Forensic medical evaluation of an isolated injury of the small bowel mesentery and its vessels (literature review extended with expert case report)

This work summarizes information from the modern scientific literature devoted to the issues of morphology and mechanisms of an isolated mesenteric injury, which is rare in expert practice. Apart from classic forensic medical papers, publications over 2000 – 2020, devoted to abdominal organ injuries, were analyzed. In the search engines PUBMED and eLibrary.ru, a selection of sources was made according to the keywords: “rupture of the mesenteric root of the small intestine,” “diagnostics,” “forensic medical evaluation.” The results of the literature analysis were used in the study of the repeated forensic medical examination materials of a case of rapid death (in 1.5 hours) due to a traumatic rupture of the mesentery of the small bowel and its large vessels. The combined analysis of the expert case report and special scientific literature allows us to devise the following conclusions: 1. A forensic expert must have expert knowledge in the normal anatomy of the abdominal aorta’s unpaired vessels and their accompanying veins location and know about their variable topographic and anatomical features. 2. Life-threatening bleeding from the damaged vessel of the mesentery of the small bowel occurs in a wide time interval after the mechanical damage. 3. The development of life-threatening intra-abdominal bleeding is due to the scope of damage and the rate of blood flow from the damaged vessel. 4. Thorough examination of the area of rupture of the mesenteric vessel and the state of the tissues in the circumference of the rupture allow to establish the mechanism of injury. 5. Ignorance of the mechanism of injury and specifics of the formation of injuries is the cause of expert errors and scientifically unfounded conclusions. 6. There is no reference material on the rate of blood flow from a damaged large vessel.

Tractotomy using the Penrose drain guide for deep lung injury caused by chest drainage: a case report

Background Pulmonary tractotomy effectively treats deep pulmonary penetrating injuries; however, it requires the accurate insertion of forceps or a stapler into the wound tract. This report describes a case of tractotomy using the Penrose drain guide for a deep lung injury caused by chest drainage. Case presentation A 75-year-old man suffered multiple rib fractures and hemothorax. After admission, chest tube drainage was performed because the patient’s respiratory condition deteriorated due to increased right pleural effusion. However, as the chest tube was stabbing into the right upper lobe, a pulmonary tractotomy was performed to treat the injury. Cutting the visceral pleura just over the tip of the chest tube caused the tube to completely penetrate the lung. A Penrose drain tube was fixed to the chest tube, which was then removed. The Penrose drain tube completely penetrated the lung and was coupled to the anvil side of the stapler to guide it smoothly into the wound tract. After stapling left the wound tract open, selective suture ligation of the damaged vessel and bronchioles was performed. Conclusions Although the indications for tractotomy using the Penrose drain guide are limited, we believe that this technique can be useful in patients with deep stabbing or penetrating lung injuries with rod- or tube-shaped foreign body remnants.

Method of diagnosis and treatment of profusional bleeding from stenosing postbulbar ulcers of the duodenum

The aim. To evaluate the effectiveness of X-ray interventions in arosive bleeding in patients with complicated duodenal ulcer. Materials and methods. X-ray endovascular interventions were used in 8 patients who developed arosive bleeding as a complication of duodenal ulcer. All patients with signs of gastrointestinal bleeding were examined according to clinical protocols. Hemodynamically stable patients underwent X-ray endovascular interventions. Results and discussion. In the near future, bleeding stopped in all 8 (100 %, OR–0.04 [0.005–0.29], p=0.03) patients. On day 2, two patients who underwent embolization of their own hepatic artery had a recurrence of bleeding (0.56 [0.065–4.76], p=0.29). Repeated angiography and embolization attempts were ineffective, and both patients died. In patients who underwent gastroduodenal and pancreatouodenal artery embolization, bleeding did not resume. Thus, we obtained good results as 6 out of 8 patients recovered (75 %), despite the severity of their condition and a disappointing prognosis (OR–9.0 [1.0–46.7], p <0.05). Conclusions. Adherence to the tactics mentioned above in the treatment of bleeding in duodenal ulcer was highly effective, especially in superselective embolization with the detection of bleeding gel. If the presence of arosive bleeding is confirmed, emergency surgical treatment with suturing of the damaged vessel is shown in hemodynamically unstable patients, and endovascular intervention is possible in hemodynamically stable patients. Further studies are needed to determine the criteria for a high risk of arosive bleeding developing in patients with complicated duodenal ulcer as well as to prevent its occurrence through the use of X-ray endovascular interventions.

A temporary bypass used in end-to-end anastomosis of major vessels without stopping blood flow in the segment under repair

