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Mon Jul 21 07:07:57 BST 2008

Hi Jose

Need more info:
Time to hospital
Time of resus and operation
pH, temp and Lactate

These would help me decide if Damage control was required. If he is normothermic, pH > 7,25 and his operative time was about 90-100 mins - then would only have left off the pyloric exclusion (I would only do this for a severe injury (Gr3) near the ampulla - D2). D3 I treat like small bowel.

Anything otherwise would have had bowel ends stapled / tied off and damage-control performed.

What was the reason for the "compromised viability" - if you suspect a vascular injury, maybe bowel end stapling, a temporary closure and a relook at 24 hours would be a better bet. I have stopped using a two layer closure for bowel repairs about 4 years ago and have actually seen a lower leak rate! I use a single layer continuous vicryl 3/0 or 2/0 for all my repairs. This has also been shown to have lower adhesion formation rates long-term.

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of josemaya01
Sent: 19 July 2008 02:02
To: trauma-list
Subject: Ref:trauma-list Digest, Vol 61, Issue 31

Dear all:
Last night a 19 y old, male patient arrived to our hospital with a GSW in his abdomen, BP 90/60, conscious but combative, maybe under the influence,he was resuscitated with a 1:1 scheme of PRBC and FFP, laparotomy was performed and the findings were a perforation of ascending colon, near hepatic flexure, another perforation at about 10 cm distally in the transverse colon, viability looked compromised so a right hemicolectomy was done with ileotransverso anastomosis, he also had a perforation and mesenteric compromise of jejunum, so a resection and anastomosis was done,and he also had a perforation of the third portion of the duodenum,grade II injury, a pyloric exclusion was done and gastrostomy and jejunostomy along with a two layer closure. Drainage was placed nearby duodenum closure.
Any thoughts or comments are welcomed.

José Mayagoitia, MD, FACS
Hospital General de Mexicali, Mëxico

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