Faculty Bibliography

Explosives create and energize particles that act as projectiles prone to further fragmentation or create other secondary missiles in the body. These fragments may result in secondary injuries. This has been repeatedly described in the orthopedic and neurosurgical literature. We report the same process for abdominal injuries after fascial penetration in the military setting. This is an observational case series study. Local wound exploration as a standard approach was performed in conscious patients who sustained abdominal wall injuries. Patients with negative physical examination were excluded from the study. An intraperitoneal injury was assumed in those with a full-thickness fascial defect, and laparotomy was performed. Twenty patients met the study eligibility criteria. Of those 20 patients, 12 had negative wound exploration and were excluded from the study, while abdominal organ injuries were found in eight (40%) patients. During laparotomy, projectile-induced injuries in a sprayed distribution were found in three (38%) of these patients. These injuries were far from the predictable trajectory and in the absence of bone fragmentation. The overall mean number of peritoneal defects was 1.7, and a mean 6.8 intra-abdominal injuries for each peritoneal defect were found when through-and-through injuries were excluded.Despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. Under mass casualties, wound exploration with a full-thickness fascial defect could serve as an indicator of possible intra-abdominal injuries, and consequently indicate exploratory laparotomy.

BACKGROUND:The small intestinal bacterial overgrowth (SIBO) breath test has had positive results in 84% of patients with irritable bowel syndrome vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with symptoms consistent with irritable bowel syndrome who have undergone previous abdominal surgery. OBJECTIVE:To identify causative factors for SIBO. DESIGN/METHODS:Retrospective review. SETTING/METHODS:Tertiary colorectal surgery clinic. MAIN OUTCOME MEASURE/METHODS:Result of SIBO breath test. RESULTS:We identified 77 patients whose differential diagnosis included SIBO from January 1, 2005, to December 31, 2007; 18 were excluded because of noncompliance with testing and 2 because of a decision to treat SIBO without formal testing. Symptoms were chronic abdominal pain in 30 patients (53%), bloating in 25 (44%), constipation in 37 (65%), and diarrhea in 7 (12%). Mean (SD) symptom duration was 45 (22) months. Of the 57 patients enrolled in this study, 45 (79%) tested positive for SIBO and 37 (82%) of those had a history of surgery, whereas 12 (21%) tested negative for SIBO and 9 (75%) of those had a history of surgery. Of the 36 SIBO-positive patients with a history of abdominal surgery (mean number of procedures, 2), the surgery locations were as follows: female reproductive organs, 23 (64%); hindgut, 15 (42%); foregut, 8 (22%); and midgut, 6 (17%). Open surgery alone was performed in 32 patients (56%) vs laparoscopic surgery in 7 (12%). Both open and laparoscopic procedures had been performed in 6 patients (11%). Four patients (7%) had a history of small intestinal obstruction. The mean age of SIBO-positive patients was higher than that of SIBO-negative patients (57 vs 44 years; P < .01). Analysis did not reveal any clinically significant independent factor associated with SIBO. CONCLUSION/CONCLUSIONS:Physicians should consider SIBO in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.

INTRODUCTION/BACKGROUND:Trauma in pregnancy is the leading cause of non-obstetrical maternal death and remains a major cause of fetal demise. The objective of this study was to examine the outcomes of pregnant patients sustaining abdominal injury. PATIENTS AND METHODS/METHODS:This is a retrospective analysis of all pregnant trauma patients admitted to two level 1 trauma centers from February 1, 1996 to December 31, 2008. Patient data abstracted included mechanism of injury, physiologic parameters on admission, Injury Severity Score (ISS), abdominal Abbreviated Injury Scale (AIS), gestational age, diagnostic and surgical procedures performed,complications, and maternal and fetal mortality. Univariate analysis and logistic regression analysis were used. RESULTS:During the 155-month study period, 321 pregnant patients were included, of which 291 (91%)sustained a blunt injury, while 30 (9%) were victims of penetrating trauma. Of the penetrating injuries,22 (73%) were gunshot wounds, 7 (23%) stab wounds, and 1 (4%) shotgun injury. The overall maternal and fetal mortality was 3% (n = 9) and 16% (n = 45), respectively. Mean age was 22 6 year-old, and the mean ISS was 12 16. The overall mean abdominal AIS was 2 1.2. When adjusted for age, abdominal AIS,ISS, and diastolic blood pressure, the penetrating trauma group experienced higher maternal mortality [7%vs. 2% (adjusted OR: 7; 95% CI: 0.65–79), p = 0.090], significantly higher fetal mortality [73% vs. 10% (adjusted OR: 34; 95% CI: 11–124), p < 0.0001] and maternal morbidity [66% vs. 10% (adjusted OR: 25; 95% CI: 9–79)p < 0.0001]. CONCLUSIONS:Fetal mortality and overall maternal morbidity remains exceedingly high, at 73% and 66%,respectively, following penetrating abdominal injury. Penetrating injury mechanism, severity of abdominal injury and maternal hypotension on admission were independently associated with an increased risk for fetal demise following traumatic insult during pregnancy.

The purpose of this study was to describe the characteristics of this unique patient population, their clinical presentations, and outcomes. The Los Angeles County and University of Southern California Medical Center Trauma Registry was used to retrospectively identify patients who sustained perineal injuries. Information included gender, age, vital signs, trauma scores, mechanisms of injury, studies performed, surgeries performed, and outcomes. Pediatric patients and injuries related to obstetric trauma were not included. Sixty-nine patients were identified between February 1, 1992 and October 31, 2005. One patient died on arrival; 85 per cent (58 of 68) were males, mean age was 30 +/- 12 years, and there was a penetrating mechanism in 56 per cent. Vital signs on admission were systolic blood pressure 119 +/- 33 mmHg, heart rate 94 +/- 27 beats/minute, and respiratory rate 20 +/- 6 breaths/min. Glasgow Coma Scale (GCS) was 13 +/- 3, Revised Trauma Score (RTS) was 7.2 +/- 1.5, and Injury Severity Score (ISS) was 11 +/- 12. CT scan was obtained for 23 (33%) patients. Lower extremity fractures were 35 per cent and pelvic fractures 32 per cent. The most common surgery was débridement and drainage, diversion with colostomy in five patients (7%). Overall mortality was 10 per cent. Mortality group mean scores were: GCS, 6; RTS, 5.74; and ISS, 34. The survival group mean scores were: GCS, 14; RTS, 7.7; and ISS, 8. There was a statistically significant association between mortality and GCS, RTS, and ISS scores (P < 0.001). Most patients with perineal injuries (93%) can be managed without colostomy. Associated injuries are not uncommon, particularly bony fractures. Mortality is mostly the result of exsanguination related to associated injuries.