Damage control surgery for severe pancreatic trauma

Pancreatic trauma as a challenge before and during explorative laparotomy is associated with multiple visceral injuries or critical conditions. Its optimal management remains controversial.The current concept of damage control surgery (DCS) has been increasingly accepted. DCS

Medical aspects of terrorist bombings: A focus on damage control surgery and damage control resuscitation

Although terrorist bombings have tormented the world for a long time, currently they have reached unprecedented levels and become a continuous threat without borders, race or age. Almost all of them are caused by improvised explosive devices. The unpredictability of the terrorist bombings, leading to simultaneous generation of a large number of casualties and severe "multidimensional" blast trauma require a constant vigilance and preparedness of every hospital worldwide. Approximately 1.0%-2.6% of all trauma patients and 7% of the combat casualties require a massive blood transfusion. Coagulopathy is presented in 65% of them with mortality exceeding 50%. Damage control resuscitation is a novel approach, developed in the military practice for treatment of this subgroup of trauma patients. The comparison with the conventional approach revealed mortality reduction with 40%-74%, lower frequency of abdominal compartment syndrome(8% vs 16%), sepsis(9% vs 20%), multiorgan failure(16% vs 37%) and a significant reduction of resuscitation volumes, both crystalloids and blood products. Damage control surgery(DCS) and damage control resuscitation(DCR) are promising new approaches, contributing for the mortality reduction among the most severely wounded patients. Despite the lack of consensus about the optimal ratio of the blood products and the possible influence of the survival bias, we think that DCR carries survival benefit and recommend it in trauma patients with exsanguinating bleeding.

Formation damage control of high permeability sandstone reservoir

The concern on formation damage control of high permeability sandstone reservoir has been growing in oil industry in recent years. The invasion of particles and the filtrate of drilling fluid are proven as one of the key factors accounting for reservoir damage. Based on the ideal packing theory, the practical software has been developed to optimize the blending proportion of several bridging agents, and the core flooding tests were conducted to evaluate return permeability of core samples contaminated with different drilling fluids. Experimental results show that the ideal packing approach can reduce the dynamic filtration rate, improve the return permeability and drawdown the breakthrough pressure, indicating that this kind of drilling fluids can meet the demands of formation damage control for high permeability sandstone reservoirs. Some applying procedures for formation damage control are also proposed in this paper.

How Learning from Trauma Benefits the Obstetric Population?Damage Control Surgery

The recent implementation of trauma-validated damage control strategies in severe postpartum hemorrhage proves the importance of interdisciplinary management in the obstetric patient.Massive hemorrhage control techniques and damage control surgery are clear examples of how learning from trauma can benefit the obstetric population.Currently,most obstetric programs do not include training in this type of interventions.Nevertheless,it has been shown that these interventions are useful in the management of severe postpartum hemorrhage.The aim of this article is to introduce the application of damage control surgery principles in the management of massive obstetric hemorrhage.We propose to include appropriate training and the implementation of damage control surgery in obstetric management protocols.The prompt application of damage control principles can be considered in patients with persistent hemodynamic instability despite control of the source of bleeding.

Optimized clinical practice for superaged patients with hip fracture:significance of damage control and enhanced recovery program

With the advent of global aging,the incidence,mortality,and medical costs of hip fracture among aged patients are increasing annually.The number of controlled clinical studies and health economics analyses that conform to evidence-based medicine principles is growing day by day.However,unfortunately,no specific recommendations regarding the procedures for the treatment of hip fracture are available.Meanwhile,the existence of both traditional treatment systems and new treatment theories means that most doctors confront difficult choices in their daily practice.These factors make the therapeutic approach for aged patients,especially among superaged patients with hip fracture,extremely challenging.This study focuses on superaged patients(>80 years as defined by the World Health Organization)with hip fracture and includes their preoperative pathological condition;therapeutic decision-making in terms of the benefit and risk ratio,damage control theory,and enhanced recovery after surgery were also investigated.These patients were discussed specifically by combining the current treatment strategies from several experts and the results of a meta-analysis published recently.The study presents some new ideas and approaches currently recognized in the field,such as preoperative assessment,surgical planning,safety consideration,complication intervention,and enhanced recovery implementation,and further presents some clear interpretations regarding misunderstandings in clinical practice.Finally,optimized treatment according to damage control principles and enhanced recovery after surgery during the perioperative period among superaged hip fracture patients is defined.

