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Tue Feb 6 18:13:41 GMT 2007

Absolute postulation, but what about a mesenteric artery intimal tear that
later causes dissection and subsequent thrombotic obstruction?

_________________
Dr Ross Hofmeyr
MBChB (Stell) ATLS ACLS
wildmedic at gmail.com
ross at wildmedix.com
www.wildmedix.com
"Semper Paratus"

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Kashuk, Jeffry
Sent: 06 February 2007 07:53 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Case Discussions X2

Tim,
 I want to comment on case#2..... a few months ago, I had a 50 yo pt
with a GSW to the left flank area. At exploration, the hematoma was
fairly extensive and explored. There was extensive muscular bleeding
from the psoas but no renal, ureter, colon, small bowel, or major
vascular injury. We had to unroof a fair amt of colon to be sure there
was no injury but again, good bleeding, intact colon in mid sigmoid
area. He went home POD 7 on regular diet with nl bowel function only to
return 3 days later with peritonitis and he also perforated the colon
area... He healed and went home with his Hartman's procedure. 
 I think that in both cases, either  we have devascularized the Colon,
or there was blast injury from either the missile or blunt trauma (in
your case)that necrosed late... In my case there was not even extensive
mesenteric hematoma present.. but how could I have predicted this and
done a resection at the time ? I certainly would have had difficulty not
exploring and unroofing to be sure there was no injury..

Jeff Kashuk
Denver,Co 
-----Original Message-----
From: Hardcastle, Tim, Dr <tch at sun.ac.za> [mailto:tch at sun.ac.za] 
Sent: Monday, February 05, 2007 10:17 PM
To: Trauma-List (E-mail)
Subject: Case Discussions X2

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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Case Discussions X2