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Objective: To compare sedation protocols for dynamic bronchoscopy (DB) in the evaluation of expiratory central airway collapse (ECAC)., Materials and Methods: This observational study included adult patients (≥18 years) referred to Mayo Clinic, Jacksonville, FL, from March 2023 to July 2024, for suspected ECAC. Patients were grouped based on sedation protocols: propofol (Protocol 1), remimazolam (Protocol 2), and remimazolam/fentanyl (Protocol 3). The primary outcome was the quality of assessment during DB, rated on a 4-point Likert scale (1 = poor, 4 = excellent). Secondary outcomes included anesthesia duration and post-anesthesia care unit (PACU) length of stay. Statistical analyses included Fisher's exact test, ordinal logistic regression, and Kruskal-Wallis tests., Results: Seventy-three patients met the inclusion criteria. Overall, DB quality of assessment was significantly associated with sedation protocol (P=0.01 Ordinal regression results suggest that protocol 3 (remimazolam/fentanyl) may be comparable to protocol 1 (propofol) (OR0.40, 95%CI 0.12-1.33, P = 0.13), with both showing a tendency for better performance than protocol 2 (remimazolam) (OR0.14, 95%CI 0.04-0.46 P=0.002 vs protocol 3; OR0.35, 95%CI 0.09-0.29 P=0.115 vs protocol 1). No significant differences were found in PACU length of stay among the three protocols (P = 0.13). No post-procedural complications were reported., Conclusion: Protocol 3 (remimazolam/fentanyl) demonstrated significantly higher odds of achieving a better quality of assessment compared to Protocol 2 (remimazolam) and showed comparable performance to Protocol 1 (propofol). These findings suggest that remimazolam/fentanyl is an effective sedation option for DB, providing improved assessment quality without increasing PACU stay. Larger prospective studies are necessary to confirm these results., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To provide a standardized step-by-step guide for continuous positive airway pressure (CPAP) titration during dynamic flexible bronchoscopy (DB)., Patients and Methods: This descriptive study included patients referred to Mayo Clinic for concern regarding expiratory central airway collapse (ECAC) who underwent DB with CPAP titration from April 5, 2023, to February 9, 2024. Demographic characteristics, comorbidities, pulmonary function test results, and procedural details such as anesthesia protocols, CPAP settings, outcomes of pneumatic stenting, complications, and severity of ECAC were recorded. The procedure is performed with the patient under light sedation. After assessing dynamic breathing maneuvers for airway collapsibility, a CPAP mask is attached with initial pressure set at 6 cm H 2 O and titrated in increments of 2 cm H 2 O until successful pneumatic stenting of the airway., Results: The study group included 33 patients. The mean ± SD age was 67.45±8.73 years, 21 (63.6%) were female, and 26 (78.8%) presented with shortness of breath. The median ECAC severity score was 11 (IQR, 7 to 13). Of the 32 patients who underwent pulmonary function tests, 20 (62.5%) had normal results and 12 (37.5%) had a serrated flow-volume loop. The median CPAP setting to maintain airway patency was 12 cm H 2 O (IQR,10 to 14 cm H 2 O). We reported no intraprocedural or postprocedural complications., Conclusion: This study provides a detailed guide to performing CPAP titration during DB. We believe that this description of technique will support a systematic approach for further research to assess the impact of pneumatic stenting in ECAC., (Copyright © 2024 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Introduction: Cystic and cavitary pulmonary lesions (PLs) frequently require histologic confirmation for an accurate diagnosis. Shape-sensing