Abdominal pain physiology may be better understood studying electrophysiology, histology, and symptom scores in patients with the symptoms of gastroparesis (Gp) treated with gastric electrical stimulation (GES). Ninety-five Gp patients' symptoms were recorded at baseline and during temporary and permanent GES. Gastric-emptying times and cutaneous, mucosal, and serosal electrogastrograms were obtained. S100-stained, full-thickness gastric biopsies were compared with autopsy controls. Sixty-eight patients reported severe pain at baseline. Severe pain patients' mean pain scores decreased with temporary GES from 3.62 to 1.29 (P < 0.001) and nonsevere pain from 1.26 to 0.67 (P = 0.01). With permanent GES, severe mean pain scores fell to 2.30 (P < 0.001); nonsevere pain changed to 1.60 (P = 0.221). Mean follow-up was 275 days. Mean cutaneous, mucosal, and serosal frequencies and frequency-to-amplitude ratios were markedly higher than literature controls. For patients with Gp overall and subdivided by etiology and severity of pain, S-100 neuronal fibers were significantly reduced in both muscularis propria layers. GES improved severe pain associated with symptoms of Gp. This severe pain is associated with abnormal electrogastrographic activity and loss of S100 neuronal fibers in the stomach's inner and outer muscularis propria and, therefore, could be the result of gastric neuropathy.

OBJECTIVE:Clinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI.METHODS:All adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI)>30. Obese and non-obese patient groups were compared for surgical management and outcome.RESULTS:A total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n=47; non-obese n=68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different.CONCLUSIONS:While obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI>30. However, patients with a BMI>40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.

Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.

OBJECTIVES:While non-operative management of renal trauma in selected patients is now an accepted management option, predictors of failure of this treatment strategy are still unclear.METHODS:Five-year retrospective study of all patients with blunt renal injuries managed non-operatively at a Level I Trauma Center. Abstracted data included patient demographics, initial vital signs, base deficit, associated injuries, use of blood transfusion, management, and outcomes. Patients with successful non-operative management (S-NOM) and failure of non-operative management (F-NOM) were compared with two-tailed Student's t test, Fisher's exact test, or chi-square analysis as appropriate.RESULTS:Over five years, 271 patients out of 12,252 trauma cases (2.2%) had blunt renal injury; 239 (88%) were initially managed non-operatively, and ten (4.1%) of these patients later requiring operation or intervention. No differences in age, sex, initial vitals, or GCS were found between S-NOM and F-NOM. The F-NOM patients were more seriously injured than the S-NOM patients (ISS 31 vs. 21, p < 0.001); had worse acidosis (ABG base deficit of-9.1 vs. -4.5, p < 0.001); required more blood products (12 units PRBC vs. 2.6 units PRBC, p < 0.001); and had significantly longer hospital lengths of stay (37 days vs. 12 days, p < 0.001). Angiography was used more frequently in the F-NOM patients (40% vs. 8.7%, p < 0.02). In the F-NOM only 3 (30%) required direct kidney intervention: 1 nephrectomy, 1 open urinoma drainage and 1 open nephrostomy tube placement. All of these patients had grade V renal injuries. The rest of the F-NOM patients had operative interventions not directly related to their renal injuries: 1 splenectomy and 6 missed bowel injuries.CONCLUSION:Non-operative management of blunt renal injuries is successful in most cases. Patients with a high base deficit, ongoing transfusion requirements, and greater Injury Severity Scores have a higher likelihood of requiring operation, but these procedures most often are to address non-renal abdominal injuries. High-grade blunt renal injuries that are hemodynamically stable can be treated expectantly on an individual basis with close follow-up. Any patient with hemodynamic instability, renal pedicle injury, renal artery thrombosis, or urinary extravasation will likely require operative intervention.

