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Thu Jul 23 04:28:12 BST 2009

without a lot of  l
"look see" personal optical scan of the damage and the saponification to WAG the leakage, I would opt for washout  q 24 hours until things stabilize. I agree with resection of necrotic material but after 72 hours do not attempt an anastomosis of anything until at least 6-8 weeks

Personal approach would be KISS principle
Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of moore677 at aol.com
Sent: Wed 7/22/2009 10:24 PM
To: trauma-list at trauma.org
Subject: DILEMMA

16yo female transferred from a Level II trauma center in California on PTD 6, s/p exlap, hepatorrhaphy, and repair L diaphragm after being ejected.? On further review of CT, found to have a pancreatic transection and re-explored.? Op note says significant saponification, no obvious injury, VAC placed, widely drained, and exlap aborted.

No further intervention done as trauma center attempting to transfer to local Level I's.? Only radiographs sent with patient are MRCP and plain radiographs.? MRCP uninterpretable.? Repeat CT shows bilateral liver injuries (right grade III, left grade V that is either completely ischemic or necrotic or both), pancreatic transection at neck/body with normal appearing duodenum, grade IV splenic lac, and significant amount of intraperitoneal fluid.? Drain over liver contains bile with the remaining 3 have high amylase and lipase.

Our ERCPist was able to stent the transection.? I have scheduled her in the AM for repeat abdominal exploration.? Will debride any liver that is grossly necrotic or infected and drain widely.

Would anyone?have gone?after the pancreas if the ERCPist was unable to stent?? Now that we have stented, would you still go after?? I anticipate the saponification to be extensive, and any thing short of a minimalist approach to be disastrous.

Dell.....

Forrest "Dell" Moore, MD, FACS
Trauma Critical Care Surgery
Director, Surgical and Trauma Critical Care
St. Joseph's Hospital and?Medical Center
Phoenix, AZ?
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