robotic-assisted bronchoscopy (ssRAB) with mobile cone beam computed tomography (mCBCT) offers a minimally invasive alternative to traditional biopsy techniques like CT-guided transthoracic biopsy. This study aimed to evaluate the diagnostic performance and safety of ssRAB in cystic and cavitary PLs., Material and Methods: A retrospective study was conducted at Mayo Clinic Florida, of patients who underwent ssRAB with mCBCT for cavitary and cystic PLs from October 2020 to February 2024. Baseline clinical, demographic, lesion characteristics, and procedure-related data were collected. Diagnostic yield, accuracy, sensitivity for malignancy and complication rates were calculated while logistic models identified associations between variables and diagnostic yield., Results: 52 patients were included, 54 nodules were sampled. ssRAB provided a diagnostic yield of 83 % and a diagnostic accuracy of 83 %, with a sensitivity for malignancy of 97 % and specificity of 58 %. Pneumothorax occurred in 4 % of cases, with one requiring chest tube insertion. Nashville bleeding scale ≥ 2 occurred in 4 % of procedures. There was no significant association between lesion size, distance to chest wall, type of lesion and diagnostic yield., Conclusion: ssRAB with mCBCT demonstrated high diagnostic yield and sensitivity for malignancy in cavitary and cystic PLs, with a low complication rate. Its ability to perform mediastinal staging in the same anesthetic event, along with its safety profile, suggests ssRAB as a valuable tool in the assessment of air-filled pulmonary lesions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Shape-sensing Robotic-assisted Bronchoscopy (ssRAB) has emerged as a promising tool for improved performance when sampling pulmonary nodules (PPN). Previous studies suggest that the 1.1 mm cryoprobe is as effective compared to fine needle aspiration (FNA), for different lesions sizes. We aim to compare the 1.1 mm cryoprobe performance to FNA for sampling PPN < 20 mm with ssRAB., Material and Methods: We conducted a retrospective cohort study from November 2022 to February 2024 of patients who underwent ssRAB with cryobiopsy for evaluation of PPN. We compared the diagnostic yield and sensitivity for malignancy of cryobiopsy and FNA for the same PPN. Descriptive statistical analysis was conducted using the McNemar's Test and Comparison of proportion. Multivariate logistic regression assessed the impact of PPN characteristics on the yield of each tool., Results: We included 256 patients, with a combined 284 procedures, and 324 nodules sampled. The median maximum and minimum nodule size was 1.6 cm (IQR 1.17-2.4) and 1.17 cm (IQR 0.86-1.7) respectively. The overall ssRAB diagnostic yield was 93.8 % and sensitivity for malignancy was 97.5 %. Cryobiopsy had a diagnostic yield of 92 % and sensitivity of 96 %, FNA had a 70.4 % and 79.29 % respectively (P < 0.001). Cryobiopsy had a significantly higher performance compared to FNA across the analyzed categories (P < 0.05), except for the sensitivity of mixed-type lesions (P = 0.11). PPN < 10 mm and ≥ 10 mm - <15 mm sampled with FNA, had lower odds of achieving a diagnosis compared to the ≥ 20 mm group (OR = 0.305 IC95%: 0.142-0.65, p < 0.001; OR = 0.497 IC95%: 0.263-0.939, p = 0.031, respectively). Complications occurred in 5.98 % (N = 17) of cases., Conclusion: Cryobiopsy demonstrates a statistically higher diagnostic yield and sensitivity for malignancy compared to FNA. Remarkably, FNA showed reduced diagnostic odds in PPN < 15 mm. ssRAB with cryobiopsy could enhance PPN diagnostic yield, leading to earlier lung cancer diagnosis and improve long-term survival rates., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Competing Interests: Disclosure: There is no conflict of interest or other disclosures.