Purpose: Diabetes mellitus (DM) is commonly associated with gastroparesis (GP) and is associated with significant attendant morbidity and mortality (DIG, 75 (2-3): 83-89, 2007). Gastric electrical stimulation (GES) is used for both DM and non-DM GP, but detailed pathophysiologic comparisons between diagnostic groups are lacking. We aimed to compare clinical outcomes, electrogastrography, and histology among diabetics vs. non-diabetic GP patients treated with temporary GES. Methods: We prospectively collected data on 80 consecutive patients (26 diabetic, 54 non-diabetic, 67 f, 13 m, mean age of 43 with GP) undergoing temporary and subsequent permanent GES for drug refractory GP. Symptoms evaluated were nausea, vomiting, epigastric pain, bloating/distension, and anorexia/early satiety and total symptom score (TSS) the sum of the five symptom scores from 0 to 4, max. 20. Total gastric emptying time (TGET: the sum of percent of retained isotope at 1, 2, and 4 hours) and cutaneous, mucosal, and serosal EGGs, reported as frequency and amplitude, were measured before and during treatment with temporary GES. Full thickness biopsy was done with subsequent implantation of permanent GES and showed the number of CD-117 (Cajal) cells and S-100 (neuronal) cells per hpf from 10 fields. Two tailed unpaired t tests were performed for each category. Results: The two groups had similar improvement in vomiting and TSS. Both baseline 4 hr GET and post-treatment TGET were greater in diabetics than non-diabetic patients. The serosal EGG frequency was significantly lower in diabetic patients. The mucosal EGG frequency was also lower in the diabetic patient group, although this difference did not reach statistical significance. The diabetic group demonstrated lower numbers of both S-100 (neuronal) and CD-117 (Cajal) cells in both inner and outer muscle layers, but the only statistical significant parameter was the outer CD-117 (Cajal)cells, which were lower in the diabetic group (See Table).Table 1: Comparison of means for GP patients (symptoms & gastric emptying)Conclusion: In this group of patients undergoing temporary and later permanent GES, a number of differences exist between DM and non-DM groups for both baseline physiologic measures and treatment effects for temporary GES. Disclosure: Dr Thomas Abell-Licensor, Consultant, Investigator, Medtronic, Inc.Table 2: Comparisons of means for GP patients (Biopsy & EGG)

BACKGROUND:Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients. METHODS:All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death. RESULTS:During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients. CONCLUSION:Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.

Purpose: Many patients with gastroparesis (GP) have abdominal pain and many other GP patients undergo gastric electrical stimulation (GES). However, the characteristics and responses of abdominal pain to GES have not been defined. Methods: We reviewed data on 80 consecutive patients (13 males, 67 female, mean age of 43, 26 diabetic, 53 idiopathic, 1 post surgical) undergoing temporary and later subsequent permanent GES for drug refractory GP. The patients were categorized into two groups on a scale of 0-4, none to worse as: Severe pain (pain scores >3) and Mild to Moderate pain (pain scores <3). Symptom scores were measured before and during treatment with temporary GES. Outcomes were measured as change in vomiting score, change in abdominal pain, and change in total symptom scores (TSS). Two tailed unpaired t tests were performed for each category. Results: Patients with Severe pain had more vomiting at baseline and their improvement in vomiting score was greater than patients with Mild to Moderate vomiting. Also patients with Severe pain showed more improvement in pain than the Mild to Moderate group with temporary GES. Patients with Severe pain also had a significantly greater baseline TSS than patients with Mild to Moderate pain and the improvement was greater for the Severe pain group. (See Table).TableConclusion: In this group of GP patients, improvements in vomiting and pain were greater in patients with Severe abdominal pain than with Mild to Moderate pain after temporary GES. Based on this sample of GP patients, we conclude that abdominal pain should not be a contraindication for a trial of gastric electrical stimulation. Disclosure: Dr Thomas Abell-Licensor, Consultant, Investigator: Medtronic, Inc.

Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group ( P < 0.001), with cost of $120,647.30 and $62,952.72 respectively ( P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.