Surgical hemostatic options for damage control of pelvic fractures

The diagnosis and treatment of pelvic ring disruption has significantly changed over the past 30 years.It was not until the 1980s that the concept of damage control surgery was applied in the management of severely traumatized patients.The contents of damage control surgery mainly include three phases：the initial stage,the goal of severe pelvic trauma treatment is using simple surgical techniques to control life-threatening bleeding;the second stage,the physiological disturbances of the patients were corrected by ICU resuscitation;and the third stage,the definitive surgery performed for the injuries.1 About 10% to 20% of patients with severe unstable pelvic fracture also present with hemodynamic instability,and the mortality rate of them can be as high as 40%.2-4 Although hemodynamic resuscitation techniques have made great progress,some patients do not respond or poorly respond to resuscitation treatment.

Application of damage control orthopedics in 41 patients with severe multiple injuries

Objective： To probe the feasibility and efficacy of damage control orthopedics （DCO） in treating severe multiple injuries. Methods： A retrospective analysis was made on the clinical data of 41 patients （31 males and 10 females, aged 18-71 years, mean： 36.4） with multiple injuries admitted to our department and treated by DCO from January 1995 to December 2005. Results： As a first-stage therapy, devascularization of internal iliac arteries was performed in 29 patients with pelvic fractures combined with massive bleeding, including ligation of bilateral internal iliac arteries in 21 patients and embolization of bilateral internal iliac arteries in 8. And early external fixation of pelvis was performed in 10 patients. Ten patients with severe multiple injuries combined with femoral fractures were managed with primary debridement and temporal external fixation and 2 patients with spinal fractures combined with spinal cord compression received simple laminectomy. Thirty-one patients received definite internal fixation after resuscitation in intensive care unit. The overall mortality rate was 12.1% （5/41） with an average injury severity score of 41.4. The main causes of death were hemorrhagic shock and associated injuries. Complications occurred in 7 patients including acute respiratory distress syndrome in 3 cases, thrombosis of right common iliac artery in 1, subphernic abscess in 2 and infection of deep wound in lower extremity in 1. After treatment, all the patients got cured. Conclusions： Prompt diagnosis and integrated treatment are keys to higher survival rate in patients with severe multiple injuries. In this condition, DCO is an effective and safe option.

Damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma

Objective： To discuss damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma. Methods： The data of 53 cases of severe polytrauma who had mainly sustained orthopaedic trauma were retrospectively analyzed. And the methods and timing of damage control orthopaedics were discussed in this study. Results： We succeeded in rescuing the lives of all the 53 patients, and 38 patients returned to their former work. Conclusions： Injury Severity Score （ISS90） should be 17 in severe polytrauma patients, but in severe polytrauma patients who have mainly sustained orthopaedic trauma, the ISS90 of bone and joint injuries should be 16. We recommend that primary minimallyinvasive external fracture stabilization should be made for extremities and pelvis in these patients to avoid additional surgical trauma and that definitive secondary fracture care should be performed after medical stabilization for these patients in intensive care unit （ICU）.

