List Archives

Fri Feb 16 21:51:12 GMT 2007

Dr. Zunorain Dodhy,

Your account appears to be in order.  Have you checked you email client for
possible issues.  Mine started sending certain trauma-list messages to my
Junk Mail folder.  Perhaps you could review these settings.

Phil 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of zunorain dodhy
Sent: Friday, February 16, 2007 3:25 PM
To: trauma-list at trauma.org
Subject: Not receiving trauma digest

Dear Trauma site manager,

Since the 7th of Feb I have not been receiving the trama digest. ANy
reasons?

Yours,

Dr. Zunorain Dodhy 

----- Original Message ----
From: "trauma-list-request at trauma.org" <trauma-list-request at trauma.org>
To: trauma-list at trauma.org
Sent: Wednesday, 7 February, 2007 3:02:46 PM
Subject: trauma-list Digest, Vol 44, Issue 9

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    trauma-list at trauma.org

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Today's Topics:

   1. RE: Case Discussions X2 (Hardcastle, Tim, Dr <tch at sun.ac.za>)
   2. Re: trauma-list Digest, Vol 44, Issue 8 (Dibdob2 at aol.com)
   3. RE: Case Discussions X2 (charles frosolone)
   4. RE: Case Discussions X2 (Hardcastle, Tim, Dr <tch at sun.ac.za>)
   5. RE: Case Discussions X2 (Dr Ross Hofmeyr)

Content-Transfer-Encoding: quoted-printable
From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
Precedence: list
Subject: RE: Case Discussions X2
Date: Wed, 7 Feb 2007 07:05:42 +0200
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <000101c74a1a$8b4ec970$0200000a at wildmedicdesk>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <3FE6F2A76FE75C418D3E0481CD75EA1E328E10 at TYGEVS01.tyg.sun.ac.za>
Content-Type: text/plain;
    charset="iso-8859-1"
MIME-Version: 1.0
Message: 1

Ross

Possible, but one would expect more signs of ischaemis colon segment - this
was a simple 1,5cm hole!

Tim

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr Ross Hofmeyr
Sent: Tuesday, February 06, 2007 8:14 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Case Discussions X2

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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Content-Transfer-Encoding: 7bit
From: Dibdob2 at aol.com
Precedence: list
Subject: Re: trauma-list Digest, Vol 44, Issue 8
Date: Wed, 7 Feb 2007 00:07:12 EST
To: trauma-list at trauma.org
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <d1e.6c72c09.32fab880 at aol.com>
Content-Type: text/plain; charset="US-ASCII"
MIME-Version: 1.0
Message: 2

please remove me from this list

From: "charles frosolone" <frosolone at hotmail.com>
Precedence: list
Subject: RE: Case Discussions X2
Date: Wed, 07 Feb 2007 06:04:49 +0000
To: trauma-list at trauma.org
In-Reply-To: <3FE6F2A76FE75C418D3E0481CD75EA1E328E10 at TYGEVS01.tyg.sun.ac.za>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
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Message: 3

Tim

Retractor injury? Have seen vigorous or scissoring retractors cause injuries

to  bowel. Would be in a place far away from the trauma and would be a clean

cut.

C Frosolone, MD, FACS

>From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
>Subject: RE: Case Discussions X2
>Date: Wed, 7 Feb 2007 07:05:42 +0200
>
>Ross
>
>Possible, but one would expect more signs of ischaemis colon segment - this

>was a simple 1,5cm hole!
>
>Tim
>
>-----Original Message-----
>From: trauma-list-bounces at trauma.org
>[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr Ross Hofmeyr
>Sent: Tuesday, February 06, 2007 8:14 PM
>To: 'Trauma &amp; Critical Care mailing list'
>Subject: RE: Case Discussions X2
>
>
>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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>or previous e-mail messages attached to it may contain information that is
>confidential or legally privileged.  If you are not the intended recipient,
>or a person responsible for delivering it to the intended recipient, you 
>are
>hereby notified that you must not read this transmission and that any
>disclosure, copying, printing, distribution or use of any of the 
>information
>contained in or attached to this transmission is STRICTLY PROHIBITED.  If
>you have received this transmission in error, please immediately notify the
>sender by telephone or return e-mail and delete the original transmission
>and its attachments without reading or saving in any manner.  Thank you.
>
>===========================================================================
=
>==
>
>--
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>
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Content-Transfer-Encoding: quoted-printable
From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
Precedence: list
Subject: RE: Case Discussions X2
Date: Wed, 7 Feb 2007 12:51:20 +0200
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <BAY118-F10A42B969579D704E5CCF3A09E0 at phx.gbl>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <3FE6F2A76FE75C418D3E0481CD75EA1E328E11 at TYGEVS01.tyg.sun.ac.za>
Content-Type: text/plain;
    charset="iso-8859-1"
MIME-Version: 1.0
Message: 4

Charles

Interesting suggestion - but we don't use this type of retractor

Tim

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of charles frosolone
Sent: Wednesday, February 07, 2007 8:05 AM
To: trauma-list at trauma.org
Subject: RE: Case Discussions X2

Tim

Retractor injury? Have seen vigorous or scissoring retractors cause injuries

to  bowel. Would be in a place far away from the trauma and would be a clean

cut.

C Frosolone, MD, FACS

>From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
>Subject: RE: Case Discussions X2
>Date: Wed, 7 Feb 2007 07:05:42 +0200
>
>Ross
>
>Possible, but one would expect more signs of ischaemis colon segment - this

>was a simple 1,5cm hole!
>
>Tim
>
>-----Original Message-----
>From: trauma-list-bounces at trauma.org
>[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr Ross Hofmeyr
>Sent: Tuesday, February 06, 2007 8:14 PM
>To: 'Trauma &amp; Critical Care mailing list'
>Subject: RE: Case Discussions X2
>
>
>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
>
>
>
>
>
>---------------------------------------------------------------------------
-
>--
>CONFIDENTIALITY NOTICE - This e-mail transmission, and any documents, files
>or previous e-mail messages attached to it may contain information that is
>confidential or legally privileged.  If you are not the intended recipient,
>or a person responsible for delivering it to the intended recipient, you 
>are
>hereby notified that you must not read this transmission and that any
>disclosure, copying, printing, distribution or use of any of the 
>information
>contained in or attached to this transmission is STRICTLY PROHIBITED.  If
>you have received this transmission in error, please immediately notify the
>sender by telephone or return e-mail and delete the original transmission
>and its attachments without reading or saving in any manner.  Thank you.
>
>===========================================================================
=
>==
>
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html
>
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Content-Transfer-Encoding: quoted-printable
From: Dr Ross Hofmeyr <wildmedic at gmail.com>
Precedence: list
Subject: RE: Case Discussions X2
Date: Wed, 7 Feb 2007 13:59:23 +0200
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <45c9bf21.3a433dc3.1b58.3274 at mx.google.com>
Content-Type: text/plain; charset="iso-8859-1"
MIME-Version: 1.0
Message: 5

Oh well... Theory come, theory go.

-----Original Message-----
From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Sent: 07/02/07 07:05
Subject: RE: Case Discussions X2

Ross

Possible, but one would expect more signs of ischaemis colon segment - this
was a simple 1,5cm hole!

Tim

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr Ross Hofmeyr
Sent: Tuesday, February 06, 2007 8:14 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Case Discussions X2

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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