injuries. The presence of a seat belt mark across the abdomen increases suspicion of abdominal injuries.

Delayed presentation of blunt duodenal injuries in children. Case report and review of literature.

BACKGROUND: Duodenal injuries are rare in children and classically present following a fall over the handle bar. Retroperitoneal location of the duodenum may lead to delay in diagnosis, and missed injuries are associated with increased morbidity and mortality. CASE REPORT: A 5-year-old child was admitted to the National Trauma Center, in Tirana (Albania), 28 hours after a Motor Vehicle Crash (MVC), complaining of mild abdominal pain. He was febrile (39°C) and had a white blood cells count of 18,000 mm³. On physical exam he had mild tenderness. Plain abdominal X-rays and Focused Abdominal Sonography for Trauma (FAST) were negative for free air or free fluid. The CT scan of the abdomen demonstrated free air and fluid in the retroperitoneal space. At laparatomy, a perforation of the second portion of the duodenum was found. A single layer suture repair of the duodenum with wide drainage was performed. The patient was discharged from the hospital tolerating oral feeding 8 days later. CONCLUSION: Duodenal injuries in children are rare. Most duodenal hematomas are managed non-operatively. This is a case of MCV with delayed presentation that was treated surgically for perforation successfully.

[Esophageal injury following blunt thoracic trauma. A case report and review of the literature]. / Verletzungen der Speiseröhre nach stumpfem Thoraxtrauma. Eine Fallpräsentation und Literaturübersicht.

The aim of this article was to raise the awareness of the difficulties physicians face in the diagnosis and treatment of esophageal perforation following blunt thoracic trauma. We present a case of esophagus perforation following blunt chest trauma in the course of a motorcycle accident. Within 24 h the patient was admitted to the University hospital, and presented with progressive pain, subfebrile temperature, leukocytosis and pneumomediastinum. Emergency surgery revealed extensive esophageal lesions. A two-stage surgical approach was chosen with initial resection and temporary closure of the esophagus. After 2 months the integrity of the esophagus could be restored without complications.

The first prevalence survey of nosocomial infections in the University Hospital Centre 'Mother Teresa' of Tirana, Albania.

A survey was conducted in the largest hospital in Albania to estimate the prevalence and risk factors for nosocomial infections (NIs). A one-day prevalence survey was carried out between October and November 2003 in medical, surgical and intensive care wards. Centers for Disease Control and Prevention definitions were used. Study variables included patient and hospital characteristics, surgical procedures, invasive devices, antibiotic treatment, microbiological and radiological examinations, infection signs and symptoms. Risk factors were determined using logistic regression. In all, 185 NIs were found in 163 of 968 enrolled patients. Urinary tract infections (33.0%), surgical site infections (24.3%), pneumonia (13.0%) and venous infections (9.2%) were the most frequent NIs. The prevalence of NIs was higher in intensive care units (31.6%) than in surgical (22.0%) and medical wards (10.3%). Overall, 132 NIs (71.4%) were confirmed by microbiological examination; the single most frequently isolated micro-organism was Staphylococcus aureus (18.2%). By means of logistic regression, the following independent risk factors were identified: age >40 years, length of hospital stay, 'trauma' diagnosis at admission, and invasive devices. Even though comparisons must be made with great caution, the prevalence of NIs was higher than in western European countries and in some developing countries.

Gitelman's syndrome (familial hypokalemia-hypomagnesemia).

Gitelman's syndrome (GS) is a heritable renal disorder characterized by hypomagnesemia, hypokalemia and hypocalciuria, and is distinct from Bartter's syndrome (BS). As compared to those with BS, patients with GS present at an older age, and they have a milder clinical picture, normal or slightly decreased concentrating urine ability, reduced urinary excretion of calcium, and permanently decreased serum magnesium level. GS is caused by defective NaCl transport in the distal convoluted tubule, and is linked to the gene encoding the thiazide sensitive Na-Cl-cotransporter located on chromosome 16q. Patients with BS, on the other hand, have mutations in the transporters in the thick ascending loop of Henle (NKCC2, ROMK, and C1C-Kb). Treatment of GS consists of magnesium salt replacement. Long term prognosis in terms of maintaining growth, preserving renal function and life expectancy is excellent.

The first point prevalence survey of nosocomial infections in Albania: pilot study.

In May 2003, investigators were trained and prevalence pilot study was conducted at the University Hospital of Tirana, Albania. Investigators were trained to assess the organizational problems of the first prevalence survey of nosocomial infections (NIs) in Albania. Twelve investigators were trained in 2 days. After the training, the pilot study was conducted in 3 wards. The investigators collected data using a standard form and the definitions of the Centers for Disease Control, USA. The training improved the investigators' knowledge of NI epidemiology and surveillance. The pilot study underlined the lack of information in the clinical documentation and lack of collaboration between clinicians and the laboratory: microbiological examinations were performed only in 13 (16.5%) patients and none of the 11 NIs reported was confirmed in the laboratory. This led to a review of the survey protocol, above all in order to increase the use of microbiological laboratory.

[Guidelines for a prevalence survey of nosocomial infections in the University Hospital "Madre Teresa" in Tirana, Albania]. / Indagine di prevalenza delle infezioni ospedaliere presso il Centro Ospedaliero Universitario "Madre Teresa" di Tirana, Albania: proposta di un protocollo operativo.

The authors present guidelines for the first prevalence survey of nosocomial infections in the University Hospital "Madre Teresa" in Tirana (almost 1,600 beds), the only tertiary health-care centre in Albania. The survey is a joint project involving Italy and Albania, to be coordinated by the Italian National Health Institute. The paper describes goals, methodology and organization of the prevalence survey. The improvement of local expertise in epidemiology and microbiology is one of the most important goals. Therefore, Albanian personnel training and improvement of the infection microbiological diagnosis are fundamental aspects of the project.

[Hysterectomy for a benign lesion: can the vaginal route be used in all cases?]. / Hystérectomie pour lésion bénigne: peut-on tout faire par voie vaginale?

OBJECTIVE: To determine which factors indicate the vaginal route cannot be used for hysterectomy and study the morbidity of this technique in comparison with the abdominal route. METHODS: A retrospective study was conducted in 682 patients who underwent hysterectomy for benign lesions between 1992 and 1996. Genital prolapses and/or urinary incontinence accounted for 31% of the indications. Mean patient age was 50 years. There were 75 nulliparous patients and 27% of all patients had a pelvic history (including cesarean section) which might compromise vaginal hysterectomy. RESULTS: Hysterectomy was performed via the abdominal route in 39.7% of the cases and via the vaginal route in 60.3% including 5.7% with laparoscopic assistance. Factors which dictated the abdominal route were: large size of the uterus (47%), pelvic background (30%), tubo-ovarian pathology (6%), multiple elements (6%), unknown (11%). Operation time depended on the surgical route, parity, pelvic background and associated techniques (prolapse, oophorosalpingectomy, uterine segmentation). Morbidity was very low and the same for both routes: 1.8% operative accidents (mainly bladder wounds), 1% reoperation, only one case of thromboembolism and less than 0.5% postoperative fever. DISCUSSION: There is no absolute contraindication to vaginal hysterectomy. It would appear unreasonable to an unexperienced surgeon to use the vaginal route for a fixed uterus with an estimated weight over 400 g in nulliparous patients with a pelvic background. In a department with vaginal training, 84% of all hysterectomies could be performed by vaginal route, because half of the indications for the abdominal route are excessive or a matter for laparoscopic assistance.