Damage control surgery for severe thoracic and abdominal injuries

Objective: To investigate the application of damage control surgery in treatment of patients with severe thoracic and abdominal injuries.Methods: A retrospective study was done on 37 patients with severe thoracic and abdominal injuries who underwent damage control surgery from January 2000 to October 2006 in our department. There were 8 cases of polytrauma ( with thoracic injury most commonly seen), 21 of polytrauma (with abdominal injury most commonly seen) and 8 of single abdominal trauma. Main organ damage included smashed hepatic injuries in 17 cases,posterior hepatic veins injuries in 8, pancreaticoduodenal injuries in 7, epidural or subdural hemorrhage in 4,contusion and laceration of brain in 5, severe lung and bronchus injuries in 4, pelvis and one smashed lower limb wound in 3 and pelvic fractures and retroperitoneal hemorrhage in 6. Injury severity score (ISS) was 28-45 scores (38.4 scores on average), abbreviated injury scale (ALS) ≥ 4.13. The patients underwent arteriography and arterial embolization including arteria hepatica embolization in 4 patients, arteria renalis embolization in 2 and pelvic arteria retroperitoneal embolization in 7. Once abbreviated operation finished, the patients were sent to ICU for resuscitation. Twenty-four cases underwent definitive operation within 48 hours after initial operation, 5 underwent definitive operation within 72 hours after initial operation, 2 cases underwent definitive operation postponed to 96 hours after initial operation for secondary operation to control bleeding because of abdominal cavity hemorrhea.Two cases underwent urgent laparotomy and decompression because of abdominal compartment syndrome and 2 cases underwent secondary operation because of intestinal fistulae (1 case of small intestinal fistula and 1 colon fistula) and gangrene of gallbladder.Results: A total of 28 patients survived, with a survival rate of 75.68%, and 9 died (4 died within 24 hours and 5 died 3-9 days after injury). The trauma deaths at the early stage were caused by severe primary injuries resulting in failure of respiration and circulation, while mortality at the later stage was caused by multiple organ failure.Conclusions: Damage control surgery is important for the treatment against severe thoracic and abdominal injuries. It is suggested that the surgeon should select the reasonable auxiliary examination before operation, and take the proper time to perform damage control and definitive surgery.

Temperature effects of shape memory alloys(SMAs)in damage control design of steel portal frames

The objective of the present study is to analytically investigate temperature effects of an axial-type seismic damper made of shape memory alloys(SMAs)equipped in steel frames.Based on a modified multilinear one dimensional constitutive model of SMAs,two types of SMAs are employed,which have different stress plateau and different stress growth rate with temperature increase.Temperature effects of SMA dampers on seismic performance upgrading are discussed in three aspects:different environment temperatures;rapid loading rate induced heat generation and different SMA fractions.The analysis indicates that the effect of environment temperature should be considered for the SMA damper in steel frames.However,the rapid loading rate induced heat generation has little adverse effect.

Establishment of a combat damage control surgery training platform for explosive combined thoraco-abdominal injuries

Purpose:It is challenging to prepare military surgeons with the skills of combat damage control surgery(CDCS).The current study aimed to establish a damage control surgery(DCS)training platform for explosive combined thoraco-abdominal injuries.Methods:The training platform established in this study consisted of 3 main components:(1)A 50 m×50 m square yard was constructed as the explosion site.Safety was assessed through cameras.(2)Sixteen pigs were injured by an explosion of trinitrotoluene attached with steel balls and were randomly divided into the DCS group(accepted DCS)and the control group(have not accepted DCS).The mortality rate was observed.(3)The literature was reviewed to identify the key factors for assessing CDCS,and testing standards for CDCS were then established.Expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards.Then,a 5-day training course with incorporated tests was used to test the efficacy of the established platform.In total,30 teams attended the first training course.The scores that the trainees received before and after the training were compared.SPSS 11.0 was employed to analyze the results.Results:The high-speed video playback confirmed the safety of the explosion site as no explosion fragments projected beyond the wall.No pig died within 24 h when DCS was performed,while 7 pigs died in the control group.After a literature review,assessment criteria for CDCS were established that had a total score of 100 points and had 4 major parts:leadership and team cooperation,resuscitation,surgical procedure,and final outcome.Expert questionnaire results showed that the scientific score was 8.6±1.25,and the feasibility score was 8.74±1.19.When compared with the basic level,the trainees’score improved significantly after training.

Parametric study on damage control design of SMA dampers in frame-typed steel piers

This paper focuses on damage control design of SMA dampers in steel frame piers.A parametric study based on time history analyses is carried out on frametyped bridge piers with axial-type SMA damping device.The parameters examined are design parameters of strength ratioαF and stiffness ratioαK.Seismic performance indexes on displacement and strain are investigated under three JRA recommended Level 2 Ground TypeПstrong earthquake motions.Design recommendations are suggested following the results of the parametric study.

