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Background:Duodenal injuries are infrequent occurrences in traumatic abdomen.1 Most common cause of duodenal trauma are gunshot wounds and stab injuries.1 The purpose of this study is to determine the surgical outcome of penetrating duodenal injuries focusing on duodenal leakage.Methods:A retrospective chart review with a descriptive-analytical design analysed medical records of 36 patients meeting inclusion criteria from a 966-patient database with penetrating abdominal trauma, admitted to Groote Schuur Hospital trauma centre, Cape Town, South Africa, over 72 months (2014–2019). Demographic data (age, sex), preoperative assessments, operative interventions, and postoperative complications were recorded, with complications graded using the Clavien-Dindo classification.Results:Out of 966 patients admitted during the study period with penetrating abdominal trauma, 36 (3.73%) had penetrating duodenal injuries. All 36 patients were male, with a mean age of 27.17 (SD 8.28) years. Thirty-three (91.67%) patients sustained gunshot wounds, and the remaining three (8.33%) had stab wounds. Fifteen (41.67%) patients underwent damage control surgery (DCS). Six (16.67%) patients developed a duodenal leak (DL). Ten (27.78%) patients died, including five DL patients, who died due to sepsis.Conclusion:Simple duodenal repair appears to be the best management option for penetrating duodenal injuries, except for severe injuries graded AAST IV-V where adjunct surgical techniques may be necessary.

BackgroundSelective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is routinely practised in our trauma centre. This study aims to report the outcomes of patients who have failed SNOM.MethodsPatients presenting with PAT from 1 May 2015 – 31 January 2018 were reviewed. They were categorised into immediate laparotomy and delayed operative management (DOM) groups. Outcomes compared were postoperative complications, length of hospital stay and mortality.ResultsA total of 944 patients with PAT were reviewed. After excluding 100 patients undergoing damage control surgery, 402 (47.6%) and 542 (52.4%) were managed non-operatively and operatively, respectively. In the SNOM cohort, 359 (89.3%) were managed successfully without laparotomy. Thirty-seven (86.0%) patients in the DOM group had a therapeutic laparotomy, and six (14.0%) had an unnecessary laparotomy. Nine (20.9%) patients in the DOM group developed complications. The DOM group had lesser complications. However, the two groups had no difference in hospital length of stay (LOS). There was no mortality in the non-operative management (NOM) group.ConclusionIn this study, we demonstrated no mortality and less morbidity in the DOM group when appropriately selected compared to the immediate laparotomy group. This supports the selective NOM approach for PAT in high volume trauma centres.

Background:Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL.Methods:All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded.Results:Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%.Conclusion:DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

Introduction: Retained haemothorax (RH) after trauma varies between 4%-20%. Empyema and fibrothorax are the most severe complications. Traditionally a RH was managed by reinsertion of a thoracoctomy tube (TT). Recent literature suggests better outcomes with video-assisted thoracoscopic surgery (VATS). Material and Methods: A prospective randomized-controlled study of VATS versus TT reinsertion for retained traumatic haemothoraces was established at the Trauma Centre at Groote Schuur Hospital (UCT HREC 119/2013). Randomisation was computer generated. Inclusion and exclusion criteria were clearly defined. All patients with suspected retained haemothorax on x-ray had a CT-chest performed. Demographics, mechanism of injury, type of procedure, length of hospital stay (LOS), complications, additional procedures, antibiotic usage and positive microbial cultures as well as follow-up, were recorded. Outcomes were LOS and complications. Results: 49 patients were analysed: (n = 24) in the VATS arm and (n = 25) in the TT reinsertion arm. * Length of hospital stay for VATS (days): pre-procedure: 7 ([+ or -]3), post-procedure: 5 ([+ or -]2), Total: 12 (+/-4). * LOS for TT reinsertion: pre-procedure: 6 ([+ or -]2), post-procedure: 6 ([+ or -]6), Total: 14([+ or -]7). No statistical difference. * Complications: VATS: 2, TT reinsertion: 10 (p = 0.01) Conclusions: No statistically significant difference in LOS between the 2 groups, at this point. Obvious difference in complications favouring VATS as the treatment modality for RH.

