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Thu, 21 Feb 2002 18:42:53 +0200 (IST)

On Wed, 20 Feb 2002,  alster wrote:

> In the first case I agree with you. In spite of his rapid declining
> condition we should have operated him on. The problem is that our
> active Service was meanwhile having 1 liver transplant and the 3 other
> OR (book to trauma) were with other gunshotwound victims. Besides, we
> only had Leucocytosis previously... Would you operate his hemogram, I
> mean, that pt?

I would not have operated for the leukocytosis. I would for the relentless
pain.  I would not have ordered the CT scan. It is quite useless in this
setting. 

I think that he had infarcted small bowel. 

> About the second... well her clinical picture was so dramatic I think
> a laparotomy would have further deteriorated her quickly...

A useful aphorism in surgery I have learned is:
A patient is never too sick to have a reoperation. 

I think it applies to this case too.  The patient is not deteriorating
because of bad humors. She is going down the whirlpool because there is an
abdominal catastrophe. A missed injury, for example. 

A re-laparotomy is the fastest, cheapest and safest method of finding out. 

I think that for injuries to the distal pancreas, distal pancreatecomy is
the treatment of choice.  I don't think you should feel bad about the
choice of operation. 

However, I have learned the hard way, that one should carefuly ligate the
pancreatic duct, or oversew the stump if a stapler is used. 

Avi 

 U/S did not
> showed any significant collections. Besides, let me remind you her CT
> was operated, I mean, We operated her on based on CT findings. If no
> CT was done no one would have operate her! And as Zsolt Balogh has
> pointed out what I described was the two-hit theory of MOF in severely
> injured patients!
> 
> What I'm asking is what if we had not performed pancreatectomy plus
> splenectomy? Would that make a difference? What if we could use some
> sort of intra-op exam like ulta-sound or intra-op cholangiography so
> we could determine if there was for real a laceration of the wirsung's
> duct? And what about that Dr. Rick Fry's pt : why he/she could stay
> alive and did not die? Non operative management of pancreatic injury?  
> Luck I guess.
> 
> When I was back to my first year resident I still remember my 2nd year
> colleague: "When you're an intern, no matter how much you try to kill
> our patient (new drugs, treatments or even negligence) they just do
> not die!". What if our today's standard treatment for SIRS/SEPSIS is
> just the other side of the coin?
> 
> What's still missing?
> 
> 2nd Patient: 19Y/O white latin female was also victim of a gunshot
wound on the back exiting at epigastric level. She got a ride from her
boyfriend who was driving a motorcycle when 2 other guys in a car tried to
rob him. As soon as he accelerated, trying to run away, his girlfriend was
shot on the back and he suffered only scratches in his right arm. There
was a trauma to the tail of the pancreas.
> 
> 
> C Alster, MD
> 

==========================================================================
Aviel Roy-Shapira, M.D.              Soroka University Hospital &
Dept. of Surgery A. and              Ben-Gurion University Medical School 
the Critical Care Unit               POB 151, Beer Sheva, Israel

email:avir@bgumail.bgu.ac.il         Fax:972-7-6403260 voice:972-7-6403390

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