The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma

Impact of Pelvic Fracture on Patients with Blunt Bowel Mesenteric Injury: Is Immediate Laparotomy Warranted?

The management of blunt abdominopelvic trauma with combined hemoperitoneum and pelvic fractures is challenging for trauma surgeons. Although angioembolization can achieve hemostasis in most visceral organ injuries and pelvic fractures after blunt abdominal trauma, it cannot effectively control hemorrhage in patients with blunt bowel mesenteric injury (BBMI). This study aimed to determine the risk factors associated with hemodynamically unstable patients with BBMI and to test the hypothesis that pelvic fracture is an independent risk factor for patients with unstable BBMI and concomitant pelvic fracture to guide the therapeutic sequence for difficult-to-manage patients. This retrospective study reviewed the data of hospitalized patients with trauma between 2009 and 2021 and included 158 adult patients with surgically proven BBMI. The patients were divided on the basis of the presence of a shock episode before emergency laparotomy. The shock group included 44.3% of all patients in the study (n = 70). Clinical injury severity and prognosis for patients in the shock group were poorer than those for patients in the non-shock group, and more invasive treatments and transfusions were performed for patients in the shock group than for those in the non-shock group. Pelvic fractures were more frequently associated with the shock group than with the non-shock group (21.4% vs. 5.7%; p = 0.003). In multivariate analysis, the presence of intracerebral hemorrhage (odds ratio [OR] = 10.87, 95% confidence intervals [CIs]: 1.70-69.75) and rib fracture (OR = 5.94, 95% CIs = 1.06-33.45) was identified as an independent predictor of shock, whereas the effect of pelvic fracture did not achieve statistical significance (OR = 2.94, 95% CIs = 0.66-13.13) after adjusting for confounding factors. For patients with BBMI, outcomes need to be improved during early diagnosis, and treatments should be expeditiously performed on the basis of the rapid identification of unstable hemodynamic status. Our results support the recommendation of emergency laparotomy in unstable patients with concomitant pelvic fractures, followed by damage control TAE if needed.

The Benign Side of the Abdominal Wall: A Pictorial Review of Non-Neoplastic Diseases

The abdominal wall is the location of a wide spectrum of pathological conditions, from benign to malignant ones. Imaging is often recommended for the evaluation of known palpable abdominal masses. However, abdominal wall pathologies are often incidentally discovered and represent a clinical and diagnostic challenge. Knowledge of the possible etiologies and complications, combined with clinical history and laboratory findings, is crucial for the correct management of these conditions. Specific imaging clues can help the radiologist narrow the differential diagnosis and distinguish between malignant and benign processes. In this pictorial review, we will focus on the non-neoplastic benign masses and processes that can be encountered on the abdominal wall on cross-sectional imaging, with a particular focus on their management. Distinctive sonographic imaging clues, compared with computed tomography (CT) and magnetic resonance (MR) findings will be highlighted, together with clinical and practical tips for reaching the diagnosis and guiding patient management, to provide a complete diagnostic guide for the radiologist.

Emergency repair and smoking predict recurrence in a large cohort of ventral hernia patients

PURPOSE

Ventral hernias are frequent and hernia repair is regularly performed by general surgeons. Emergency repair is less frequent and can be challenging. Long-term data comparing outcomes of emergency- vs. elective ventral hernia repair are scarce.

METHODS

Consecutive patients undergoing emergency and elective ventral hernia repair at our institution were prospectively entered in our HerniaMed database between August 2013 and February 2020. Patients were contacted after 1 and 5 years to assess long-term complications. Risk factors for emergency repair and hernia recurrence were assessed by univariate and multivariate analysis.

RESULTS

We included 1307 patients. Emergency and elective hernia repair were performed in 11% and 89% of patients with 1-year follow-up rates of 94% and 92%. Female gender, BMI > 40 kg/m², ASA class 3 and 4, large size umbilical herniation (> 4 cm) and epigastric herniation were more frequent in emergency hernia repair. Binary logistic regression analysis identified emergency repair and smoking as predictors of recurrence (Odds ratio: 4.04 and 95% confidence interval: 1.67-14.21, p = 0.004; Odds ratio: 2.94 and 95% confidence interval: 1.33-9.15, p = 0.011). Furthermore, female gender and significant comorbidity (ASA class 3 and 4) were risk factors for emergency repair (Odds ratio: 1.98 and 95% confidence interval: 01.05-3.74, p = 0.034; Odds ratio: 3.54 and 95% confidence interval: 1.79-6.98, p < 0.001).

CONCLUSIONS

Emergency repair and smoking predicted hernia recurrence. Females and highly comorbid patients are at increased risk for emergency repair and should be prioritized for early elective hernia repair.

A Retrospective Cohort Study on the Clinical Characteristics of Patients with Surgical Blunt Bowel and/or Mesenteric Injuries among Motorcyclists and Car Occupants

(1) Background: Surgical blunt bowel and/or mesenteric injuries (BBMIs) are rare but challenging for trauma surgeons. Surgical BBMI is associated with specific injury mechanisms, such as direct compression by the handlebar in motorcycle accidents or rapid acceleration and deceleration of the impact forces associated with seatbelt injuries in motor vehicle collisions. However, the discussions on the implications of BBMI and the mechanisms of road traffic accidents remain scarce. This retrospective study assessed the clinical and injury characteristics of surgically proven BBMI among motorcyclists and car occupants based on trauma-registered data obtained from a level I trauma center in Taiwan. (2) Methods: Medical data of 72 motorcyclists and 38 car occupants who had surgical BBMI between January 2009 and December 2020 were reviewed. Patient characteristics, injuries, and outcomes in both groups were compared and analyzed. (3) Results: Motorcyclists with surgical BBMI had a significantly higher Injury Severity Score (median [Q1–Q3], 18 (9–27) vs. 16 (9–18), p = 0.044) and lower Glasgow Coma Scale score (15 (11–15) vs. 15 (15–15), p = 0.034]) than car occupants. Motorcyclists with surgical BBMI had a higher incidence of pelvic fractures (18.1% vs. 2.6%, p = 0.032) and upper limb fractures (23.6% vs. 7.9%, p = 0.042) and a significantly higher rate of chest tube insertion than car occupants (29.2% vs. 10.5%, p = 0.027). However, there were no significant differences in the outcomes of morbidity and mortality between motorcyclists and car occupants with surgical BBMI. (4) Conclusions: This study demonstrated there were no significant differences in outcomes between motorcyclists and car occupants with surgical BBMI. However, motorcyclists with surgical BBMI were injured more severely, along with injuries to the head/neck and extremities, than car occupants.