Characterization and prevention of formation damage for fractured carbonate reservoir formations with low permeability

Stress sensitivity and water blocking in fractured carbonate reservoir formations with low permeability were determined as the main potential damage mechanisms during drilling and completion operations in the ancient buried hill Ordovician reservoirs in the Tarim Basin. Geological structure, lithology, porosity, permeability and mineral components all affect the potential for formation damage. The experimental results showed that the permeability loss was 83.8%-98.6% caused by stress sensitivity, and was 27.9%-48.1% caused by water blocking. Based on the experimental results, several main conclusions concerning stress sensitivity can be drawn as follows： the lower the core permeability and the smaller the core fracture width, the higher the stress sensitivity. Also, stress sensitivity results in lag effect for both permeability recovery and fracture closure. Aimed at the mechanisms of formation damage, a modified low-damage mixed metal hydroxide （MMH） drilling fluid system was developed, which was mainly composed of low-fluorescence shale control agent, filtration control agent, lowfluorescence lubricant and surfactant. The results of experimental evaluation and field test showed that the newly-developed drilling fluid and engineering techniques provided could dramatically increase the return permeability （over 85%） of core samples. This drilling fluid had such advantages as good rheological and lubricating properties, high temperature stability, and low filtration rate （API filtration less than 5 ml after aging at 120 ℃ for 4 hours）. Therefore, fractured carbonate formations with low permeability could be protected effectively when drilling with the newly-developed drilling fluid. Meanwhile, field test showed that both penetration rate and bore stability were improved and the soaking time of the drilling fluid with formation was sharply shortened, indicating that the modified MMH drilling fluid could meet the requirements of drilling engineering and geology.

Damage alarming of long-span suspension bridge based on GPS-RTK monitoring

Structure damage identification and alarming of long-span bridge were conducted with three-dimensional dynamic displacement data collected by GPS subsystem of health monitoring system on Runyang Suspension Bridge.First,the effects of temperature on the main girder spatial position coordinates were analyzed from the transverse,longitudinal and vertical directions of bridge,and the correlation regression models were built between temperature and the position coordinates of main girder in the longitudinal and vertical directions;then the alarming indices of coordinate residuals were conducted,and the mean-value control chart was applied to making statistical pattern identification for abnormal changes of girder dynamic coordinates;and finally,the structural damage alarming method of main girder was established.Analysis results show that temperature has remarkable correlation with position coordinates in the longitudinal and vertical directions of bridge,and has weak correlation with the transverse coordinates.The 3%abnormal change of the longitudinal coordinates and 5%abnormal change of the vertical ones caused by structural damage are respectively identified by the mean-value control chart method based on GPS dynamic monitoring data and hence the structural abnormalities state identification and damage alarming for main girder of long-span suspension bridge can be realized in multiple directions.

Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit

BACKGROUND The management of high-grade pancreatic trauma is controversial.AIM To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries.METHODS A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma(AAST) Grade Ⅲor greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified.RESULTS Over a twenty-year period, 14 patients underwent pancreatic resection for highgrade injuries. Seven patients sustained AAST Grade Ⅲinjuries and 7 were classified as Grades Ⅳ or Ⅴ. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy(PD). Overall, there was a predominance of blunt aetiologies(11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases(7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies.CONCLUSION We advocate that high-grade pancreatic trauma should be managed in high-volume hepatopancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.

Conservative management of multi-trauma induced peritonitis:Experience,outcomes,and indications

BACKGROUND The concept of mandatory laparotomy in treating traumatic peritonitis has been increasingly questioned recently.AIM To summarize and share the experience of conservative treatment of patients with multi-trauma induced peritonitis.METHODS A retrospective review was performed on patients with multiple injury induced traumatic peritonitis.RESULTS A total of 184 patients with multiple injury induced traumatic peritonitis were reviewed.46 of them underwent conservative treatment.None of the 46 patients with conservative treatment switched to surgical treatment,and all of them were cured and discharged after successful conservative treatment.No significant abnormal findings were observed at regular follow-up after discharge.CONCLUSION Conservative management is safe,effective,feasible,and beneficial in hemodynamically stable patients with traumatic peritonitis if there is no definite evidence of severe abdominal visceral organ injury.

