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Traumatic gastric transection: A case report
Traumatic
Gastric Transection:
By Mark H. Kimmins,
Dan Poenaru,
Kingston, l This report documents the first known pediatric survivor of seat-belt-associated gastric transection. An 1%year-old boy presented with abdominal ecchymoses after a motor vehicle accident. Physical and radiological examination determined the need for abdominal exploration. During the operation, a near-complete transection of the stomach was found, which was repaired by primary anastomosis. After an initially unremarkable recovery period, gastric stasis and pyloric obstruction developed. Radiologically and endoscopically, this was determined to be secondary to a traumatic distal vagotomy. Neither gastric transection nor traumatic vagotomy had been reported previously in the pediatric population with abdominal seat-belt injuries. This report demonstrates an exceptionally rare seat-belt-related injury, and its unusual postoperative complication. It also emphasizes the significance of the “seat-belt sign” in the assessment of motor vehicle-related blunt abdominal trauma, and outlines potential problems associated with the wearing of adultdesigned lap belts by pediatric passengers. Copyright o 1996 by W.B. Saunders Company INDEX trauma,
WORDS: vagotomy,
Blunt trauma, pylorospasm.
seat-belt
injuries,
gastric
ASTRIC TRANSECTION caused by seat-belt trauma is a very rare injury which is usually fatal. An expected consequence of this condition may be a traumatic vagotomy, which had not been described previously in this setting. G
CASE REPORT An 11-year-old boy was hospitalized after a two-car, head-on collision. He was a rear-seat passenger, wearing a lap-belt-type restraining device. After initial assessment at a community hospital, he was transferred to our trauma center in stable condition. During transport, he vomited 1 L of frank blood. At the time of arrival at the emergency department, he had stable vital signs, was fully conscious, and complained of abdominal pain. Examination showed bruising across the epigastrium, with tenderness and guarding over the same area. A nasogastric (NG) tube was inserted and frank blood obtained. A computer tomography (CT) scan showed the presence of hemopneumoperitoneum, a large hematoma in the lesser sac, and the tip of the NG tube lying outside the stomach within the hematoma. During laparotomy, the peritoneal cavity was found to contain fresh blood. A near-complete transection of the stomach at the antrum was observed, and only a l-cm portion of the posterior stomach wall was intact (Fig 1). A hand-sewn primary repair of the stomach was performed, and small serosal tears in the distal transverse colon were oversewn. Postoperatively the patient initially recovered well, but then returned with vomiting. An upper gastrointestinal (UGI) series and endoscopy showed a patent intact anastomosis, and severe pylorospasm (Fig 2) consistent with a complete traumatic distal
Journal
of Pediafm
Surgery,
Vol31,
No 6 (June),
1996: pp 757-756
A Case Report
and lhab Kamal
Ontario
vagotomy. Cisapride was begun, and the patient recovered slowly over the next several months. He is asymptomatic 9 months after the accident and is being weaned from the Cisapride. DISCUSSION
Seat-belt gastric transection is exceedingly rare, and we report on the first known pediatric survivor of this injury. There have been reports of this injury in adults, but the mortality rate is high and the injury usually is associated with other injuries.le3 Tso et al recently reported a case of pediatric stomach perforation in association with seat-belt injury in their retrospective analysis of abdominal injuries in restrained pediatric passengers.4 Seat-belt traumatic vagotomy had not been reported previously. However, traumatic vagotomy has been postulated to explain a case of gastric stasis in an 8-year-old child after closed abdominal injury.5 The classic “seat-belt syndrome” and “seat-belt sign” refer to a pattern of abdominal wall, visceral, and vertebral injuries caused by lap-belt-style restraining devices6,7 and requiring urgent diagnostic imaging and subsequent surgical intervention. The likely mechanism of injury in our patient is similar to that previously described, ie, sudden deceleration causing abrupt compression of the abdominal viscera against the bony spine, and shearing forces at “free-fixed” junctions. 1,4,8-10 Although no obvious associated vertebral injury occurred in this case, a high level of suspicion for Chance fractures must be maintained in any patient with seat-belt injuries.1+7,g Our patient was wearing a lap-belt-type restraint, which increases the likelihood of abdominal seat-belt injury.*JO Lap belts are designed to be worn at or below the level of the anterior superior iliac spines, but have a tendency to ride cephalad over the abdomen. In children, the risk of injury is greater because of the relative immaturity of their bony pelvis, and their higher center of gravity.4 In our patient, the abdominal ecchymosis was along the
From the Department of Surgery, Queen’s Utuversity, Kingston, Ontario. Presented at the 27th Annual Meeting of the Canadian Association of Paediatric Surgeons, Montreal, Quebec, September 2-4, 199.5. Address reprint requests to Dr Dan Poenaru, Hotel Dieu Hospital, 166 Brock St, Kingston, Ontario, Canada K7L 5G2. Copyright o 1996 by W B. Saunders Company 0022-3468/96/3106-0004$03.00/O
767
KIMMINS,
758
Fig 1. lntraoperative photograph. held together only by a narrow bridge
The two of posterior
stomach wall.
halves
are
epigastrium, suggesting that the seat belt may have been improperly placed, or that the child did not fit the adult seat belt, and that he “submarined” under the belt upon impact. The traumatic vagotomy in our patient was not visualized at the time of the laparotomy, but must be implied in light of the transected and disrupted stomach. The long-term outcome of inadvertent or
Fig 2. After open throughout
gastroscopy. The pylorus the examination.
