New Case ? comments?

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Bill

Pray and then try the following:
The pancreas: Options for the pancreas is resect the head and implant the tail into a Roux-y loop. Alternatively there is work form the Durban Unit in South Africa which suggests inplanting the pancreas body/tail into the posterior stomach. See Injury. 2000 Jun;31(5):394-5. you have not given any indication as to the status of the CBD however - if this is also injured (try a trans cholecystic cholangiogram) then a Whipple is the best option, alternately you could do a low choledocho-enterostomy into a Braun loop with the previously described procedures (have done 2 of the latter)

The PV: You may have burned your bridges by not shunting at the primary op. A graft repair with either vein or goretex is the best options now - but your venous infarction rate to the bowel is going to be high.

Feeding tube only once you have let some of the edema settle and I'd do a feeding jejunostomy rather than a tube.

When she miscarries leave it alone - at her gestation mostly will be a complete miscarraige. D&C only if dead fetus not aborted after death confirmed.

Humbly
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
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-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of William Bromberg
Sent: Friday, January 27, 2006 4:13 PM
To: trauma-list at trauma.org
Subject: New Case ? comments?


Last evening (about 4:30 PM) I got a bad one and I'm looking for ideas.

18yo black female, 3 months pregnant with self-inflicted (by report) GSW to epigastrum using an AK-47 (7.62mm at 2350 fps ? I looked it up). Exit wound (big) in the mid back at about L1-2. Primary survey, airway intact (talking), breath sounds OK, BP 75/30, no movement below shoulders, sensory level mid-T.

In the OR we found the track to go through the liver left of the falciform, through distal stomach, through the head of the pancreas ? totally destroying the head but leavnig the duodenum totally uninjured ? directly through the portal vein (shredding it), directly through the cava (just big holes  front and back) and then right through the spine. The small bowel had a smaller injury ? seemed to be shrapnel (maybe spine fragments?).

Procedures performed ? repair cava, ligation portal vein, repair gastric perforations, repair small bowel perforations. She was packed open and sent to the unit. This morning she is warm, not coagulopathic. OK now for the questions.

What do I do about her pancreas?

What do I do about her portal vein ? her bowel is VERY edematous at this point (no surprise)?

Feeding tubes?

When she miscarries does she need a D&C?

Any other thoughts.

Thanks,
Bill

William J. Bromberg
Savannah Surgical Group
912 350-7412

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