Background and Objective: Robotic-assisted bronchoscopy (RAB) has emerged as an advanced technology for lung cancer diagnosis. This review explores the three approved robotic bronchoscopy systems: Ion™ Endoluminal (Intuitive Surgical, Sunnyvale, CA, USA), Monarch™ (Johnson & Johnson, Redwood City, CA, USA), and Galaxy System™ (Noah Medical, San Carlos, CA, USA), and their different operational systems. This narrative review aims to summarize their findings and outcomes for sampling peripheral pulmonary lesions (PPL) suspected of lung cancer., Methods: A search in PubMed and Google Scholar databases was conducted for articles and abstracts published between January 2018 to May 2024 using the terms "robotic bronchoscopy" or "robotic-assisted bronchoscopy" for biopsy of PPL., Key Content and Findings: Lung cancer is the leading cause of cancer-related mortality. The introduction of RAB aims to improve the feasibility and safety of sampling PPL. Current literature describes high diagnostic yields with low risk of complications, allowing concurrent hilar and mediastinal staging within the same procedure. RAB can potentially improve early diagnosis and treatment of pulmonary malignancies and survival rate in long term, while progressing towards therapeutic applications in the near future., Conclusions: As RAB evolves, its potential as a "one-stop shop" for diagnosis, staging, and treatment can positively impact lung cancer detection, focusing on improved patient-centered outcomes and reducing multiple diagnostic and therapeutic procedures., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-456/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Purpose: Incorporating surgical skills education in trauma care is essential for young surgeons and surgical trainees. This study describes an innovative e-learning course for teaching trauma care surgical skills in an international cooperative setting. Furthermore, it aims to offer valuable insights on enhancing e-learning practices., Methods: The Panamerican Trauma Society and the Spanish Surgical Association have joined forces to launch an online course focusing on advanced trauma care surgical skills. This report provides an in-depth examination of the project and scrutinizes participant feedback through a post-course survey. The survey thoroughly evaluates their satisfaction level, the usefulness of the course content, and their view on its clinical relevance., Results: Three hundred eighty-two surgeons from 16 countries completed an online course. Three hundred seventy-nine of them responded to the post-course survey. The mean age was 36, with 64% females and 36% males. The course consisted of 9.9 h of academic content, including 5 h of video lectures and 4.9 h of live discussions. Ninety-seven percent of the participants were practicing general and acute care surgeons, and only 2% were exclusively dedicated to trauma surgery. Sixty-one percent of participants highly valued real-time interaction with faculty, and 95% believed their trauma surgical skills would improve. Additionally, 93% of the participants were satisfied or very satisfied with the e-learning experience., Conclusions: The use of video-based instructional materials has revolutionized surgical education. With online courses in trauma surgery, surgeons can now improve their skills and better prepare themselves to handle severe trauma cases. This innovative approach to surgical education has proven to be very effective and can potentially enhance patients' quality of care., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Experiential avoidance (EA) is a psychological mechanism associated with several mental health disorders and is regarded as a relevant target by third-generation cognitive behavioral therapies. It has been mainly assessed through self-report questionnaires, and the AAQ-II is the most used tool. Its psychometric evidence has been mostly tested through the classical test theory (CTT) and very scarcely assessed through Item Response Theory (IRT)., Methods: We used the Graded Response Model to examine its psychometric properties in Spanish-speaking university students (n = 1503; women = 995 (66.2%), mean age = 19.29, SD = 2.45). We tested whether the empirical data fit the model's predictions and estimated the dispersion of persons and items along the experiential avoidance continuum. Moreover, we examined category probability curves to identify the response probability of each answer. Likewise, an item-person map was made where the measurement of persons and items, both on the same scale and along the experiential avoidance continuum, could be observed jointly. Finally, we tested the gender invariance of the scale., Results: We found that the values of the individuals and the items were in the established range to be considered an adequate measure of EA. Additionally, we observed high discrimination indices for all items. The current version with seven answer options could not be optimal and should be tested in future studies. Finally, we found evidence of differential functioning by gender in one of the seven items of the instrument., Conclusions: Our results indicate that the AAQ-II is a suitable tool for measuring EA and accurately classifying and differentiating EA levels in university students., (© 2024. The Author(s).)