Purpose: A relationship between migraines and gastroparesis (GP) has been observed but the pathophysiology and mechanisms are unknown. We compared histologic, electrophysiologic, and clinical outcomes to define any differences between drug refractory GP patients with Migraines and those with No Migraines, undergoing temporary gastric electrical stimulation (GES). Methods: We reviewed data on 80 consecutive patients: 28 Migraine (35%) and 52 No Migraine (65%); 13 males, 67 female, mean age of 43 (26 diabetic, 53 idiopathic, 1 post surgical) undergoing temporary and latter permanent GES for drug refractory GP. Symptoms evaluated included vomiting, nausea, epigastric pain, bloating/distension, and anorexia/early satiety (scored from 0 to 4 for each) and total symptom score (TSS) with a max of 20. Vomiting score and TSS were measured before treatment and during treatment with temporary GES. Four hour Gastric Emptying Time (GET) % retention before and during treatment along with cutaneous, mucosal, and serosal EGG was also measured, reported as frequency and amplitude. Outcomes were reported as change in vomiting scores, change in TSS, and change in 4 hour GET. A full thickness gastric biopsy was performed at the time of subsequent permanent GES placement and was analyzed for S-100 (neuronal) and CD-117 (Cajal) cells. Two tailed unpaired t tests were performed for each category. Results: Vomiting and TSS scores at baseline were higher among patients with migraines. Also the migraine patients had more improvement in vomiting scores with temporary GES. Patients with migraines had more normal gastric emptying scores at baseline and a greater change after temporary GES. The amplitude of mucosal EGG in patients with Migraines was higher than in the No Migraine group. There was no statistical difference between the Migraine group and the No Migraine group in outer or inner S-100 cells (neuronal) outer or inner CD-117 (Cajal) cells, cutaneous EGG frequency and amplitude, or serosal EGG frequency and amplitude. (See Table).Table: Table. Comparison of Migraine vs. No MigraineConclusion: GP Patients with Migraines have different baseline physiology as well as better symptom improvement from temporary GES compared with No Migraine GP patients. Disclosure: Dr Thomas Abell-Licensor, Consultant, Investigator, Medtronic, Inc.

Purpose: Gastroparetic (GP) patients often present with gastrointestinal symptoms perceived to be psychiatric or psychosomatic in origin. We hypothesized specific differences will exist in gastric histology and physiology, as well as treatment outcomes, in depressed patients compared to those without self-reported depression. Methods: We reviewed prospective data on 80 consecutive patients (47 depressed and 33 not depressed by self-identification) (67 f, 13 m, mean age of 43, with 26 diabetic, and 53 idiopathic and 1 post-surgical) undergoing temporary and later permanent gastric electrical stimulation (GES) for drug refractory gastroparesis. Symptoms evaluated included nausea, vomiting, epigastric pain, bloating, and early satiety. Each symptom was scored from 0 to 4 based upon frequency and severity, and total symptom score (TSS) is the sum of the five symptom scores with a maximum of 20. Vomiting and TSS were measured before treatment and during treatment with temporary GES and four hour Gastric Emptying Time (GET) was measured before and during treatment. Outcomes were reported as change in: vomiting scores, TSS, and 4 hour GET. Cutaneous, mucosal, and serosal EGG were reported as frequency and amplitude and full thickness gastric biopsies, done at the time of subsequent GES placement, for the number of CD-117 cells (Cajal) and S-100 (neuronal) cells per high powered fields (hpf) from 10 fields. Two tailed unpaired t tests were performed for each clinical and treatment outcome. Results: The depressed patients had greater baseline TSS and greater change in TSS in response to temporary GES. There were no statistically significant differences in gastric emptying times between the two groups. We also found no statistically significant histological differences between the two groups, although the depressed patients had less S-100 (neuronal) cells in both inner and outer layers. (See Table).Table 1: Comparison of GP Patients (Symptoms & Gastric Emptying)Conclusion: In this group of GP patients undergoing GES, depressed patients appear to have some symptom differences at baseline when compared to nondepressed patients. In addition, depressed patients improved more than non depressed patients after GES. Depression, although common in GP patients, appears not to be a contraindication to a trial of GES. Disclosure: Dr Thomas Abell-Licensor, Consultant, Investigator, Medtronic, Inc.Table 2: Comparison of GP Patients (Biopsy & EGG)

