Case Discussions X2

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Dear all

Just to briefly share 2 interesting cases from the past week or so with you.

1) 40-something male, direct blunt abdominal trauma admitted with acute abdomen and otherwise stable, early SIRS phase. Taken for laparotomy with the following finding: Massive retroperitoneal biloma. Transection of piloro-duodenal junction and the thrid part of the duodenum as only injuries. D2 and pancreas head intact (CBD looked intact once Kocherisation done).
What we did was a repair of the third part of the duodenum, close the first part duopdenal stump and do a B2-type gastro-jejunal anastomosis after a segmental gastric resection. He is currently in ICU, but seems to be improving.

I would appreciate comment as to what others would have done - have such combined injuries been decribed before?

2) 21-y/o corpulent female, MVC passenger - restrained tripod harness, seatbelt sign; clinically acute abdomen. At laparotomy decided on by clinical basis alone a meter of ischaemic small bowel found and resected (mesenteric laceration). Some bruising noted in both paracolic gutters but colon macroscopically normal after bilateral mobilisation.Initially did fine, but deteriorated on day 6 post-op and we relapped her suspecting an anastomotic leak. What we found was wierd! The jejuno-ileal anastomosis was intact and looked healing well, but there was a blow-out of the mid-decending colon, mesenteric-intraperitoneal border, with much fecal contamination that was cleanable. This has been defunctioned as a colostomy and mucus fistula. Her abdomen was left open with a VAC-pack and the has been retruned after 48 hours for a wash and closure She is back in ICU and weaning ventilation and so on.

I have never seen a delayed colon perforation after blunt trauma; small bowel - with mesenteric devascularisation yes, but not colon. What is even more bizarre is the fact that the team doing the index laparotomy looked at the colon and it looked fine! Also the ends bled well after minimal debridement, so I'm really not sure why a well perfused colon would just perforate??? Unless tehre was a contusion that underwent full-thickness necrosis???

Your insight and wisdom awaited.

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
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

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