Iatrogenic duodenal injury occurring during laparoscopic cholecystectomy (LC) is managed surgically, though rarely a large, persistent fistula is refractory to surgical interventions. We present the case of a 40-year-old woman transferred to our centre following elective LC for a reported perforated duodenal ulcer. An uncontained leak was found to originate from a 1.5 cm duodenal defect, with no evidence of ulceration. A duodenostomy tube was placed. One month after abdominal closure, the patient continued to have a persistent, large duodenal fistula. A through-the-scope covered oesophageal stent was placed under endoscopic and fluoroscopic guidance. Five weeks later, it was successfully retrieved and no subsequent extravasation of contrast from the duodenum was noted. Unrecognised iatrogenic duodenal injuries sustained during LC can be catastrophic. In cases of massive duodenal defects and high-output biliary fistula uncontrolled after surgical intervention, endoscopic-guided and fluoroscopic-guided placement of a fully covered oesophageal stent may be lifesaving.

BACKGROUND:There is debate in the trauma literature regarding the effect of prolonged prehospital transport on morbidity and mortality. This study analyzes the management of hepatic trauma patients requiring surgery and compares the outcomes of the group that was transferred to the University of New Mexico Hospital (UNMH) from outside institutions, to the directly admitted group. MATERIALS AND METHODS:The UNMH Trauma Database was queried from 2005-2012. Of 674 patients who sustained liver injuries, 163 required surgery: 46 patients (28.2%) underwent interhospital transfer, and 117 (71.8%) were directly admitted. Variables examined included transfer status, trauma mechanism, transport type, injury severity score (ISS), liver injury grade, and associated injuries. Outcome variables included length of stay (LOS) and 30-day mortality. Outcomes of the transfer group (TG) and direct admit group (DAG) were compared. RESULTS:Both TG and DAG had the same median age (31 y, P = 0.33). The blunt-to-penetrating ratio was the same for each group (48% blunt: 52% penetrating, P = 1.0). Median ISS was 25 for the TG and 26 for the DAG. Grade III or higher injury occurred in 29 (63%) of the TG and in 68 (58%) of the DAG (P = 0.56). Median hospital LOS was 14 d for TG and 9 d for DAG (P = 0.15). Median intensive care unit LOS was 4 d for both groups (P = 0.71). Thirty-day mortality was 20% in each group (P = 0.27). Using a multiple logistic regression model for the outcome of mortality, only age, ISS, and liver injury grade, not transfer status or transport type, had a significant effect on mortality. CONCLUSIONS:There was no significant difference in liver injury grade, ISS, LOS, and mortality between TG and DAG. In the patient population of our study, transfer status did not affect outcome.

The aim of this study was to review a Level 1 trauma center's use of early (< 72 hours from injury) limited MRI to "clear" cervical spine extradural soft tissue injuries in ICU patients sustaining blunt trauma. A retrospective review of the records of patients meeting entry criteria during 1997 was performed. Demographic data, cervical spine radiographic and imaging evaluation, results, and follow-up information were gathered. One hundred and fifty patients met criteria. Forty-one patients had initial static radiographs that revealed cervical spine trauma. Twenty-seven of the 108 patients with normal initial static radiographs had evidence of extradural soft tissue injury on MRI indicating potential spinal column instability. Twenty-one of the 108 patients had negative MRI and were liberated from cervical spine precautions at a mean of 2.9 +/- 0.9 days from injury. The remaining patients were cleared of cervical spine precautions by plain radiographs and reliable clinical examinations, or by dynamic radiographs, or they died before complete evaluation. The diagnosis of acute injury to the cervical spine from blunt trauma in ICU patients must include evaluation of the osseous spine and extradural soft tissues. Dynamic studies such as flexion and extension views place the obtunded ICU patient at risk of potential neurologic injury. MRI is a noninvasive imaging technique that allows evaluation of extradural soft tissue injury with potentially less patient risk and with fewer personnel. MRI allows early liberation of cervical spine precautions in those patients with negative studies. Further studies are needed to compare specific ligamentous injury patterns by MRI with dynamic studies of the C-spine to further define MRI injury patterns indicating risk of acute spinal instability.

s Of Papers To Be Presented At The Twenty-Ninth Annual Scientific Meeting Of The Western Trauma Association, February 28-March 6, 1999, Crested Butte, Colorado

s Of Papers To Be Presented At The Joint Meeting Of The American Association For The Surgery Of Trauma (Fifty-Eight Annual Meeting) And The Trauma Association Of Canada, September 24-26, 1998, The Renaissance Harborplace Hotel, Baltimore, Maryland

Elderly pedestrians struck by motor vehicles have the highest mortality rate of all pedestrian injury victims. One thousand eighty-two motor vehicle-pedestrian accidents occurring in a metropolitan area over a 5-year period were studied. Age-specific injury rates and fatality rates were evaluated with respect to the injury severity scores (ISS) for all fatally injured autopsied pedestrians. Of the 1,082 injuries, 131 fatalities occurred. Mean ISSs were found to be significantly higher for pedestrians dying at the scene of the accident (mean ISS, 54.83) and higher for those dying in the emergency department (mean ISS, 45.18), than for pedestrians who died in the hospital (mean ISS, 30.57) (P less than .0001). The mortality rate for pedestrians aged greater than or equal to 60 years was substantially higher than for those adults aged less than 60 years of age (P less than .001). Elderly patients involved in accidents were much more likely to die than younger pedestrians (44.6% v 10.4%; P less than .0001). Elderly pedestrians were significantly overrepresented in the group of pedestrians dying in the hospital compared with younger injury victims (52.5% v 21.5%; P less than .008). This study shows that elderly pedestrians struck by motor vehicles die at a higher rate because they succumb to injuries in the hospital more frequently than younger pedestrians. This may reflect the greater susceptibility of the elderly to metabolic, surgical, and infectious complications after admission to the hospital. A decrease in mortality rates of elderly patients suffering pedestrian injuries will probably follow improved in-hospital intensive care services for the elderly.

A 20-year-old man developed sinoatrial Wenckebach after moderate blunt chest and cardiac trauma from a motor vehicle accident. This unusual dysrhythmia is manifested by grouped beating, a constant PR interval, progressive shortening of the cycle length, and repetitive pauses. Sinoatrial Wenckebach has not previously been described in association with blunt cardiac injury.