The authors developed an original set of tools and a method of carrying out end-to-end anastomosis on major vessels, without stopping blood circulation in the vascular segment being repaired. The proposed set of tools includes 10 tubes (temporary vascular grafts) made of medical silicone with external diameters from 8 to 26 mm. The length of each tube is not less than 10 cm, and the wall thickness is 1.2 mm. A spiral notch with a step of 1.2 mm is made on the outer surface of the tubes, to a depth of 1 mm. The set of tools also includes a set of metal hollow half cylinders with a through hole made in the middle, designed to extract the temporary shunt of the appropriate diameter. Before the formation of a vascular anastomosis, a silicone tube is selected, the outer diameter of which corresponds to the inner diameter of the damaged vessel. It is necessary to cut off a length of the tube, so that 23 cm of it could be introduced into the lumen of the proximal and distal segments of the damaged vessel. A stay-suture is laid in the center of the temporary bypass, on a site of its wall between two neighboring spiral notches. The ends of the temporary bypass, pre-filled with saline solution, are introduced into the distal and proximal ends of the divided vessel and are firmly fixed in the lumen of the vessel with two elastic bands. After placing the temporary bypass in the lumen of the damaged vessel, the blood flow is restored. Using the intraluminar temporary shunt as a scaffold, the edges of the vessel are approximated and stitched to its entire circumference, tying the first and last stitches of this seam. The last additional suture is placed in the area of the stay-suture overlying the wall of the temporary vascular shunt and is not tightened. A half-cylinder is placed above the untightened vascular suture and a stay-suture is placed at its opening. After that, tightly pressing the metal hollow half-cylinder to the vascular wall, and applying traction to the ends of the stay-suture the mechanical destruction of the silicone tube along the line of the spiral incision ensues. As a result, the tube is transformed into a double silicone rod, which is pulled through a through hole in the metal half-cylinder floor. After the extraction of the tube, the anastomosis is completed by tying a knot on the provisional suture. To simulate the proposed method, 10 operations were performed using a closed experimental circuit that completely simulates the real situation of restoring a damaged major vessel. The time of the operation, the technical features of the intervention, as well as the volume of blood loss, which was estimated by reducing the volume of blood circulating in the experimental circuit, were evaluated. Experimental testing with the use of a model simulating the situation of restoring a damaged major vessel, demonstrated the effectiveness of the developed method of applying a vascular end-to-end anastomosis with the use of a destructible temporary bypass; the average time of the operation was 10 minutes, and the volume of blood loss did not exceed 5 ml. The proposed set of tools and method can be effectively used in case of major vessels injury. The technique completely excludes the need for interrupting blood flow through the sutured vessel; it allows to reduce the volume of blood loss in vascular trauma, minimizes the time of ischemia in the area of blood supply to the damaged artery or venous stagnation of the drained segment (when suturing a vein), as well as to facilitate the imposition of a vascular suture to surgeons who do not have sufficient qualification in vascular surgery.

Interrelationships between structure and function during the hemostatic response to injury

Extensive studies have detailed the molecular regulation of individual components of the hemostatic system, including platelets, coagulation factors, and regulatory proteins. Questions remain, however, about how these elements are integrated at the systems level within a rapidly changing physical environment. To answer some of these questions, we developed a puncture injury model in mouse jugular veins that combines high-resolution, multimodal imaging with functional readouts in vivo. The results reveal striking spatial regulation of platelet activation and fibrin formation that could not be inferred from studies performed ex vivo. As in the microcirculation, where previous studies have been performed, gradients of platelet activation are readily apparent, as is an asymmetrical distribution of fibrin deposition and thrombin activity. Both are oriented from the outer to the inner surface of the damaged vessel wall, with a greater extent of platelet activation and fibrin accumulation on the outside than the inside. Further, we show that the importance of P2Y12signaling in establishing a competent hemostatic plug is related to the size of the injury, thus limiting its contribution to hemostasis to specific physiologic contexts. Taken together, these studies offer insights into the organization of hemostatic plugs, provide a detailed understanding of the adverse bleeding associated with a widely prescribed class of antiplatelet agents, and highlight differences between hemostasis and thrombosis that may suggest alternative therapeutic approaches.

The Floatel Superior Loose-Anchor Incident and its Significance for Design and Operation of Semi-Submersibles

The combination of dynamic positioning (DP) and conventional anchoring of semi-submersible platforms in the oil industry has recently lead to a serious incident with large loss potential: the Floatel Superior platform suffered severe damage to its hull from a loose anchor in heavy seas during the night of November 6th–7th, 2012. This paper discusses the root causes leading to the incident. The investigation report from the Petroleum Safety Authority Norway (PSA) concludes that damage leading to the loose anchor had developed over several months, and various warning signs during that period were not heeded. The main reason for the damage was rooted in the combined operation mode where position-keeping by use of DP resulted in large environmental loads on the anchors while they were stowed in their bolsters along the vessel side in rough weather when the installation was at survival draught and operating on DP. The anchors on Floatel Superior had also been exposed to environmental loads in excess of the design capacity during extended transit two years prior to the incident. The incident itself was handled efficiently by the crew and emergency preparedness organizations, with 336 people evacuated by helicopter and the remaining 38 crew members transporting the damaged vessel to shore for repairs. In this paper, an immediate recommendation for removing anchors from the splash-zone while operating on DP is presented as relevant for other installations with similar class notation. In a longer perspective, the investigation found that both well-established design codes and their application in the actual design had shortcomings which played a role in the cause of events. The vessel design appears to have been performed with a principal focus on sub-units (anchor, winch, bolster, pendant-wire attachment) and to an insufficient extent on the combined system use under which it was to be operated. A long-established method of design for connections of auxiliary structures to the main hull structure also showed shortcomings in the event: the doubler plates or pads used to attach the bolsters to the hull did not function as weak links as intended.

The Effect of Sloshing in Tanks on the Hull Girder Bending Moments and Structural Reliability of Damaged Vessels

The structural reliability analysis of damaged vessels has commonly been conducted by neglecting the effect of sloshing. In this paper, the coupled motion of the damaged vessel and sloshing is set up based on the assumption that the damaged tanks are of rectangular shape. The sloshing effects in tanks are modeled by a linear multimodal approach. Then the effect of sloshing in tanks on the hull girder bending moments and the failure probability are studied for an oil tanker in various damage conditions. It is concluded that in certain tank resonance conditions, sloshing effects cannot be neglected. In such cases sloshing damping plays an important role on the sloshing effects.