POENARU,
is seen face-on
AND
KAMAL
and did not
traumatic distal vagotomy in children is unclear. The success of conservative measures in our patient mitigates against early surgical options such as pyloromyotomy or pyloroplasty. This case illustrates the need for proper positioning of lap seat belts, the potential need for pediatric seat belts, and the need to maintain a high level of clinical suspicion in dealing with any trauma patient who has the “seat-belt sign.”
REFERENCES 1. Carragher AM, Cranley B: Seat belt stomach transection in 6. Doersch KB, Dozier WE: The seat belt sign-Intestinal and association with ‘chance’ vertebral fracture. Br J Surg 74:397, 1987 mesenteric injuries. Am J Surg 116:831-833,196s 7. Garrett JW, Braunstein PW: The seat belt syndrome. J 2. Dajee H, MacDonald AC: Gastric rupture due to seat belt Trauma 2:220-238, 1962 injury. Br J Surg 69:436-437,1982 8. Asbun HJ, Irani H, Roe EJ, et al: Intra-abdominal seat belt 3. Shamblin JR: Seat belt injuries. Arch Surg 97:474-477,1968 injury. J Trauma 30:189-193.1990 4. Tso EL, Beaver BL, Haller JA: Abdominal injuries in 9. Newman KD, Bowman LM, Eichelberger MR, et al: The lap restrained pediatric passengers. J Pediatr Surg 28:915-919, 1993 belt complex: Intestinal and lumbar spine injury in children. J 5. Kernohan RM, Humphreys WG: Closed abdominal trauma Trauma 30:1133-1140,199O in a child causing avulsion of the common bile duct and gastric 10. Williams RD, Sargent FT: The mechanism of intestinal stasis. Injury 16:235-237,1985 injury in trauma. J Trauma 3:288-294, 1963
Gastric Transection:
By Mark H. Kimmins,
Dan Poenaru,
Kingston, l This report documents the first known pediatric survivor of seat-belt-associated gastric transection. An 1%year-old boy presented with abdominal ecchymoses after a motor vehicle accident. Physical and radiological examination determined the need for abdominal exploration. During the operation, a near-complete transection of the stomach was found, which was repaired by primary anastomosis. After an initially unremarkable recovery period, gastric stasis and pyloric obstruction developed. Radiologically and endoscopically, this was determined to be secondary to a traumatic distal vagotomy. Neither gastric transection nor traumatic vagotomy had been reported previously in the pediatric population with abdominal seat-belt injuries. This report demonstrates an exceptionally rare seat-belt-related injury, and its unusual postoperative complication. It also emphasizes the significance of the “seat-belt sign” in the assessment of motor vehicle-related blunt abdominal trauma, and outlines potential problems associated with the wearing of adultdesigned lap belts by pediatric passengers. Copyright o 1996 by W.B. Saunders Company INDEX trauma,
WORDS: vagotomy,
Blunt trauma, pylorospasm.
