Expectant management in delayed presentation of war casualties with penetrating abdominal trauma.

INTRODUCTION: While the management of acute civilian abdominal injuries is well established, The literature regarding the management of battle-related abdominal injuries presented in a delayed fashion is scarce. The objective of this study was to investigate the safety of non-operative management approach in delayed evacuation of battle-related abdominal injuries. METHODS: Clinical records of thirty-seven hemodynamically normal patients with battle related injuries and Computed Tomography (CT) findings of penetrating abdominal trauma were retrospectively studied. RESULTS: All 37 patients suffered penetrating abdominal injuries during the civil war in Syria. In this complex scenario, the casualties presented after a minimum 12-hour delay to our hospital. All patients had abnormal abdominal CT scans with no clinical peritoneal signs. Twenty-one [of the 37] patients exhibited 29 hard signs on CT scan. Of these, 17 patients were treated non-operatively and 4 underwent exploratory laparotomy (of which 2 were non-therapeutic). Sixteen patients exhibited a total of 75 soft signs on CT scan; 15 were treated non-operatively and one underwent non-therapeutic laparotomy. No complications were recorded in either the operative or non-operative groups. In total, 32 patients (86%) were treated non-operatively. Five patients (14%) underwent exploratory laparotomy (3 of which were non-therapeutic). Length of stay was dependent on the unique requirements of each individual patient as determined by the state department for returning across the border. CONCLUSION: We propose that in battle related casualties, acute survivable penetrating abdominal trauma may be safely treated non-operatively in selected patients who are hemodynamically normal and in whom there is an absence of abdominal pain or tenderness on repeated clinical assessment.

The role of bariatric surgery in normalization of the coagulation profiles.

BACKGROUND: Bariatric surgery achieves appropriate excess weight loss, controlling related co-morbidities, including coagulation abnormalities. OBJECTIVE: We investigated the change in the coagulation profile after postoperative weight stabilization, correlating between EWL ratio and change in the coagulation profile. SETTING: This study took place in our teaching institution (university setting). METHODS: Between the years 2012 and 2014, 67 patients underwent surgery; 47 patients underwent laparoscopic sleeve gastrectomy (SG) and 20 patients underwent Roux-en-Y gastric bypass (RYGB). Average follow-up of postoperative thromboelastography (TEG) parameters was 30 ± 10.8 months (12-77). Average body mass index (BMI) before surgery was 41.7 ± 4.6kg/m2, average percentage of EWL at the time of data collection was 79%. Patients were divided into 3 groups, 6 patients had EWL < 50%, 13 had an EWL > 100%, and 48 had EWL between 50% and 100%. EXCLUSION CRITERIA: use of anticoagulation, antiplatelet, or contraceptive medications; known thrombophilic, renal, hepatic, and hematologic diseases/disorders. Two follow-up groups: 1-2 years and over 2 years. Patients underwent pre and postoperative TEG coagulation studies, including maximal amplitude (MA), and clot strength (G). RESULTS: Coagulation profile improved after bariatric surgery. Most prominent change seen in MA and G. There was a linear correlation between the EWL ratio and improvement of MA values starting at 50% EWL peaking at 60%-70%. There was no difference in the coagulation profile after surgery in the two surgery groups (SG and RYGB). CONCLUSIONS: Achieving appropriate weight loss after bariatric surgery improves the coagulation profile as measured by TEG, probably decreasing thromboembolic risk in those patients. We recommend expanding the current indication for bariatric surgery to include patients with altered coagulation profile measured by TEG.

Intraabdominal challenges affecting abdominal wall reconstruction.

Abdominal wall defects may arise from trauma, infection, and prior abdominal surgeries, such as tumor resections. Although ideally reconstruction should be accomplished as soon as possible to restore the integrity and function of the abdominal wall, it is not always a viable option. A successful reconstruction must take into consideration the local environment of the defect, as well as the global condition of the patient. Therefore, it is imperative that a multidisciplinary team be involved to optimize the patient's care, particularly when a defect is complicated by a wound infection, an abscess, a fistula, or a neoplasm. Our goal in this article is to explore the challenges evoked by each of these special situations, and review the necessary steps for successful management.

Does hysterectomy affect genital sensation?

OBJECTIVES: To evaluate vaginal and clitoral sensation before and after hysterectomy and to assess pre- and post-surgery changes in sexual function. STUDY DESIGN: Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina and clitoris 1 day prior to and 3 months following surgery. A survey was performed 18 months following operation to evaluate long-term changes in sexual function. PARTICIPANTS: Twenty-seven women, aged 30-57 years, who were admitted for elective hysterectomy. MAIN OUTCOME MEASURES: Genital sensation and reported sexual function. RESULTS: There was significant deterioration in sensation to cold and warm stimuli at the anterior and posterior vaginal wall after surgery. Vaginal vibratory sensation thresholds tended to increase. Clitoral thermal and vibratory sensation thresholds remained unchanged before and after surgery. Of the 22 patients who participated in the follow-up survey, 17 did not report any decline in sexual function, while 4 patients reported deterioration in genital sensation and in sexual function. CONCLUSION: The results demonstrate quantifiable sensory loss in the vagina after hysterectomy, with preservation of clitoral sensation. Only a minority of patients reported a decline in their sexual function. These findings highlight the relative importance of clitoral as compared to vaginal sensation in sexual function.