Management of combined injury of the pancreas and upper urinary tract

The Morbidity of Trauma Nephrectomy

Mortality has been shown to be high in patients after trauma nephrectomy (TN). However, there are little data regarding morbidity in survivors. The objective of this study was to determine the morbidity rates associated with TN with attention directed to renal failure (RF) and formation of intra-abdominal abscess (IAA). Patients who underwent TN over a 9-year period (1996 to 2004) were identified from the trauma registry. Records were reviewed for all complications after TN in patients surviving at least 48 hours. Eighty-nine patients were identified with TN; 61 per cent resulted after penetrating trauma. Overall mortality was 34 per cent. Seventy-one patients survived greater than 48 hours; 51 (72%) experienced at least one morbidity. There was no difference in morbidity rates between patients undergoing blunt trauma and those undergoing penetrating trama. Patients with morbidities were significantly older, more severely injured, and had higher mortality rates and longer hospital courses. Infectious complications were seen in 52 per cent, respiratory in 48 per cent, gastrointestinal in 30 per cent, coagulopathy in 25 per cent, and RF and IAA were each seen in 14 per cent of patients. Patients undergoing TN are severely injured with significant morbidity. The results from this study allow us to establish benchmarks to assess complication rates for patients who undergo TN, which can provide prognostic information and goals to improve patient outcomes.

Predictors of the Need for Nephrectomy After Renal Trauma

BACKGROUND

Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma.

METHODS

This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center.

RESULTS

Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy.

CONCLUSION

Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.

Management of combined renal and pancreatic trauma

During a 15-year period we treated 38 patients with combined renal and pancreatic injuries (40 kidneys): 18 patients (19 kidneys) with renal contusion (89% from blunt trauma) and 20 with renal laceration or vascular injuries (90% from penetrating trauma). All patients with renal contusion were managed conservatively without complication, despite major pancreatic injury in a third. The 16 patients with significant renal and pancreatic injuries were classified as a high risk group: 3 underwent nephrectomy for vascular injuries that could not be repaired but all of the remaining kidneys were salvaged. Perinephric abscesses developed in 2 of these patients, for a major complication rate of 15%. No secondary nephrectomies were necessary, nor did urinary fistulas develop. We conclude that significant renal injuries in patients with major pancreatic injuries may be managed by renal repair with an increased but acceptable complication rate and that nephrectomy should be performed only if the degree of renal injury precludes repair.

Apparent exceptions to the usual patterns in renal trauma

Selected cases of renal injuries illustrate the impression that clinical exceptions often may reflect errors in diagnostic interpretation and reaction rather than actual complications, rendering a policy incompetent or dangerously unreliable. These cases, as well as a comparison of debates regarding the management of renal trauma, are intended to offer further encouragement to a non-operative approach to injuries of intermediate degree.

Severe blunt trauma of upper urinary and intestinal tracts in a child

A 7 1/2-year-old boy sustained severe trauma to the upper abdomen, including transection of the common bile duct, transection of the second part of the duodenum, contusion of the head of the pancreas, traumatic thrombosis of the left renal artery, thrombosis of the right lower pole renal vasculature and avulsion of the right renal pelvis. A staged elective repair of the upper urinary tract, and later the upper gastrointestinal tract, was accomplished when he was referred 5 1/2 months after the initial injury.

Penetrating high-velocity genitourinary injuries. Part II: Ureteral, lower tract, and genital wounds

Penetrating ureteral wounds appear to occur at a constant low rate and demand internal splinting without ureterotomy drainage in the multiple-injured patient. Concomitant upper urinary tract and colonic or pancreatic injury absolutely requires the use of nephrostomy drainage. Most prostatic or prostatomembranous rupture can be approached retropubically, or if extensive tissue damage and uncontrollable hemorrhage are present, by transpubic methods. Intravesical fixation of the prostatomembranous rupture provides the best anchorage and approximation. Rectoprostatic-bladder wounds should be approached suprapubically and may be drained transcoccygeally also. Section of the obturator nerve may provide postoperative pain relief in severe pubic ramus fractures. Small high-velocity entrance wounds in the external genitalia warrant exploration because of great internal disruption. The skin of the external genitalia should be closed primarily.