seat-belt
injuries,
gastric
ASTRIC TRANSECTION caused by seat-belt trauma is a very rare injury which is usually fatal. An expected consequence of this condition may be a traumatic vagotomy, which had not been described previously in this setting. G
CASE REPORT An 11-year-old boy was hospitalized after a two-car, head-on collision. He was a rear-seat passenger, wearing a lap-belt-type restraining device. After initial assessment at a community hospital, he was transferred to our trauma center in stable condition. During transport, he vomited 1 L of frank blood. At the time of arrival at the emergency department, he had stable vital signs, was fully conscious, and complained of abdominal pain. Examination showed bruising across the epigastrium, with tenderness and guarding over the same area. A nasogastric (NG) tube was inserted and frank blood obtained. A computer tomography (CT) scan showed the presence of hemopneumoperitoneum, a large hematoma in the lesser sac, and the tip of the NG tube lying outside the stomach within the hematoma. During laparotomy, the peritoneal cavity was found to contain fresh blood. A near-complete transection of the stomach at the antrum was observed, and only a l-cm portion of the posterior stomach wall was intact (Fig 1). A hand-sewn primary repair of the stomach was performed, and small serosal tears in the distal transverse colon were oversewn. Postoperatively the patient initially recovered well, but then returned with vomiting. An upper gastrointestinal (UGI) series and endoscopy showed a patent intact anastomosis, and severe pylorospasm (Fig 2) consistent with a complete traumatic distal
Journal
of Pediafm
Surgery,
Vol31,
No 6 (June),
1996: pp 757-756
A Case Report
and lhab Kamal
Ontario
vagotomy. Cisapride was begun, and the patient recovered slowly over the next several months. He is asymptomatic 9 months after the accident and is being weaned from the Cisapride. DISCUSSION
Seat-belt gastric transection is exceedingly rare, and we report on the first known pediatric survivor of this injury. There have been reports of this injury in adults, but the mortality rate is high and the injury usually is associated with other injuries.le3 Tso et al recently reported a case of pediatric stomach perforation in association with seat-belt injury in their retrospective analysis of abdominal injuries in restrained pediatric passengers.4 Seat-belt traumatic vagotomy had not been reported previously. However, traumatic vagotomy has been postulated to explain a case of gastric stasis in an 8-year-old child after closed abdominal injury.5 The classic “seat-belt syndrome” and “seat-belt sign” refer to a pattern of abdominal wall, visceral, and vertebral injuries caused by lap-belt-style restraining devices6,7 and requiring urgent diagnostic imaging and subsequent surgical intervention. The likely mechanism of injury in our patient is similar to that previously described, ie, sudden deceleration causing abrupt compression of the abdominal viscera against the bony spine, and shearing forces at “free-fixed” junctions. 1,4,8-10 Although no obvious associated vertebral injury occurred in this case, a high level of suspicion for Chance fractures must be maintained in any patient with seat-belt injuries.1+7,g Our patient was wearing a lap-belt-type restraint, which increases the likelihood of abdominal seat-belt injury.*JO Lap belts are designed to be worn at or below the level of the anterior superior iliac spines, but have a tendency to ride cephalad over the abdomen. In children, the risk of injury is greater because of the relative immaturity of their bony pelvis, and their higher center of gravity.4 In our patient, the abdominal ecchymosis was along the
From the Department of Surgery, Queen’s Utuversity, Kingston, Ontario. Presented at the 27th Annual Meeting of the Canadian Association of Paediatric Surgeons, Montreal, Quebec, September 2-4, 199.5. Address reprint requests to Dr Dan Poenaru, Hotel Dieu Hospital, 166 Brock St, Kingston, Ontario, Canada K7L 5G2. Copyright o 1996 by W B. Saunders Company 0022-3468/96/3106-0004$03.00/O
767
KIMMINS,
758
Fig 1. lntraoperative photograph. held together only by a narrow bridge
The two of posterior
stomach wall.
halves
are
epigastrium, suggesting that the seat belt may have been improperly placed, or that the child did not fit the adult seat belt, and that he “submarined” under the belt upon impact. The traumatic vagotomy in our patient was not visualized at the time of the laparotomy, but must be implied in light of the transected and disrupted stomach. The long-term outcome of inadvertent or
Fig 2. After open throughout
gastroscopy. The pylorus the examination.
POENARU,
is seen face-on
AND
KAMAL
and did not
traumatic distal vagotomy in children is unclear. The success of conservative measures in our patient mitigates against early surgical options such as pyloromyotomy or pyloroplasty. This case illustrates the need for proper positioning of lap seat belts, the potential need for pediatric seat belts, and the need to maintain a high level of clinical suspicion in dealing with any trauma patient who has the “seat-belt sign.”
REFERENCES 1. Carragher AM, Cranley B: Seat belt stomach transection in 6. Doersch KB, Dozier WE: The seat belt sign-Intestinal and association with ‘chance’ vertebral fracture. Br J Surg 74:397, 1987 mesenteric injuries. Am J Surg 116:831-833,196s 7. Garrett JW, Braunstein PW: The seat belt syndrome. J 2. Dajee H, MacDonald AC: Gastric rupture due to seat belt Trauma 2:220-238, 1962 injury. Br J Surg 69:436-437,1982 8. Asbun HJ, Irani H, Roe EJ, et al: Intra-abdominal seat belt 3. Shamblin JR: Seat belt injuries. Arch Surg 97:474-477,1968 injury. J Trauma 30:189-193.1990 4. Tso EL, Beaver BL, Haller JA: Abdominal injuries in 9. Newman KD, Bowman LM, Eichelberger MR, et al: The lap restrained pediatric passengers. J Pediatr Surg 28:915-919, 1993 belt complex: Intestinal and lumbar spine injury in children. J 5. Kernohan RM, Humphreys WG: Closed abdominal trauma Trauma 30:1133-1140,199O in a child causing avulsion of the common bile duct and gastric 10. Williams RD, Sargent FT: The mechanism of intestinal stasis. Injury 16:235-237,1985 injury in trauma. J Trauma 3:288-294, 1963