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We report the case of a 33-year-old man who had received multiple gunshot wounds to the abdomen; consequently, he was diagnosed with a traumatic dissection of the abdominal aorta at the level of the superior mesenteric artery (SMA) extending to just below the renal arteries with a posterior pseudoaneurysm of the aorta. He had wounds in the right upper quadrant and in the left lower back. He demonstrated signs of peritonitis for which he was taken to the operating room for exploratory laparotomy. A right common iliac to SMA bypass with a 7-mm ringed polytetrafluoroethylene (PTFE) graft was created. The celiac trunk was then ligated, and through the right groin sheath, a thoracic endograft stent (Cook Medical, Bloomington, IN) was inserted at the level of the thoracic aorta with resolution of the blood flow to the aorta, visceral and iliac arteries, as well as retrograde flow into the bypass graft. The literature on traumatic abdominal aortic pseudoaneurysm was reviewed, and based on that, we believe this report describes a unique case of a traumatic aortic pseudoaneurysm at the level of the celiac trunk, as well as our operative approach.

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BACKGROUND: Senior surgical residents are of paramount importance in directing further therapeutic modalities based on their interpretation of critical diagnostic imaging. We propose that senior surgical residents are proficient with interpreting radiologic imaging studies in the trauma patient. METHODS: A prospective cohort study was performed comparing surgery resident interpretations of computed tomography (CT) scans of the head, maxillofacial bones, spine (cervical, thoracic, lumbar), chest, abdomen, pelvis, and chest X-rays versus final radiologists' reports at a Level II trauma center from September 2014 to May 2015. A Cohen κ coefficient and a statistical analysis of variance testing were used to make multiple comparisons of the data. RESULTS: There were 951 trauma alerts activated in the period stated. Of these, 860 met our age inclusion criteria (age, > 18 years). There were 204 images included with an overall accuracy of 81.3%. Residents were more than 70% successful interpreting seven of nine categories. They achieved an accuracy of 84.6%, 62.5%, and 75% in the cervical, thoracic, and lumbar spine categories, respectively. Forty-one of 50 CT scans of the head were interpreted correctly. Maxillofacial CT scans proved to be the weakest category, with only 50% read accurately. In regard to CT scans of the abdomen and pelvis, 80% proficiency was achieved. Abdominal x-rays were read correctly in all instances and chest x-rays 83.3%. On κ analysis, there was an overall moderate agreement between the two groups with K = 0.449, and an overall p less than 0.0005 (Table 1). A perfect agreement existed with abdominal x-rays. CONCLUSION: Senior surgical residents are capable of interpreting critical images obtained in the trauma setting. When discordance existed with attending radiologists' interpretation, it did not change the clinical outcome or result in any critically missed findings. LEVEL OF EVIDENCE: Therapeutic/Care Management study, Level IV.

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Acute appendicitis is a commonly diagnosed surgical problem in the pediatric population. Arterio-venous malformations (AVM) of the colonic tract are rarely reported in the pediatric literature. A 13-year old boy who presented with acute appendicitis with concurrent cecal AVM is reported in whom appendectomy was done. Later on radiological investigations AVM was confirmed.

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BACKGROUND: To determine the role of a combined laparoscopic exploration and lavage (LELA) in abdominal stab wounds (ASW). We hypothesized that peritoneal penetration (PP) is not an indication for exploratory laparotomy (EL) if LELA is negative. METHODS: A prospective study (Jan 2002-Dec 2003) was carried at our Level I Trauma Center. Patients with anterior fascia penetration in wound exploration and with systolic blood pressure greater than 90 mmHg were included. Patients with back and flank injuries, evisceration and presentation after six hours were excluded. LELA was considered positive if red blood cell count was >5000 and white blood cell count was >150 in a lavage without the presence of bile, gross blood, food fibers or stool. RESULTS: Eighty-nine patients with anterior ASW (AASW) were included. Twenty-eight patients underwent laparoscopy to rule out PP. Seventeen patients had PP and 8 demonstrated injuries that required immediate exploratory laparotomy. The remaining 9 underwent LELA. Four patients had positive LELA that demonstrated injuries (sigmoid, right colon, and small bowel [n: 2]). Five patients had a negative LELA and avoided an unnecessary EL. CONCLUSION: LELA in AASW shows a promising role to rule out mainly hollow viscus injuries. This technique could decrease the number of non-therapeutic laparotomies, length of stay and hospital costs without increasing the incidence of missed abdominal injuries.

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BACKGROUND: This study aims to determine the current status of the Allen test for assessing the circulation of the hand. METHODS: The Ovid electronic database was searched using multiple search terms and keywords. Bibliographies of pertinent articles were examined. Data involving results of Allen tests, criteria for abnormality and outcomes, specifically those related to adverse events, were extracted. RESULTS: The criteria for an abnormal Allen test are not agreed upon. The significance of an equivocal or abnormal test is unclear. The test is not accurate in predicting postcannulation hand ischemia. Results of the test suffer from poor interrater reliability. Most critically ill patients cannot cooperate for the performance of the test as described. CONCLUSIONS: Performance of an Allen test before radial artery cannulation should not be considered a "standard of care."

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