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World journal of emergency surgery [journal]
- Methylene Blue injection via superior mesenteric artery microcatheter for focused enterectomy in the treatment of a bleeding small intestinal arteriovenous malformation. [Journal Article]
- World J Emerg Surg 2014; 9(1):17.
Obscure gastrointestinal bleeding from the small intestine may present the Acute Care Surgeon with a formidable diagnostic and therapeutic challenge. Despite the current array of diagnostic studies, localization of the causative pathology may be elusive, especially when the bleeding is intermittent. When a small intestinal arteriovenous malformation is the responsible lesion, a technique combining super-selective angiography with intra-operative methylene blue injection and focused enterectomy has been described in a number of case series. The current case report utilizes this same approach with emphasis on computed tomography angiography representing a key first step in the diagnostic algorithm.In this case report, we describe the diagnosis and treatment of obscure gastrointestinal bleeding emanating from an arteriovenous malformation in the small intestine of a 52 year old male. After an extensive work-up including upper and lower endoscopy, double balloon enteroscopy and capsule endoscopy, he was referred for computed tomography angiography. Though he was not actively bleeding, a jejunal arteriovenous malformation was localized on imaging. This prompted directed transfemoral angiography, placement of a super-selective microcatheter in the 4th jejunal arterial branch, intra-operative methylene blue injection and focused enterectomy with pathological confirmation. The patient was found to be free of gastrointestinal bleeding on 6 month follow-up.A step-wise, rational diagnostic approach should be utilized in the evaluation of obscure gastrointestinal bleeding. In the non-actively bleeding patient, computed tomography angiogram may facilitate the diagnosis of a small intestinal arteriovenous malformation. Methylene blue injection via a super-selective angiographic microcatheter may then allow for focused enterectomy.
- The value of Serum BNP for diagnosis of intracranial injury in minor head trauma. [Journal Article]
- World J Emerg Surg 2014; 9(1):16.
Head injury is the main cause of death among individuals younger than 45 years old. Cranial Computerized tomography (CT) is commonly used for diagnosis of head injury. Brain Natriuretic Peptide (BNP) is a peptide originally isolated from brain ventricles. The main aim of this study is to investigate BNP as an indicator of head injury among patients presenting to emergency department (ED) with minor head trauma.This was a prospective study conducted at the emergency department of the Numune Training and Research Hospital. A total of 162 patients who presented to the ED with minor head injury were enrolled. The patients were categorized into 2 groups as the cranial CT-negative and positive groups. The normality of the data was tested using One Sample Kolmogorov Smirnov test. Mann-Whitney U test was used to compare 2 independent groups while the Kruskal-Wallis test was utilized for comparison of more than 2 groups. A p-value of <0.05 was considered to be significant.Ninety-six (59.3%) patients were male and 66 (40.7%) were female. The cranial CT-negative group had a median BNP level of 14.5 pg/ml while the cranial CT-positive group had a median BNP level of 13 pg/ml. There was no statistically significant difference between these two groups for serum BNP levels (p > 0.05).This study suggested that serum BNP level wasn't used in defined of intracranial injury.
- Position paper: timely interventions in severe acute pancreatitis are crucial for survival. [Journal Article]
- World J Emerg Surg 2014; 9(1):15.
Severe acute pancreatitis has high mortality, but multiple and timely interventions can improve survival. Early in the course of the disease aggressive fluid resuscitation is needed for the prevention and treatment of shock. In conjunction with leaking capillaries this results in increased tissue edema, which may lead to intra-abdominal hypertension and abdominal compartment syndrome. Invasive hemodynamic monitoring is essential for optimizing fluid therapy while monitoring of intra-abdominal pressure is necessary for identification patients at risk of developing abdominal compartment syndrome. Abdominal compartment syndrome develops usually within the first days after hospitalization. Conservative treatment modalities are useful in prevention but also in the treatment of abdominal compartment syndrome. If conservative management fails surgical decompression of abdomen may be needed. Multiple organ dysfunction syndrome and increased intra-abdominal pressure predispose patients with severe pancreatitis to secondary infections. Extrapancreatic infections predominate during the first week of the disease, whereas infection of pancreatic necrosis usually develops later. Early enteral nutrition reduces the risk of infections whereas advantage of prophylactic antibiotics is lacking evidence. Surgery for infected pancreatic necrosis is associated with high mortality when performed within the first two weeks of the disease. Therefore surgery should be postponed as late as possible, preferably later than four weeks after disease onset.
