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Sat Feb 18 18:26:44 GMT 2006

Tim,

Sounds like you really DO know surgery, eh?  WOW - great save.  

I do not know of any adverse effects or increased leak rates that
result from delayed small bowel repair/reconnect.  I wonder if anyone on
the list has a better handle on this.  As to the gastro-duo hookup, I
will assume that his prior surgery for a perfed DU was a plication and
not a resection - personally I would do a resection and "Roux-Y or
something similar", 'cause I am not sure I would really like to do the
likes of a B-I in the face of the damage you have described, especially
given the fact that you still have a pancreatic remnant that is quite
capable of leaking those "nasty digestive juices" as John Ranson used to
refer to them......

Good luck, and let us know what you did - and how he did.

Take care,
Ron

>>> tch at sun.ac.za 02/17 9:47 AM >>>
Dear List

Have been involved over the past 24 hours with a case that may be of
interest:

30 something y/o male shot through the driver door (RHD) of his
mini-van (he was a state witness for the prosecution in a gang case -
they got to him!!!) Worst of all he is the husband of one of our Trauma
Radiographers. Time is 11h00.

Two entry wounds through right iliac wing mid ax line, one exit left
lower chest and the other bullet in the left chest wall 6th ICS, mid-ax
line.

Catch: Previous Laparotomy for perfed DU!!!!

Chest drain left in Resus Bay - minimal air no blood, pericardial sonar
negative. Taken directly to OR. 1000ml mainly venous blood and faecal
material on opening via a xiphi-pubic incision. +++ adhesions delaying
entry in to abdo with ongoing bleeding.

Findings: Destroyed (R) hemi-colon lifted out on opening, ligated and
removed. Bullet caused numerous bleeding holes and mesenteric wounds to
small bowel, exits through the transverse mesocolon, transecting head of
pancreas, portal vein and pylorus-duodenal junction and out through a
lateral hole in stomach and the diaphragm. Duodenal loop otherwise
intact.

Procedures: Clamped Portal vein for haemorrhage control and ligated
numerous other bleeders.
Ligated bowel ends and oversew bleeding stomach and open duodenal end,
pack retroperitoneum. Still bleeding from body/tail of pancreas and do a
quick spleno-pancreatectomy (6 minutes), with mass ligation of the
vessels. At this point he has bled significantly and we close with a
"vac-pack". Time is 13h20.

pH is 7,16; lactate 13,5 and temp is amazingly 35.7. Keep him in the
OR, dry everything off and aggressively fluid resus to correct all
parameters for 2 hours. By this time he has had 40 units of blood and
other products. Time 15h35.

We got the cell-saver for the next session by pure luck

pH then 7,36; lactate 12 and temp now 37.2. We reopen and find bowel at
point of impaired viability on venous infarction basis. My vascular
colleagues harvest Safena Magna and in 17 minutes do a reversed vein
interposition repair of the PV, whereafter the bowel perks up and we
spend a few minutes improving on haemostasis and replace the temporary
closure, Time now 16h50.

Spend an hour or so in the OR correcting the parameters and move to the
ICU when it is clear he is still in with a chance and we decide to not
withdraw therapy. Time now 7pm. He has now had over 70 units of blood
and other products, including 1500ml cell-saved blood.

Next day (this morning) pH is corrected, haematocrit is 40%, clotting
is corrected and yet Lactate is still high, but he is improving and
coming down on inotropes etc and ventilating well. We decide to go back
and review the bowel. Time 12h45. We find that all is viable except the
terminal 20cm of residual ileum and this is resected. No ongoing
surgical bleeding and there is no bile leak - will check for intact bile
ducts later. We leave a drain over the pancreas head and place a Bogota
bag and get out. His lactate is slightly down and his BE is almost
normal post-op. His inotropes are still weaning.

Plan is to go back in on Sunday and try to hook up the bowel
anastomoses, bring out stomas etc.

We will have to see. The only reason this guy is alive is damage
control and team work from all concerned.

My question: What is the effect of the delayed primary repairs to the
small bowel on the leak rate after repair. What is the best way to
reconstruct his gastro-duodenal junction - can we just anastomose it or
should we rather do a Roux-Y or something similar????

Regards
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (SU)
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa

2 Lorient Close
Vredekloof, Brackenfell
7560, Western Cape,
South Africa
e-mail: tch at sun.ac.za 
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302
Home: +27219813098
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