Pediatric vascular injuries: acute management and early outcomes.

BACKGROUND: Although uncommon in children, traumatic vascular injuries have the potential for lifelong disability. We reviewed these injuries, their acute management, and early outcomes at a Level I trauma center. METHODS: Retrospective review of patients identified through trauma registry was query of all noniatrogenic vascular injuries in a pediatric population during a 13-year period. Demographics, injury type and management, concomitant injuries, and inpatient outcomes were analyzed. RESULTS: From 1995 to 2008, 8,247 children with traumatic injuries were admitted. Of which 116 (1.4%) sustained 138 significant vascular injuries; 111 arterial and 27 venous. Mean age was 12.7 years ± 4.1 years. Penetrating mechanism was more frequent (57.8%; 67 of 116) than blunt (42.2%; 49 of 116). The overall mean injury severity score was 17.3, of which 12.3 ± 11.7 was for penetrating trauma and 24.1 ± 19.3 for blunt trauma. Thirteen of the 36 patients with torso injuries and one with carotid/jugular injury died. The surviving 102 patients sustained 118 vascular injuries (102 arterial and 16 venous). Of this group, 15 (14.6%) had multiple vascular injuries. There were 23 (22.5%) with torso injuries, 72 (70.6%) with extremity injuries, and 7 (6.9%) with cerebrovascular injuries. Primary repair was the most common arterial repair technique for survivors (25.5%, 26 of 102) and was used more frequently in penetrating trauma (35.0%, 21 of 60) than blunt trauma (12.0%, 5 of 42). Limb salvage was 97.4% (113 of 116). CONCLUSIONS: Pediatric vascular trauma is uncommon. Penetrating mechanism is more common than blunt. Injuries to the torso carry a high mortality. Limb salvage is almost universal.

Diaphragmatic injuries: what has changed over a 20-year period?

Traumatic diaphragmatic injuries are uncommon events but are associated with a high mortality. We hypothesize that injury pattern has changed over time with increasing prevalence of blunt injuries. A retrospective chart review was performed of 124 patients who sustained traumatic diaphragmatic injuries over the 20-year period between January 1, 1986 and December 31, 2005. Penetrating trauma accounted for 65 per cent (80/124) of all diaphragm injuries, and blunt trauma for 35 per cent (44/124). Mean Injury Severity Scores of 19 +/- 9 and 34 +/- 13 were observed for the penetrating and blunt trauma groups, respectively (P = 0.001). Blunt traumatic diaphragm injuries increased from 13 per cent in the first 10-year period to 66 per cent in the second 10-year period (P = 0.001). The overall mortality was 9 per cent (11/124) with 10 deaths resulting from blunt trauma and one resulting from penetrating trauma (P < 0.001). The mortality rate increased from 3 to 17 per cent over the two decades (P = 0.007). Our data suggests that over the last 20 years, the increase in mortality associated with traumatic diaphragmatic injury is primarily related to an increase in the proportion of patients with blunt trauma as a cause of their diaphragmatic injury and associated injuries.

The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy.

BACKGROUND: Laparoscopic surgery in pregnant women has become increasingly more common since the 1990s; however, the safety of laparoscopy in this population has been widely debated, particularly in emergent and urgent situations. METHODS: A retrospective chart review of all pregnant women following a nonobstetric abdominal operation at a University hospital between 1993 and 2007. Perioperative morbidity and mortality for the mother and fetus were evaluated. RESULTS: Ninety-four subjects were identified; 53 underwent laparoscopic procedures and 41 underwent open procedures. Cholecystectomy and appendectomy were performed in both groups with salpingectomy/ovarian cystectomy only in the laparoscopic group. No maternal deaths occurred, while fetal loss occurred in 3 cases within 7 days of the operation and in 1 case 7 weeks postoperatively. This and other perinatal complications occurred in 36.7% of the laparoscopic group and 41.7% of the open group. CONCLUSION: Laparoscopic appendectomy and cholecystectomy appear to be as safe as the respective open procedures in pregnant patients; however, this population in particular remains at risk for perinatal complications regardless of the method of abdominal access.