- Early recognition of acute thoracic aortic dissection and aneurysm. [Journal Article]
- World J Emerg Surg 2013; 8(1):47.
Thoracic aortic dissection (TAD) and aneurysm (TAA) are rare but catastrophic. Prompt recognition of TAD/TAA and differentiation from acute coronary syndrome (ACS) is difficult yet crucial. Earlier identification of TAA/TAD based upon routine emergency department screening is necessary.A retrospective analysis of patients that presented with acute thoracic complaints to the ED from January 2007 through June 2012 was performed. Cases of TAA/TAD were compared to an equal number of controls which consisted of patients with the diagnosis of ACS. Demographics, physical findings, EKG, and the results of laboratory and radiological imaging were compared. P-value of > 0.05 was considered statistically significant.In total, 136 patients were identified with TAA/TAD, 0.36% of patients that presented with chest complaints. Compared to ACS patients, TAA/TAD group was older (68.9 vs. 63.2 years), less likely to be diabetic (13% vs 32%), less likely to complain of chest pain (47% vs 85%) and head and neck pain (4% vs 17%). The pain for the TAA/TAD group was less likely characterized as tight/heavy in nature (5% vs 37%). TAA/TAD patients were also less likely to experience shortness of breath (42% vs. 51%), palpitations (2% vs 9%) and dizziness (2% vs 13%) and had a greater incidence of focal lower extremity neurological deficits (6% vs 1%), bradycardia (15% vs. 5%) and tachypnea (53% vs. 22%). On multivariate analysis, increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction were independent predictors of ACS.Increasing heart rate, chest pain, diabetes, head & neck pain, dizziness, and history of myocardial infarction can be used to differentiate acute coronary syndromes from thoracic aortic dissections/aneurysms.
- Assessment of maxillofacial trauma in emergency department. [Journal Article]
- World J Emerg Surg 2014; 9(1):13.
The incidence and epidemiological causes of maxillofacial (MF) trauma varies widely. The objective of this study is to point out maxillofacial trauma patients' epidemiological properties and trauma patterns with simultaneous injuries in different areas of the body that may help emergency physicians to deliver more accurate diagnosis and decisions.In this study we analyze etiology and pattern of MF trauma and coexisting injuries if any, in patients whose maxillofacial CT scans was obtained in a three year period, retrospectively.754 patients included in the study consisting of 73.7% male and 26.3% female, and the male-to-female ratio was 2.8:1. Mean age was 40.3 ± 17.2 years with a range of 18 to 97. 57.4% of the patients were between the ages of 18-39 years and predominantly male. Above 60 years of age, referrals were mostly woman. The most common cause of injuries were violence, accounting for 39.7% of the sample, followed by falls 27.9% and road traffic accidents 27.2%. The primary cause of injuries were violence between ages 20 and 49 and falls after 50. Bone fractures found in 56,0% of individuals. Of the total of 701 fractured bones in 422 patients the most frequent was maxillary bone 28,0% followed by nasal bone 25,3%, zygoma 20,2%, mandible 8,4%, frontal bone 8,1% and nasoethmoidoorbital bone 3,1%. Fractures to maxillary bone were uppermost in each age group.8, 9% of the patients had brain injury and only frontal fractures is significantly associated to TBI (p < 0.05) if coexisting facial bone fracture occurred. Male gender has statistically stronger association for suffering TBI than female (p < 0, 05). Most common cause of TBI in MF trauma patients was violence (47, 8%).158 of the 754 patients had consumed alcohol before trauma. No statistically significant data were revealed between alcohol consumption gender and presence of fracture. Violence is statistically significant (p < 0.05) in these patients.Studies subjected maxillofacial traumas yield various etiologic factors, demographic properties and fracture patterns probably due to social, cultural and governmental differences. Young males subjected to maxillofacial trauma more commonly as a result of interpersonal violence.
- The role of emergency surgery in hydatid liver disease. [JOURNAL ARTICLE]
- World J Emerg Surg 2014 Jan 30; 9(1):12.