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management., Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest., (Copyright © 2021 Colombia Medica.)

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management., Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest., (Copyright © 2021 Colombia Medica.)

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected., Competing Interests: Conflict of interest: The authors declare that they have no conflict of interest., (Copyright © 2021 Colombia Medica.)

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%., (Copyright © 2021 Colombia Medica.)

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients., Competing Interests: Conflicts of interest: The authors declare that they have no conflict of interest., (Copyright © 2021 Colombia Medica.)

Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA., Competing Interests: Conflict of Interest: the authors declare not to have any conflict of interest, (Copyright © 2020 Colombia Medica.)

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver., Competing Interests: Conflict of interest:the authors declare not to have any conflict of interest, (Copyright © 2020 Colombia Medica.)

Pancreatic trauma is a rare but potentially lethal injury because often it is associated with other abdominal organ or vascular injuries. Usually, it has a late clinical presentation which in turn complicates the management and overall prognosis. Due to the overall low prevalence of pancreatic injuries, there has been a significant lack of consensus among trauma surgeons worldwide on how to appropriately and efficiently diagnose and manage them. The accurate diagnosis of these injuries is difficult due to its anatomical location and the fact that signs of pancreatic damage are usually of delayed presentation. The current surgical trend has been moving towards organ preservation in order to avoid complications secondary to exocrine and endocrine function loss and/or potential implicit post-operative complications including leaks and fistulas. The aim of this paper is to propose a management algorithm of patients with pancreatic injuries via an expert consensus. Most pancreatic injuries can be managed with a combination of hemostatic maneuvers, pancreatic packing, parenchymal wound suturing and closed surgical drainage. Distal pancreatectomies with the inevitable loss of significant amounts of healthy pancreatic tissue must be avoided. General principles of damage control surgery must be applied when necessary followed by definitive surgical management when and only when appropriate physiological stabilization has been achieved. It is our experience that viable un-injured pancreatic tissue should be left alone when possible in all types of pancreatic injuries accompanied by adequate closed surgical drainage with the aim of preserving primary organ function and decreasing short and long term morbidity., Competing Interests: Conflict of Interest: the authors declare not to have any conflict of interest, (Copyright © 2020 Colombia Medica.)

Background: The traditional management of complex penetrating duodenal trauma (PDT) has been the use of elaborate temporizing and complex procedures such as the pyloric exclusion and duodenal diverticulization. We sought to determine whether a simplified surgical approach to the management of complex PDT injuries improves clinical outcome., Methods: A retrospective review of all consecutive PDT from 2003 to 2012 was conducted. Patients were divided into three groups according to a simplified surgical algorithm devised following the local experience at a regional Level I trauma center. Postoperative duodenal leaks were drained externally either via traditional anterior drainage or via posterior "retroperitoneal laparostomy" as an alternate option., Results: There were 44 consecutive patients with PDT, and 41 of them (93.2%) were from gunshot wounds. Seven patients were excluded owing to early intraoperative death secondary to associated devastating traumatic injuries. Of the remaining 36 patients, 7 (19.4%) were managed with single-stage primary duodenal repair with definitive abdominal wall fascial closure (PDR + NoDC group). Damage-control laparotomy was performed in 29 patients, (80.5%) in which primary repair was performed in 15 (51.7%) (PDR + DC group), and the duodenum was over sewn and left in discontinuity in 14 (48.3%). Duodenal reconstruction was performed after primary repair in 2 of 15 cases and after left in discontinuity in 13 of 14 cases (DR + DC group). The most common complication was the development of a duodenal fistula in 12 (33%) of 36 cases. These leaks were managed by traditional anterior drainage in 9 (75%) of 12 cases and posterior drainage by retroperitoneal laparostomy in 3 (25%) of 12 cases. The duodenal fistula closed spontaneously in 7 (58.3%) of 12 cases. The duodenum-related mortality rate was 2.8%, and the overall mortality rate was 11.1%., Conclusion: An application of basic damage-control techniques for PDT leads to improved survival and an acceptable incidence of complications., Level of Evidence: Therapeutic study, level IV.

Background: The objective of this study was to describe a comprehensive five-step surgical management approach for patients with penetrating liver trauma based on our collective institutional experience., Methods: A prospective consecutive study of all penetrating liver traumas from January 2003 to December 2011 at a regional Level I trauma center in Cali, Colombia, was conducted., Results: A total of 538 patients with penetrating thoracoabdominal trauma were operated on at our institution. Of these, 146 had penetrating liver injuries that satisfied the inclusion criteria for surgical intervention to manage their hepatic and/or associated injuries. Eighty-eight patients (60%) had an American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) of Grade III (54 patients, 37%), Grade IV (24 patients, 16%), and Grade V (10 patients, 7%). This group of patients required advanced "complex" techniques of hemostasis such as the Pringle maneuver (PM), perihepatic liver packing (PHLP), and/or hepatotomy with selective vessel ligation (SVL). The focus of our study was this subgroup of patients, which we further divided into two as follows: those who required only PM + PHLP (55 patients, 63%) to obtain control of their liver hemorrhage and those who required PM + PHLP + SVL (33 patients, 37%). Of the patients who required PM + PHLP + SVL, 10 (27%) required ligation of major intrahepatic branches, which included suprahepatic veins (n = 4), portal vein (n = 4), retrohepatic vena cava (n = 1), and hepatic artery (n = 1). The remaining 23 patients (73%) required direct vessel ligation of smaller intraparenchymal vessels. The overall mortality was 15.9% (14 of 88), with 71.4% (10 of 14) related to coagulopathy. Mortality rates for Grade III was 3.7% (2 of 54), for Grade IV was 20.8% (5 of 24), and for Grade V was 70% (7 of 10). The mortality in the PM + PHLP + SVL group was higher compared with the PM + PHLP group (12 [36.4%] vs. 2 [3.6%], p = 0.001]., Conclusion: For those patients who fail to respond to PM + PHLP and/or those who have AAST-OIS penetrating liver injuries, Grades IV and V would benefit from immediate intraparenchymal exploration and SVL.