Productivity effect and overuse of pesticide in crop production in China

Chinese farmers are often accused of overusing pesticides that play a crucial role in enhancing crop yield by reducing losses to crop pests. Pesticide overuse has caused a series of negative health and environmental externalities. This paper quantiifes the productivity effect and the optimal amount of pesticides in rice, cotton and maize production in China from the economic perspective. Using survey data col ected in 2012 and 2013, both Cobb-Douglas and Weibul damage control speciifcations are used to estimate the production function. Results show that pesticides have statistical y signiifcant pro-ductivity effect on crop yield. On the condition of Weibul damage control speciifcations, the marginal products of 1 kg of the active ingredients of pesticides for rice, cotton and maize are 71.06, 22.73 and 98.45 kg, respectively. However, 57, 64 and 17%of the actual amount of pesticides are overused for rice, cotton and maize, respectively. Moreover, the productivity effect of pesticides would be overestimated using Cobb-Douglas speciifcation without incorporating a damage control agent.

Treatment of a patient with obstructive jaundice and extrahepatic portal hypertension

BACKGROUND: Recurrence of inflammation in the extrahepatic bile duct can lead to bile duct stenosis' obstructive jaundice and cavernous transformation of the portal vein. The latter can develop into extrahepatic portal hypertension (PHT). It is difficult to establish the correct method for treating these conditions. METHODS: At another hospital, a 51-year-old man developed PHT as a result of endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage to relieve cholelithiasis and obstructive jaundice. We dealt with the biliary tract obstruction through percutaneous transhepatic cholangial drainage (PTCD), followed by selective devascularization and a shunt operation 2 weeks after the disappearance of jaundice. Three months after cholecystojejunostomy, there were no obvious changes around the bile duct. RESULT: The patient recovered uneventfully and was discharged 14 days after operation. CONCLUSION: For this patient, surgery in stages was the best choice. The most suitable method to decrease jaundice is PTCD.

Key details of the duodenal-jejunal bypass in type 2 diabetes mellitus rats

AIM: To investigate which surgical techniques and perioperative regimens yielded the best survival rates for diabetic rats undergoing gastric bypass. METHODS: We performed Roux-en-Y gastric bypass with reserved gastric volume, a procedure in which gastrointestinal continuity was reestablished while excluding the entire duodenum and proximal jejunal loop. We observed the procedural success rate, long-term survival, and histopathological sequelae associated with a number of technical modifications. These included: use of anatomical markers to precisely identify Treitz's ligament; careful dissection along surgical planes; careful attention to the choice of regional transection sites; reconstruction using full-thickness anastomoses; use of a minimally invasive procedure with prohemostatic pretreatment and hemorrhage control; prevention of hypo-thermic damage; reduction in the length of the procedure; and accelerated surgical recovery using fast-track surgical modalities such as perioperative permissive underfeeding and goal-directed volume therapy. RESULTS: The series of modif ications we adopted reduced operation time from 110.02 ± 12.34 min to 78.39 ± 7.26 min (P < 0.01), and the procedural success rate increased from 43.3% (13/30) to 90% (18/20) (P < 0.01), with a long-term survival of 83.3% (15/18) (P < 0.01). CONCLUSION: Using a number of fast-track and damage control surgical techniques, we have successfully established a stable model of gastric bypass in diabetic rats.

Splenic artery trunk embolization reduces the surgical risk of liver transplantation

BACKGROUND： Portal hypertension is one of the most im- portant clinical conditions that cause intraoperative intensive hemorrhage in cirrhotic patients undergoing liver transplan- tation. Pre-transplant portal decompression may reduce the intraoperative bleeding during liver transplantation.