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Interact CardioVasc Thorac Surg 2008;7:158-160. doi:10.1510/icvts.2007.164152 © 2008 European Association of Cardio-Thoracic Surgery
Wartime major venous vessel injuries *Department of Endo and Vascular Surgery, University Hospital ‘Sestre milosrdnice’, Zagreb, Croatia Received 30 July 2007; received in revised form 21 October 2007; accepted 23 October 2007
*Correspoding author. University Department of Surgery, University Hospital ‘Sestre milosrdnice’, 10000 Zagreb, Croatia, Vinogradska 29. Tel.: +385-1-46-40-774; fax: +385-1-37-68-292.
The aim of this study is to declare our experience and to identify the important factors that influence the mortality and morbidity in patients with combat-related penetrating wounds of the abdomen (CR-PWA) with major venous vessel injuries. Twenty-six wounded with combat-related injuries of major abdominal venous vessels, admitted in the University Clinic cardiovascular surgery department during the period from 1 August 1991 through 30 October 1995, were analyzed. Patients with concomitant injured arteries and extra-abdominal injuries (n=150; 85.2%) were excluded from this study. The Penetrating Abdominal Trauma Index (PATI) score for each patient was calculated. Fifteen patients (57.69%) sustained with PATI score greater than 25 died. The mean duration of hospitalization was 16 days (range 0–86). The average hospitalization time for those surviving their complications was 17 days with a PATI of 25 or less, and 43 days with a score more than 25. Three clinical assessments of the long-term outcome were performed after a median of about 3, 5 and 10 years, respectively. Surviving patients (42.31%) were symptom free and had normal Duplex scans as well as no other surgical related complications. Higher PATI scores, postoperative complications and reoperations exert an unfavorable effect on patient outcome.
Key Words: Venous injuries; War; Wounds; Penetrating-complications
Intra-abdominal major venous vessel war injuries account for 5–10% of all war injuries and are the common cause of death at the battlefield because of exsanguinations [1]. These injuries account for 5–10% of all war injuries and are a common cause of death at the battlefield [2]. Emergency surgical repair is still considered a technical challenge with high morbidity and mortality rates (50–100%) [3–6]. However, the development of efficient transportation-ambulance services and regional war hospitals have contributed to the reduction of the postoperative morbidity of injured patients. The purpose of this study is to report our institutional experience with these injuries during the war in Croatia.
Twenty-six patients wounded with combat-related injuries of major abdominal venous vessels, admitted in the University Clinic cardiovascular surgery department during the period from 1 August 1991 through 30 October 1995, were analyzed. Patients with concomitant injured arteries and extra-abdominal injuries (n=150; 85.2%) were excluded from this study. There were 24 men and two women, mostly young patients of median age 30 years (range 18–49 years). The mechanisms of injury were as follows: mine fragments in 13 (50%) cases, high-velocity projectiles in 9 (34.62%) cases, and shotgun pellets in 4 (15.38%) cases. The mean time for evacuation from the place of injury to the hospital was 63.5 min (range 15–620 min). Treatment of these patients began on the battlefield (first medical aid), followed by transport to war hospitals where temporary control of hemorrhage was performed. Tetanus prophylaxis and penicillin crystal [6x4 M IU/d], gentamicin [3x80 mg/d] and metronidazole [3x80 mg/d] were routinely administered to all patients. Patients with evident or suspected damage of major vessels were transferred to our surgical department. Localizations of venous injuries were as follows: inferior vena cava (IVC) seven patients, superior mesenteric vein (SMV) three patients, inferior mesenteric vein (IMV) two patients, portal one patient, retrohepatic cava three patients, renal five patients, splenic one patient, iliac four patients. The Penetrating Abdominal Trauma Index (PATI) score for each patient was calculated for each organ injured by multiplying assigned risk factor by the severity of each injury estimate, and the sum of the individual organ injury score comprise final PATI [7]. The average (PATI) score was 15 (range 0–47). Fifteen patients (15%) sustained combat-related penetrating wounds of the abdomen (CR-PWA) and had a PATI score greater than 25. There were a total of 36 associated nonvascular injuries in 26 patients (Table 1).