In the future, trauma research and care will have to become better, faster, and less expensive. Surgeons in the next millennium must be able to diagnose wounds, initiate correct procedures, and anticipate complications more accurately than before. Violent crime will not abate, nor will the proliferation of more powerful arms; these trends translate into graver traumatic wounds, giving the operating team less time to stabilize patients. Time management and team coordination are becoming key elements for patient survival, especially for patients with potentially fatal wounds, such as those to the heart. The authors have reduced the time from arrival to surgery to a few minutes. The keys to this feat are readiness, team coordination, and high morale. Financial resources will continue to be limited and allocated on a need-first basis. In the future, trauma centers will compete for dwindling funds. Technology is and always will be just a tool, whereas qualified trauma surgeons are irreplaceable, much more so than in any other surgical specialty. Observation, diagnosis, and surgery are, of course, greatly facilitated by ever-evolving technology, but since the time of Hippocrates, split-second decisions can ultimately be made only by the caregiver in the white smock. Trauma surgeons in the next millennium will have to exercise judgment based on knowledge, surgical skills, and contact with patients. To err is human, but in surgery, errors often cause death, and no machine will ever relieve surgeons of that burden.

Objective: To demonstrate the applicability of nonoperative treatment to penetrating hypopharyngeal wounds., Design: A prospective study., Materials and Methods: An analysis of patients with penetrating hypopharyngeal wounds who were treated nonoperatively at the Hospital Universitario del Valle (Cali, Colombia) during 4 years (beginning January 1990) was performed. Patients older than 13 years with proven lesions produced by penetrating trauma were included. Patients with foreign-body-induced or iatrogenic lesions (orotracheal intubation, endoscopy) or immediate need for surgery (for associated lesions) were excluded. Nonoperative management consisted of nasogastric tube for feeding, suspension of oral intake, and parenteral antibiotics for 7 days., Measurements and Main Results: Fourteen patients met the above criteria. Gunshot wounds (n = 11) were the most common trauma. An esophagogram/endoscopy demonstrated the lesions. The only complication in the group consisted of a cervical abscess, which presented in a patient during the first week of treatment. There were no complications such as fistula, leakage, and Horner's syndrome., Conclusions: Conservative management is a good and safe alternative when indicated in penetrating hypopharyngeal wounds.

Pelvic radiography in blunt trauma patients is routinely used in most trauma centers. The purpose of this review was to evaluate the ability of physical examination alone to detect pelvic fractures. Among patients with blunt trauma admitted to the University Hospital del Valle in Cali, Colombia, over a 3-month period, 608 adult patients, with hemodynamic stability, without spinal involvement, and with a Glasgow Coma Scale score greater than 10 were evaluated. All patients had physical examination, pelvic x-ray and adequate follow-up. Fifty-nine (9.7%) patients had pelvic fractures, with 57 of these fractures detected by physical findings. The remaining two patients had stable fractures that required no treatment. After careful analysis, we conclude that a negative physical examination following blunt trauma has a negative predictive value of 99% probability in excluding pelvic fracture, provided that the patient is not a child, is not in coma, is hemodynamically stable without evidence of blood loss, and has no spinal cord injury. A selective use of pelvic x-ray in patients with blunt trauma is a cost-effective policy.

The study reported here evaluated the efficacy of antibiotics administered in two periods: preoperative only and additional doses postoperatively. There was no difference in developing surgical sepsis between the groups when they included antibiotics preoperatively and the severity of the trauma was minor (Abdominal Trauma Index [ATI] value < 25). Additionally, the result was the same when one of the injured organs was the colon, in contrast with past studies. One interesting point is related to the association of a Revised Trauma Index value > 20 with a colon wound: in the present study, this combination had a deleterious effect on the patients, always resulting in abdominal sepsis. Emphasis is placed on the economic benefits of the abolition of postoperative antibiotic use in patients with ATI score less than 25.