BACKGROUND:The predictors of amputation for patients with lower extremity vascular trauma are well described in the literature, but the predictors of amputation in the upper extremity are not so well defined. We hypothesize that the predictors of amputation in the lower extremity are much different when compared with the upper extremity. METHODS:Retrospective chart review of all brachial artery traumatic injuries presenting to a rural-state university trauma center. RESULTS:In a 6-year period, 41 patients presented with brachial artery injuries. Operative management was performed in 38 (93%) patients which included 23 reversed saphenous vein grafts, 13 primary repairs, and 2 synthetic grafts. There were four deaths (9.8%) and four (9.8%) amputations. Comparing the amputation and limb salvage groups, the Injury Severity Score (ISS) was 32 versus 12, whereas the Mangled Extremity Severity Score (MESS) was 7 versus 4.3. Five patients had a MESS score greater than 7; four of whom had an amputation or died. Amputation was performed in only 4 of 23 patients with neurologic deficits. Limb salvage was successful in 24 of 28 patients without a palpable pulse on arrival. CONCLUSIONS:Predictors of amputation in brachial artery injuries differ from lower extremity vascular injuries. Delayed presentation greater than 6 hours, MESS, open fracture, nerve deficits, and diminished capillary refill were not predictive of amputation for patients with brachial artery injuries. These data suggest that the vast majority of upper extremity injuries should have attempted salvage regardless of the severity scoring systems.

OBJECTIVES:Only preliminary reports have evaluated the impact of telemedicine in trauma care. This study will analyze outcomes before (pre-TM) and after (post-TM) implementation of telemedicine in the management of rural trauma patients initially treated at local community hospitals (LCH) before trauma center (TC) transfer. METHODS:Seven rural hospital emergency departments in Mississippi were equipped with dual video cameras with remote control capability. All trauma patients initially treated at these LCH with TC consultation were reviewed. Data included patient demographics, Injury Severity Score, institutional volume of patients, mode of transportation, length of stay in LCH, transfer time (TT), mortality, and hospital cost. Patients were grouped in the pre-TM and post-TM periods. Statistical testing was with two-sample Student's t test or chi analysis as appropriate. RESULTS:During 5 years, 814 traumatically injured patients (pre-TM, n = 351; post-TM, n = 463) presented to the LCH. In the pre-TM period, 351 patients were transferred directly from the LCH for definitive management to the TC. In the post-TM period, 463 virtual consults were received, of which 51 patients were triaged to the TC. There were no differences in patient age, sex, or mode of transportation. When comparing post-TM with pre-TM era, patients had a higher Injury Severity Score (18 vs. 10, p < 0.001); less incidence of blunt trauma 35 (68%) versus 290 (82%), p < 0.05; a decrease in length of stay at LCH 1.5 hours versus 47 hours, p < 0.001; as well as TT LCH to TC 1.7 hours versus 13 hours, p < 0.001. After arrival to TC during the post-TM era patients received more units of packed red bed cell 13 units versus 5 units, p < 0.001 but without difference in mortality 4 (7.8%) versus 17 (4.8%), when compared with pre-TM era. Of statistical significance there was a dramatic decrease in hospital cost when comparing post-TM and pre-TM eras ($1,126,683 vs. $7,632,624, p < 0.001). CONCLUSION:Telemedicine significantly improved rural LCH evaluation and management of trauma patients. More severely injured trauma patients were identified and more rapidly transferred to the TC. Total TC hospital costs were significantly decreased without significant changes in TC mortality. Introduction of telemedicine consultation to rural LCH emergency departments expanded LCH trauma capabilities and conserved TC resources, which were directed to more severely injured patients.