When the depth of injury was in doubt and condition of the patient and the severity of the injury allowed, or equivocal abdominal signs occurred, CT-scan of the abdomen was performed. Patients with CR-PWA with major venous vessel injuries and positive abdominal signs underwent exploratory laparotomy through a midline incision. Surgical management included lateral venorrhaphy in 16 patients, 4 underwent end-to-end anastomosis, and 3 underwent interposition grafts with synthetic prosthesis. In three patients the attempts of repair were unsuccessful. Reconstruction with synthetic prostheses was done for extensive lesions of IVC (two patients) and iliac veins (one patient).
Early complications related with venous reconstruction developed in six patients (23.08%), and this led to secondary hemorrhage in four patients (15.38%), and thrombosis in two patients (7.69%). Hemorrhage was resolved by urgent re-laparotomy and the point of leakage was re-sutured. Thrombosis was managed by means of catheter thrombectomy. No protamin was used. Five patients were reoperated for intraabdominal abscesses on the third, sixth and ninth postoperative days and intraabdominal drainage with closed system tube drains was performed. In four patients, intestinal leaks developed and colostomy was performed on the seventh and ninth postoperative days. Wound dehiscence occurred in three patients and they were reoperated on the tenth, eleventh and thirteenth days. Closure of the abdominal wall was done with mass suturing. Thirty-four combined complications related directly to CR-PWA occurred in 12 patients (46.14%). The most common complication encountered was uncontrolled wound infection, which occurred in 10 (38.46%) of all patients, followed by colon complications (7 patients; 26.92%), intraabdominal abscess (5 patients; 19.23%), septicemia (4 patients; 15.38%) and intestinal leaks (4 patients; 15.38%) and wound dehiscence (3 patients; 11.54%). Fifteen patients died; three of them with retrohepatic caval injuries died in the operating room from uncontrolled bleeding, while the other 12 died within one month during the hospital stay. Bacteriologic analysis from the infected patients showed an equal distribution of gram-positive and gram-negative infectious agents, with a predominance of Staphylococcus aureus and Acinetobacter sp. All patients initially received the same antibiotic prophylaxis, which was subsequently specifically changed according to the antibiotic sensitivity report. The mean duration of hospitalization was 16 days (range 0–86). The average hospitalization time for those surviving their complications was 17 days with a PATI of 25 or less, and 43 days with a score more than 25. The transport time had no effect on the incidence of infectious complications because all patients were admitted to the hospital and underwent surgical procedure within the proper time period. Eleven patients in this series survived (42.30%). Among the survivors there were a total of 34 major complications. Morbidity consisted of pneumonia (six), intestinal abscesses (five), deep venous thrombosis (five), postoperative hemorrhage (four), intestinal leaks (four), wound infection (three), wound dehiscence (three), thrombosis of major veins (two), intensive care unit psychosis (one) and neurogenic bladder (one). Causes of death among 15 nonsurvivors included exsanguinations in three patients in the OR. The remaining 12 patients died during ICU stay. Their causes of death included multiple system failures (MSOF) or acute respiratory distress syndrome (ARDS), or both, in 6 (50%), cardiopulmonary arrest in 4 (33.5%), and brain death in 2 (16.5%). Five (19.23%) of the 26 patients with major venous trauma had three or more intra-abdominal injuries. Analyzed according to PATI scores (Table 2), 3 (11.54%) of the 11 patients with scores of 25 or less developed complications compared to 15 (100%) of the 15 patients with scores exceeding 25.
Among survivors (11 patients; 42.30%) Duplex scans were performed on the 30th postoperative day and patent repair with no evidence of thrombosis was demonstrated in all cases. Three clinical assessments of the long-term outcome were performed after a median of about 3, 5 and 10 years, respectively. Surviving patients (42.30%) were symptom free and had normal Duplex scans as well as no other surgical related complications.
The therapeutic goal in the management of injured major venous vessels in war conditions is that the primary venous repair should be a definitive one, whereas complications and reoperations had a major impact on the outcome [8, 9]. Despite advances in shock management, resuscitation, and damage control, a complicated venous repair in war conditions cannot be advocated, because such injuries remain very lethal.
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Abstract
1. Introduction