Traumatic injuries of the extrahepatic biliary tract are infrequent, occurring in approximately 0.5% of all patients with blunt and penetrating abdominal trauma. The incidence of this injury due to blunt abdominal trauma is rare. This study reviewed patients with injuries of the extrahepatic biliary tract due to abdominal trauma over a 6-year period to determine the incidence, trauma scores, associated injuries, surgical treatment performed, complications and mortality rate. We report our experience with 14 patients with extrahepatic biliary tract trauma. A review of the literature and the discussion about the management are presented.

Autotransfusion is being increasingly used to avoid the complications of homologous blood transfusion. In abdominal trauma, however, the collected blood may be contaminated by intestinal contents when digestive or urinary lesions are present. In such situations, the reinfusion of blood is contraindicated. We present our experience with autotransfusion of blood collected by laparoscopy from the abdominal cavity of 21 trauma patients. Laparoscopy allowed the aspiration of blood and, at the same time, permitted diagnosis of visceral lesions, avoiding reinfusion of contaminated blood. No complications occurred, and hematocrit values were significantly elevated. This procedure may represent the only possible method of blood transfusion in Jehovah's Witnesses, as with one patient in our series.

Injury of the extra-hepatic biliary tract is infrequent, occurring in approximately 3.5% of all patients with blunt and penetrating abdominal trauma. The incidence of this injury caused by blunt abdominal trauma is rare. PURPOSE--Retrospective analysis of 5069 patients with abdominal trauma treated at the Department of Surgery University of São Paulo School of Medicine over a six-year period from 1986 through 1991. METHODS--Forty five patients with gallbladder and extra-hepatic ducts injury were identified (0.89%) and divided in two groups according to the nature of trauma: 12 caused by non-penetrating injuries and 33 to penetrating injuries. Records, including operative and pathology reports, were reviewed to study the site of injury, associated intra-abdominal injuries, incidence, trauma scores, treatment, morbidity, mortality rates and correlated with the nature of the trauma. RESULTS--Overall mortality was 24.4%. The incidence was greater in patients sustaining penetrating abdominal trauma (p < 0.05). Forty of the 45 patients (88.9%) had liver lacerations, the most commonly seen injuries. The patients with blunt abdominal trauma had significant different trauma scores (p < 0.05) than those with penetrating trauma, indicating greater severity in this group of patients. CONCLUSION--There is a relation between severity of trauma and incidence of extra-hepatic biliary tract injury. However, in the penetrating trauma, the incidence of trauma is correlated with the direction of the wound and there is no relation with the severity of trauma. The greater mortality seen in the patients sustaining non-penetrating injury (p < 0.05) supports this observation.

With the aim of aiding the accurate diagnosis and treatment of patients with pancreatic injuries, we reviewed the medical records of sixty-five patients, treated for traumatic pancreatic lesions at the Department of Surgery of the University of São Paulo in the 5-year period from 1989 through 1993. Records, including operative and pathology reports, were reviewed and the location of the pancreatic injury, associated intra-abdominal injuries, type of injury, trauma scores, treatment, complications and mortality rates recorded. There were 58 male and seven female patients with a mean age of 28.3 years (range, 2-77 years). Of the 65 pancreatic injuries, 45 (69.2%) were caused by penetrating wounds and twenty by blunt trauma. The most frequent site of lesion was the head of the pancreas (38.5%). Associated injuries were found in all but five of the patients. In the 65 patients, 170 intra-abdominal injuries were found (2.6 per patient). Twenty-eight of the 65 patients (43.1%) had liver lacerations. Lacerations of major abdominal vessels (27 patients), gastric lacerations (25 patients) and colorectal lacerations (17 patients) were the next most frequent injuries. Fifteen out of twenty patients died within two days after the accident from severe concomitant injuries. Simple drainage was performed in 33 patients, distal pancreatectomy in 17 and duodenopancreatectomy in six patients. Pancreas-related complications occurred in 20 (30.7%) out of 57 patients who survived the initial operation. We concluded that the type of repair employed in our series was related to the class of injury and clinical conditions (based on trauma scores). Therefore, whenever possible, conservative management (no pancreatic resection) was employed in patients that sustained class I and II injuries and pancreatic resection in class III and IV injuries.

Gastrointestinal hemorrhage continues to be a major medical problem. Even with improvements in both diagnostic and therapeutic, a significant number of patients still require surgical intervention for control of hemorrhage. When the source of persistent lower gastrointestinal hemorrhage is unknown, subtotal colectomy is a conceptually rational management choice. The authors present a case of massive lower gastrointestinal hemorrhage with unusual fatal outcome. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.

The emergency surgical treatment of severe hepatic traumas still carries a high mortality risk. We report a case of severe blunt trauma to the liver managed without surgery under CT guidance. This attitude requires haemodynamic stability of the patient, close monitoring in a surgical intensive care unit and repeated CT scans. Laparoscopy was used to the management of hemoperitoneum due to rupture of hematoma and diagnosis and treatment of bile leakage. Conservative treatment is a reasonable option in selected hemodynamically stable patient with severe hepatic trauma.

Gallbladder lesion is infrequent, occurring in approximately 0.5 to 8.5% of all patients with blunt and penetrating abdominal trauma. The incidence of gallbladder injury in such cases is low. This study reviewed 32 patients with gallbladder injury due to abdominal trauma over a 6-year period to determine the complications, associated injuries, and mortality rate.

Rupture of the diaphragm from blunt trauma is uncommon, but greatly improved prehospital care and transportation of victims has increased the frequency at which patients who sustain this injury arrive at the emergency room alive. We report a case of bilateral diaphragmatic rupture from blunt abdominal trauma in a 33-year old man. Diagnosis was established by laparoscopy after suggestive chest X-rays, liver scintigraphy, CT scan and magnetic resonance imaging. The methods used to diagnose this condition are analyzed.

Gallbladder lesions by blunt abdominal trauma are rare, due to the organ's anatomical particularities. Diagnosis is difficult, and it generally occurs during surgery. The trauma is usually associated with other lesions and is related to very serious traumas or to deceleration. Due to the scarcity of publications on this topic and to its reduced incidence, we present here a report of five patients who had suffered blunt abdominal trauma with gallbladder lesion and who were attended at the General Hospital (of the University of São Paulo Medical School) Emergency Service between 1986 and 1991. Furthermore, we analyze the incidence of this trauma, presence of associated lesion, treatment, morbidity and mortality of the patients, as well as a review of the literature.