Introduction: Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is an effective, readily available and easy-to-use technique. This study aims to audit the technique and highlight current investigative and management strategies. Methods: All adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were included. Data was captured from an approved electronic registry and analysed. Analysed parameters included demographics, major injuries, imaging, management and outcomes. Results: Over the 22-month study a total of 628 patients with PNI were seen at GSH, of which 95 patients (15.2%) required FCBT. The average age was 27.9 years and 98% were male. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted by the referral institution (1.1% prehospital, 45.3% at clinic level and 34.7% at district/level II hospital level). A total of 34 arterial injuries (19 major and 15 minor) were identified in 29 patients, of which only three had ongoing bleeding after FCBT. Computerised tomography (CT) angiography was used in 92.6% of patients, while 8 patients (8.4%) required formal angiography. Of these, 2 were purely diagnostic and 6 were performed for definitive endovascular management. A further 13 patients were managed with open neck surgery. Seventy-two patients (75.8%) were taken to theatre at 48-72 hours post injury for removal of the catheter, of which 2 had bleeding on catheter removal. The average length of hospital stay was 6.3 days and 15 patients required ICU admission. A total of 37 separate morbidities were documented in 29 patients (30.5%) and 4 patients died (4.2% mortality rate). Conclusion: This large series shows the current use of FCBT for PNI. It highlights ease of use, high rates of success at haemorrhage control (97%) and good outcomes with the technique.

Background: Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma. Methods: Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the introduction of the ERP. Demographics, mechanism of injury, injury severity scores (ISS) and penetrating abdominal trauma index (PATI) were determined for both groups. The primary end-points were length of hospital stay (LOS) and incidence of postoperative complications (Clavien-Dindo classification) in the 2 groups. The difference in means was tested using the t-test assuming unequal variances. Statistical significance was defined as p-value less than 0.05 (p<0.05). Results: The two groups were comparable with regards to age, gender, mechanism of injury, ISS and PATI scores. The mean time to solid diet, urinary catheter and nasogastric tube (NGT) removal was 3.6 (non-ERAS) and 2.8 (ERAS) days [p<0.035], 3.3 (non-ERAS) and 1.9 (ERAS) days [p<0.00003], 2.1 (non-ERAS) and 1.2 (ERAS) days [p<0.0042], respectively. There was no difference in time from admission to time of laparotomy 313 (non-ERAS) vs 358 (ERAS) minutes [p<0.07]. There were 11 and 12 complications in the non-ERAS and ERAS groups, respectively. When graded as per the Clavien-Dindo classification, there was no significant difference in the 2 groups (p<0.59). Hospital stay was significantly shorter in the ERAS group: 5.5 (SD 1.8) days vs. 8.4 (SD 4.2) days [p<0.00021]. Conclusion: This pilot study shows that ERPs can be successfully implemented with significant shorter hospital stays without any increase in postoperative complications in trauma patients undergoing emergency laparotomy for penetrating abdominal trauma.

Background: The purpose of this study was to determine whether patients with left-sided thoracoabdominal (TA) stab wounds can be safely treated with clinical and chest X-ray follow up. Method: A prospective, randomized control study was conducted at Groote Schuur Hospital from September 2009 through to November 2014. Patients with asymptomatic left TA stab wounds included in the trial were randomized into two groups. Group A underwent diagnostic laparoscopy and Group B underwent clinical and radiological follow-up. Results: Twenty-seven patients were randomized to Group A (N=27) and thirty-one to Group B (N=31). All patients were young males with a median age of 26 years (range 18 to 48). The incidence of occult diaphragm injury in Group A was 29%. All diaphragm injuries found at laparoscopy were repaired. The mean hospital stay for the patients in Group A was 5 days (SD 1.3), compared to a mean hospital stay of 2.9 days (SD, 1.5), in Group B (p<0.001). All patients in Group B had normal chest X-rays at their last visit. The mean follow-up time was 24 months (median: 24; interquartile range: 1–40). There was no morbidity or mortality in Group B. Conclusions: Clinical and radiological follow-up are feasible and appear to be safe, in the short term, in patients who harbour occult diaphragm injuries after left TA stab wounds. Until studies showing the natural history of diaphragm injury in humans are available, laparoscopy should remain the gold standard in treatment.