Hepatic hydatid disease is very common in Libya. In Zliten hospital, we operated 400 patients with hepatic hydatid cysts over period of 20 years. All patients were symptomatic. Their ages varied from 3 to 85 years including 215 female and 185male patients. Their symptoms varied from abdominal pain to abdominal mass 67 patients were admitted through Accident and Emergency Department with acute presentations including fever, skin rash, jaundice and shock with acute abdominal pain. Those 67 patients had necessary investigations, resuscitation and underwent emergency surgery. The hepatic cysts in all patients were excised, and the obstructive jaundice was cleared in those patients with obstructive jaundice. Unfortunately, one of the patients died two days after the surgery because of multiple organ failure (MOF) Morbidity was wound Infection , bile leak and recurrence rate were all reported in our series.
- Endoscopic duodenal perforation: surgical strategies in a regional centre. [Journal Article]
- World J Emerg Surg 2014; 9(1):11.
Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio-pancreatography (ERCP) and a rare complication of upper gastrointestinal endoscopy. Most are minor perforations that settle with conservative management. A few perforations however result in life-threatening retroperitoneal necrosis and require surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality.Five cases of iatrogenic duodenal perforation were ascertained between 2002 and 2007 at Cairns Base Hospital. Clinical features were analyzed and compared, with reference to a review of ERCP at that institution for the years 2005/2006.One patient recovered with conservative management. Of the other four, one died after initial laparotomy. The other three survived, undergoing multiple procedures and long inpatient stays.Iatrogenic duodenal perforation with retroperitoneal necrosis is an uncommon complication of endoscopy, but when it does occur it is potentially life-threatening. Early recognition may lead to a better outcome through earlier intervention, although a protracted course with multiple procedures should be anticipated. A number of surgical techniques may need to be employed according to the individual circumstances of the case.
- Looking beyond discharge: clinical variables at trauma admission predict long term survival in the older severely injured patient. [Journal Article]
- World J Emerg Surg 2014; 9(1):10.
Long term follow up is difficult to obtain in most trauma settings, these data are essential for assessing outcomes in the older (≥60) patient. We hypothesized that clinical data obtained during initial hospital stay could accurately predict long term survival.Using our trauma registry and hospital database, we reviewed all trauma admissions (age ≥60, ISS > 15) to our Level 1 center over the most recent 7 years. Mechanism of injury, co-morbidities, ICU admission, and ultimate disposition were assessed for 2-7 years post-discharge. Primary outcome was defined as long term survival to the end of the last year of the study.Of 342 patients discharged following initial admission, mean age was 76.2 ± 9.7, and ISS was 21.5 ± 6.9. 119 patients (34.8%) died (mean follow up 18.8 months; range 1.1-66.2 months). For 233 survivors, mean follow-up was 50.2 months (range 24.8-83.8 months). Univariate analysis disclosed post-discharge mortality was associated with age (80.1 ± 9.64 vs. 74.2 ± 9.07), mean number of co-morbidities (1.6 ± 1.1 vs. 1.0 ± 1.2), fall as a mechanism, lower GCS upon arrival (11.85 ± 4.21 vs. 13.73 ± 2.89), intubation at the scene and discharge to an assisted living facility (p < 0.001 for all). Cox regression analysis hazard ratio showed that independent predictors of mortality on long term follow-up included: older age, fall as mechanism, lower GCS at admission and discharge to assisted living facility (all = p < 0.0001).Nearly two-thirds of patients ≥60 who were severely injured survived >4 years following discharge; furthermore, admission data, including younger age, injury mechanism other than falls, higher GCS and home discharge predicted a favorable long term outcome. These findings suggest that common clinical data at initial admission can predict long term survival in the older trauma patient.
- Oesophageal injuries: Position paper, WSES, 2013. [Journal Article]
- World J Emerg Surg 2014; 9(1):9.
The oesophagus is a difficult challenge for the surgeon because of its lack of serosal covering, the tenuous, segmental blood supply and the common delay in the diagnosis of injury. Early diagnosis is the key to successful management. Recent introduction of newer, minimally invasive techniques have provided management alternatives for both the normal and the diseased organ that is injured with both early and delayed diagnosis.