The trajectory of a low-velocity bullet from the chest to the pituitary gland.

The diagnosis and treatment of gunshot injuries requires an understanding of the trajectory of the bullet in each individual case. The majority of gunshot wounds present with easily understandable trajectories resulting in a concise, stream-lined work-up. Occasionally, the initial work-up may reveal a trajectory that is atypical. This can be due to internal bullet deflection, bullet embolism, or bullets that traverse multiple body cavities. Here we present the case of a gentleman who was shot in the left posterior chest, with the bullet ultimately lying-in profile with the patient's pituitary gland. The patient suffered injuries to his left lung, left internal jugular vein, and right optic nerve. On hospital day 1, he required neurosurgical operative intervention for increased somnolence and computed tomography findings which revealed tension pneumocephalus. On hospital day 15, he was discharged home after making a full recovery with the exception of continued blindness in the right eye. Gunshot wounds involving multiple body cavities can increase the complexity of a patient's injury pattern and require increased vigilance and complete history, physical examination, and imaging to ensure optimal outcomes.

Analysis of over 2 decades of colon injuries identifies optimal method of diversion: Does an end justify the means?

INTRODUCTION: Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries. METHODS: Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded. RESULTS: A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19%), and 11 patients (10%) suffered reversal complications. There was no difference in ostomy-related (2.9% vs. 3.8%, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12% vs. 18%, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0% vs. 36%, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy. CONCLUSION: For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury. LEVEL OF EVIDENCE: Therapeutic, level IV.

Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities.

This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.