Background: Due to resource constrained pre-hospital emergency medical services (EMSs) there is a significant delay in injured patients arriving at Groote Schuur Hospital Trauma Centre (GSHTC). The aim of the study was to examine the effectiveness of EMSs in transferring trauma patients to GSHTC. The effect of any delay to laparotomy from injury was noted. Methods: A prospective audit of patients presented directly from the scene to GSHTC following abdominal trauma over a four-month period was performed. Time from contact to the arrival of EMS at scene – the response time (RT) – was used as an indicator of EMS performance. Postoperative complications were graded according to Clavien-Dindo classification of surgical complications. Results: A total of 118 patients were admitted to the trauma surgery ward following abdominal trauma. The mechanism was penetrating 101 (85.6%) [stab wounds in 67 (56.8%) and gunshot in 34 (28.8%)], and 17 (14.4%) with blunt injuries. EMSs transported 110 (93.2%) patients. A total of 48 index laparotomies were done during this period, of which 13 patients developed postoperative complications. The median RT of the EMS after contact was 53 min for patients who developed complications. It was significantly longer than for those without complications, 21 min (p<0.01). The median delay to laparotomies from injury for patients with postoperative complications was 10.3 hours and for those without complications was 7.5 hours. The delay from injury to the theatre was also a significant factor in the development of complications (p = 0.02). Conclusion: The response delay by EMS and delay from injury to the theatre increased complications. Therefore, rapid response by EMS in transferring trauma patients needs to be strengthened.

Background A previous study from Groote Schuur Hospital (GSH) highlighted the success of FCBT (PNI). Aim This study is an update highlighting the management trends and outcomes. Methods The records of all patients with PNI requiring FCBT for a neck injury presenting to GSH within an 11-month study period were reviewed. Prospectively captured data on the Electronic Trauma Health Record Application (eTHRApp), was retrospectively analysed. Analysed data included demographics, clinical signs on admission, imaging, management and major outcomes. Results Over the 11-month study period, 311 patients with PNI were seen, of which 47 patients (15.1%) required FCBT. All were male; mean age of 28.6 years (range 18-48). Most injuries were caused by stab wounds (91.5%) while 4 patients (8.5%) suffered gunshot wounds. The majority of catheters (85.1%) were inserted by the referral institution. A total of 14 arterial injuries were identified, of which only one had ongoing active bleeding with haemodynamic compromise requiring immediate surgical intervention without prior imaging. The remaining 46 patients were imaged with computerised tomography angiography (CTA). A total of 8 major arterial injuries were found, of which six were surgically repaired; and one carotid injury was stented. A further 6 minor arterial injuries were identified and managed expectantly. A further 4 patients required surgery for their neck injuries: 2 had major venous injuries ligated and 2 required surgery for aerodigestive injuries. The remaining patients had their catheter successfully removed at 48-72 hours. There was no significant bleeding observed in any of these patients. There was one mortality caused by a large cerebral infarct from a common carotid artery injury. Discussion This series shows an increasing use of FCBT for PNI. Major differences from the previous series include the increased use of CT angiography and less reliance on formal angiography for diagnostic purposes. FCBT remains a simple, easy-to-use, yet effective technique.

Background Gunshot wounds (GSW) to the chest are common presentations to trauma centres in South Africa. The clinical management and outcome of GSW to the chest are significantly altered by missile trajectory and the associated anatomical structures injured making them challenging injuries to treat. Currently, the management of GSW chest is based on scant evidence and treatment is typically according to algorithms based largely on the anecdotal experience of high volume institutions and experienced clinicians. Aim To utilise an established prospective database of one of world's busiest Trauma Centres to analyse the clinicopathological aspects of all patients with GSW to the chest. This work may strengthen the body of knowledge pertaining to the treatment of GSW to the chest and may then contribute to an evidence-based management algorithm for such injuries. Methods Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated for the year 2015 for all patients with GSW chest. The data was then analysed using descriptive statistics. Results A total of 141 patients with GSW to the chest were admitted to the Trauma Centre with a median age of 26 years. More than half of the patients, 53. 2% (n = 75) sustained an isolated GSW to the chest. Overall, 29.1% (n = 41) patients sustained a thoracoabdominal injury, which accounts for a significant higher amount of emergency surgeries compared to patients with non thoracoabdominal injuries (54% vs 15%, p = < 0.01). 9.2% (n = 13) of all patients required an emergency thoracotomy or emergency chest surgery of which 5 patients survived. Overall mortality was 7.1% (n = 10) of which 5 patients died from a thoracic cause. Discussion Civilian GSW to the chest are common injuries seen in Cape Town, often with concomitant injuries leading to increased morbidity. Significantly more emergency surgeries were done in patients with thoracoabdominal injury. Overall few patients needed chest-related emergency operative intervention (9.2%) with a survival rate of 38.5%. Overall mortality of patients with GSW chest who reached the hospital was 7.1% of whom 50% died from a thoracic cause.