Gunshots carry a heavier prognosis. Only 32% of our gunshot cases underwent a significant recovery as opposed to 61% of stab cases and 44% of the motor vehicle crash victims.

A management technique of the open abdominal wound is described. It consists of a 'sandwich' composed of a Marlex mesh and an Op-Site wound dressing with interposition of suction tubes. Such a technique prevents evisceration, protects the skin, decreases evaporation, allows accurate fluid replacement, facilitates nursing and adds to the patient's comfort.

A study was made of 45 patients with diaphragmatic herniation after penetrating trauma. In 29 the diagnosis was established during the first admission (early presentation) and in 16 during a subsequent admission (delayed presentation). The mortality rate in the early presentation group was 3 per cent compared with 25 per cent in the delayed presentation group. The presence of gangrenous or perforated abdominal viscus in the chest cavity was the single most common and severe aggravating factor. The need for diagnosis of diaphragmatic herniation during the initial admission is emphasized. As isolated diaphragmatic injuries provide few helpful clinical features to aid diagnosis, appropriate investigations and good follow-up are of paramount importance in preventing late herniation of intra-abdominal viscera through a penetrating diaphragmatic injury.

There is accumulating evidence that multiple organ failure is not always the result of an established septic focus. Increasing attention has centred on the gut as a reservoir of bacteria (and bacterial endotoxins) that can traverse the intestinal mucosal barrier (a process called 'bacterial translocation') and initiate the septic state. Although the link between haemorrhagic shock and sepsis was recognized decades ago, the full experimental demonstration of this phenomenon is more recent. It was shown to occur in three main settings: physical disruption of the gut mucosa, impaired defence mechanisms and altered gut microbial ecology. Conditions such as haemorrhagic shock, burns, protein malnutrition and sepsis are seen in the severely ill surgical patient or the multiply injured, and are known to cause various combinations of circumstances favourable to bacterial translocation and endotoxin absorption. These may play an important role in the mortality of the critically ill.

Emergency department thoracotomies have a definite role in the management of trauma patients. The best results are obtained in patients with penetrating chest injuries.

This study comprises 74 patients with penetrating injuries of the duodenum. Sixty-three of these had sustained gunshot wounds, many of which were high velocity. The change in the incidence and the severity of the gunshot injuries within the last few years resulted in changes in the operative management of the duodenal wound with gradually improving results. When pyloric exclusion was added to the operative management of grade III duodenal injuries, the postoperative leakage rate was 12%. When only primary repair was done, the leakage rate was 43%. We suggest that pyloric exclusion be added to the treatment of most severe grade II and all grade III gunshot duodenal injuries. The adequacy of primary repair and pyloric exclusion in grade IV injuries requires further study.

No abstract

In a prospective study of 22 patients with diffuse peritonitis managed by the method of electively staged multiple laparotomies, the abdomen was left open in 9 patients. The patients were selected on the basis of the severity of their intra-abdominal infection: only massive faecal peritonitis, postoperative peritonitis and pancreatic abscesses were included. These amounted to only 9 per cent of all patients with intra-abdominal infection treated over a 2-year period. Up to seven re-operations were required per patient. In view of a high mortality rate of 32 per cent, the superiority of this aggressive management strategy over conventional methods is not fully established.