Purpose: Objective criteria to predict response to Gastric Electrical Stimulation (GES) in medically-refractory gastroparesis (GP) have not been identified. Temporary GES (tGES) (GIE. 2005;61:455–6) improves GP symptoms and may be used to assess response to permanent GES (pGES). We examined long term outcomes in a large group of GP patients to define clinical and tGES-derived mucosal electrogastrogram criteria that may predict outcome to pGES. Methods: 394 consecutive GP patients (320 F, 74 M, mean age 43 years) were consented for GES over 15 years, with diagnoses: 240 idiopathic (ID), 103 diabetes mellitus (D) and 51 post-surgical (PS). To predict response to pGES 150 patients underwent tGES prior to pGES (ID 88, D 40, PS 22). All patients were assessed by symptom scores [nausea (N), vomiting (V), and total symptom (TSS)] and IDIOMS (a HRQOL measure) at baseline (b), after tGES (t) and at the latest (L) follow-up after GES, as well as a ratio (Rt) of frequency to amplitude in tGES mucosal EGG. Linear regression determined independent variables predicting the latest vomiting score. Results: Median follow-up was 57 months (range 10 months to 12 years). In analysis by etiology, virtually all patients (I, P < 0.001, DM, P≤ 0.001 and PS, P≤ 0.001) had very good responses. Among all GP patients linear regression analysis identified 3 predictors of improvement in vomiting scores: pt age, baseline vomiting score and Rt. In subset analysis, these predictors were most significant for ID. Among all categories of GP, linear regression analysis identified a low Rt derived by the use of mEGG as the single best predictor of response to tGES and pGES. Conclusion: Permanent GES for severe GP results in significant and sustained improvement of overall symptoms and quality of life. The independent predictors of response (age, Vb score, and Rt) were most significant in ID patients. Rt derived from endoscopic tGES mucosal EGG is an accurate predictive criterion of symptom improvement with GES, especially improvement in vomiting. Future studies with larger sample sizes may identify and standardize these and other factors that may predict outcomes after GES.Table: Subset AnalysisFigureSymptom Outcome: IDIOMs, Nausea (N), vomiting (V) and total symptom score (TSS) at baseline (b) after temporary GES (tGES) and at the latest (last) date of evaluation (last). All parameters showed significant improvement (see text for P values)

with the improvement of quantity (26.0±10.1% versus 5.5±4.2%,P<0.05) and the ultrastructure of ICC compared with the diabetes.Conclusions: Reduced SCF in the serum and proximal colon of diabetic mice may lead to the diabetes-associated depletion of gastrointestinal tract ICC.Exogenous SCF may improve ICC quantity and ultrastructure in diabetic colon.Thus, SCF may play an important role in the pathogenesis and therapeutics of diabetic gastrointestinal dysmotility.

BACKGROUND Nonoperative management (NOM) of low-grade blunt pancreatic injuries (LGBPI) diagnosed by computed tomographic (CT) abnormalities of the pancreas in the adult hemodynamically stable (HDS) patient has not been previously defined. We report our experience of patients with LGBPI at a single Level I Trauma Center. METHODS Adult HDS patients during a 5-year period with blunt pancreatic injuries with an abbreviated injury score of </=2 were identified through the hospital trauma registry. Management, complications, and outcome were reviewed. Patients who underwent initial emergency laparotomy, died on hospital day one, or had a Glasgow Coma Scale of three were excluded. Failure of NOM was defined by need for subsequent exploratory laparotomy or development of a pancreatic complication. Data are reported as mean +/- SEM. RESULTS A total of 120 patients were identified as having blunt pancreatic injury of which 35, with pancreatic abbreviated injury score of </=2, were blunt HDS patients with abdominal CT evidence of pancreatic injury. Amylase elevation was noted in 23 of 35 (68.5%) patients with positive CT scan findings of LGBPI. Study population consisted of 20 male patients and 15 female patients, age 32 +/- 13.22, injury severity score 21 +/- 10.08, systolic pressure 123 +/- 27.06 with mean base deficit -3.78 +/- 2. Of these 12 (34.28%) patients had an associated intra-abdominal solid organ injury. Five patients failed NOM (F-NOM), one had missed small bowel injury, three had pancreatic abscess, of which one developed a pancreatic fistula which resolved with medical management, and one F-NOM for blunt liver injury with missed bowel injury. No death in the F-NOM group and two deaths (5.71%) in the successful NOM (S-NOM) group unrelated to the pancreas. The average length of stay was 11 days +/- 9.71 days. CONCLUSION NOM of LGBPI diagnosed by CT was successful in the majority of HDS patients, with low morbidity and mortality. We propose a management algorithm for NOM of LGBPI in which the role for early ductal injury detection with endoscopic retrograde cholangio-pancreatogram or magnetic retrograde cholangio-pancreatogram should be incorporated to better analyze the most appropriate treatment.

