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Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.

BackgroundAdhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups.MethodsThe guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion.RecommendationsAdhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention.DiscussionThis guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.

Initially schooled by correspondence, Anne attended boarding school in Brisbane from the age of 11 and was inspired to do medicine by her final year zoology teacher. Since completion of her college roles, Anne has used many of the skills that enabled her earlier achievements in subsequent governance and leadership roles in the health sector in New Zealand. 1 Anne Kolbe reading to her grandchild Throughout her career, Anne has maintained an active practice in paediatric surgery. [Extracted from the article]

Duplex ultrasound scanning is currently the best available non-invasive method for vein graft surveillance. However, it is expensive and its results are highly operator dependent. The aim of the present study is to compare, another non-invasive method of graft surveillance, the transfer function index (TFI), with duplex ultrasound scanning in identifying significant stenoses in infrainguinal saphenous vein bypass grafts. Initially a retrospective pilot study was carried out between 1 January and 30 June 2002. Patients were identified from the vascular surgical operation database. The ultrasound report and TFI result of each patient were reviewed. Then a prospective comparative study was carried out between 1 July and 31 December 2002. Duplex ultrasound and TFI studies were undertaken at the 3 month interval. Comparisons were made between the accuracy and predictive value of ultrasound versus TFI in assessing significant graft stenosis. In the present retrospective study TFI measurement was significantly lower in the at-risk grafts than in the normal grafts ( P = 0.001). In the prospective group TFI was again found to be significantly lower in the at-risk group (mean TFI 0.86) than in the normal group (mean TFI 1.064, P = 0.001). The sensitivity and specificity of the TFI were 92% and 97%, respectively. The accuracy of TFI was calculated to be 98%. TFI is an accurate non-invasive method of vascular graft surveillance. TFI can be carried out in the vascular clinic and is quick and inexpensive. Normally TFI could replace duplex ultrasound surveillance, with ultrasound being reserved for those with an abnormal TFI. [ABSTRACT FROM AUTHOR]

Background: Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32–95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA. Methods: A review was undertaken of hospital and Coroner’s files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997. Results: Three hundred and twenty-nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty-three patients (16%) were initially misdiagnosed. Conclusions: Although our ability to correctly diagnose a RAAA has improved since Osler’s time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non-specific or atypical. [ABSTRACT FROM AUTHOR]

Discusses the condition of surgery in New Zealand. Background on the establishment of medical schools; Employment of medical personnel in 1998; Information on surgical training in the country.