Pericardial tamponade (PT) after penetrating thoracic injury can be lethal if not diagnosed and treated promptly. Most patients present with PT shortly after their injuries occur, but delayed presentation of PT (delayed pericardial tamponade [DPT]) has occurred as late as 73 days after initial injury. Initial evaluation of patients with an anterior mediastinal penetrating injury includes physical examination, chest x-ray, and echocardiography. CT scans of the chest can clarify the tracts of penetrating injuries in stable patients. With increased accessibility to these radiographic modalities, PT has been diagnosed in a more timely fashion, and the incidence of DPT has decreased. However, the absence of pericardial effusions on all of these studies at initial presentation does not clear the patient from risk for developing DPT.

Purpose: Electrogastrogram (EGG) recordings can be obtained from electrodes placed in the inner or outer muscularis propria of the gastric wall. The relationship between electrical activity generated by the Interstitial Cells of Cajal (ICC) and the number of cells in the muscle layers of the gastric wall has not been quantified previoulsy. We examined this relationship in patients with refractory gastrointestinal motor disorders using mucosal and serosal probes placed either endoscopically in the GI lab or serosally in the OR. We hypothesized that specific relationships might exist between ICC cell numbers, direct EGG signals, and gastric motor function. We also examined whether mucosal or serosal signals corresponded better to standardized gastric emptying studies. Methods: 29 patients (25 female, 4 male, mean age 34 years) with upper gastrointestinal motor disorders had full thickness seromuscular biopsies of the stomach at the time of gastric electrical stimulation (GES) system implantation. Immunohistochemical staining with anti-CD117 antibodies was used to identify ICC cells. The numbers of CD117 positive cells per high power field were quantified in the inner circular muscle (I) and outer longitudinal muscle (O) layers of the muscularis propria for each patient. EGG recordings were obtained from electrodes placed either endoscopically through the mucosa (M) into the inner muscle layer or surgically through the serosa (S) into the outer muscle layer at the time of placement of temporary or permanent electrical stimulation devices respectively. The EGG data are reported as average frequency (freq) in cycles per minute, average amplitude (amp) in milliVolts, and as the frequency/amplitude ratio (FAR). Pair-wise correlation coefficients (r) were calculated to assess the associations between EGG values and the number of CD117 positive cells in the inner (I) and outer (O) muscle layers of the muscularis propria as well as 4-hour GET after eating a low-fat solid meal. Results: As shown in Table 1, mucosal amplitude correlated with the outer muscle CD117 cells and mucosal amplitude, frequency, and FAR correlated with the 4-hour GET (P= 0.05 to 0.10 by correlation coefficients).Table 1: Serosal and Mucosal EGG Correlations with ICC in Inner and Outer Muscle LayersConclusion: In patients with refractory gastrointestinal motor disorders, the mucosal amplitude correlates with some measures of CD117 cells and the mucosal amplitude, frequency, and FAR correlates with the 4-hour GET. The data showed that the mucosal EGG correlated better with gastric emptying than the serosal EGG. Further studies of the correlations between gastric ICC anatomy, direct EGGs, and gastric physiology may provide clinically useful data. EGG measures obtained via endoscopy may prove to be a practical way of assessing gastric neuro-muscular function.