1
|
Rodriguez VI, Perez B, Fernandez A, Varela C, Teran A. Hollow viscus perforation in blunt abdominal trauma: A 14-year experience from a trauma center. World J Surg 2024; 48:855-862. [PMID: 38353292 DOI: 10.1002/wjs.12096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/15/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Isolated perforations of hollow viscus (HV) represent less than 1% of injuries in blunt abdominal trauma (BAT). When they do present, they are generally due to high-impact mechanisms in the segments of the intestine that are fixed. The aim of this study is to determine the incidence of major HV injuries in BAT at the "Dr. Domingo Luciani" General Hospital (HDL), and address the literature gap regarding updated HV perforations following BAT, especially in low-income settings. METHODS A retrospective review was conducted on the medical records of patients admitted to our trauma center with a diagnosis of complicated BAT with HV perforation over 14 years. RESULTS AND DISCUSSION Seven hundred sixty-one patients were admitted under the diagnosis of BAT. Of them, 36.79% underwent emergency surgical resolution, and 6.04% had HV perforation as an operative finding. Almost half (44.44%) of these cases presented as a single isolated injury, while the remaining were associated with other intra-abdominal organ injuries. The most common lesions were Grade II-III jejunum and Grade I transverse colon, affecting an equal proportion of patients at 13.33%. In recent years, an increased incidence of HV injuries secondary to BAT has been observed. Despite this, in many cases, the diagnosis is delayed, so even in the presence of negative diagnostic studies, the surgical approach based on the trauma mechanism, hemodynamic status, and systematic reevaluation of the polytraumatized patient should prevail.
Collapse
Affiliation(s)
- Veronica I Rodriguez
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
- Catherine and Joseph Aresty Department of Urology, Keck Medicine of USC, Los Angeles, California, USA
| | - Barbara Perez
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| | - Andrea Fernandez
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| | - Cristopher Varela
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| | - Adrian Teran
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| |
Collapse
|
2
|
Sethi I, Aicher AE, Zawin M, Samuel M, Mukhi A, Vosswinkel J, Jawa RS. Index CT-Based Scoring Systems in Operative Blunt Bowel and Mesenteric Injury Identification. J Surg Res 2024; 294:240-246. [PMID: 37924561 DOI: 10.1016/j.jss.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Determining the need for surgical management of blunt bowel and mesenteric injury (BBMI) remains a clinical challenge. The Faget score and Bowel Injury Prediction Score (BIPS) have been suggested to address this issue. Their efficacy in determining the need for surgery was examined. METHODS A retrospective review of all adult blunt trauma patients hospitalized at a level 1 trauma center between January 2009 and August 2019 who had small bowel, colon, and/or mesenteric injury was conducted. We further analyzed those who underwent preoperative computed tomography (CT) scanning at our institution. Final index CT reports were retrospectively reviewed to calculate the Faget and BIPS CT scores. All images were also independently reviewed by an attending radiologist to determine the BIPS CT score. RESULTS During the study period, 14,897 blunt trauma patients were hospitalized, of which 91 had BBMI. Of these, 62 met inclusion criteria. Among patients previously identified as having BBMI in the registry, the retrospectively applied Faget score had a sensitivity of 39.1%, specificity of 81.2%, positive predictive value (PPV) of 85.7%, and negative predictive value (NPV) of 31.7% in identifying patients with operative BBMI. The retrospectively applied BIPS score had a sensitivity of 47.8%, specificity of 87.5%, PPV of 91.7%, and NPV of 36.8% in this cohort. When CT images were reviewed by an attending radiologist using the BIPS criteria, sensitivity was 56.5%, specificity 93.7%, PPV 96.3%, and NPV 42.8%. CONCLUSIONS Existing BBMI scoring systems had limited sensitivity but excellent PPV in predicting the need for operative intervention for BBMI. Attending radiologist review of CT images using the BIPS scoring system demonstrated improved accuracy as opposed to retrospective application of the BIPS score to radiology reports.
Collapse
Affiliation(s)
- Ila Sethi
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Aidan E Aicher
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Marlene Zawin
- Department of Radiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Michael Samuel
- Department of Radiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Ambika Mukhi
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - James Vosswinkel
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York.
| |
Collapse
|
3
|
Aljehaiman F, Almalki FJ, Alhusain A, Alsalamah F, Alzahrani K, Alharbi A, Alkhulaiwi H. Prevalence, Pattern, Mortality, and Morbidity of Traumatic Small Bowel Perforation at King Abdulaziz Medical City: A Retrospective Cohort Study. Cureus 2024; 16:e52313. [PMID: 38357047 PMCID: PMC10866392 DOI: 10.7759/cureus.52313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction Bowel perforation, whether from trauma or other causes, presents with diverse clinical scenarios. Small bowel perforation (SBP), a potentially fatal condition often linked to blunt trauma like motor vehicle accidents, necessitates prompt detection and intervention, crucial for improved outcomes. This study investigated the prevalence, predictors, presentation, diagnostic findings, morbidity, and mortality of traumatic SBP for comprehensive insights. Methodology This was a retrospective cohort study conducted at King Abdulaziz Medical City, Riyadh. A review of 838 cases, which represent all abdominal trauma patients from January 2017 to March 2023, was done. Forty patients who developed SBP and have complete data were included in this study. One case was excluded due to incomplete medical records. Data were collected with the non-probability convenience sampling technique via the BestCare system using a data collection sheet. Data were analyzed with IBM SPSS 29 (IBM Corp., Armonk, NY). Results Out of all abdominal trauma cases (n=838), 40 patients developed SBP (n=40, 4.77%). Males constituted 87.5%, and the most common mechanism was motor vehicle accidents (57.5%). Complications included cardiac arrest, disseminated intravascular coagulation (DIC), and leak (7.5% each). In motor vehicle accidents, SBP primarily affected patients who were in the driver's position (78.3%). Clinical signs at presentation revealed abdominal tenderness (52.5%), abdominal distension (22.5%), and abnormal systolic blood pressure (mean 115.3 mmHg). Linear regression showed gender and age positively associated with morbidity (p=0.474, p=0.543) while BMI exhibited a negative relationship (p=0.314). Logistic regression revealed non-significant predictors of mortality, except for mean initial hematocrit (HCT) (p=0.721, aOR=0.098). Conclusion Our study provides crucial findings on the incidence, patterns, mortality, and morbidity of traumatic bowel perforation, contributing to the existing body of research. The identified prevalence of 4.77% and mortality at 17.5% from the studied population underline the serious impact of this condition, and the 37.5% complication rate observed demonstrates the potential risks involved. The average hospital stay is found to be 14 days, adding further to the disease burden. These findings underscore the importance of specific preventative measures, particularly related to motor vehicle accidents (MVAs), and highlight potential markers for predicting outcomes, such as age, gender, and mean initial HCT. This substantiates the need for further research involving larger cohorts and prospective designs to gain comprehensive insights and establish more robust preventative and treatment strategies.
Collapse
Affiliation(s)
- Fahad Aljehaiman
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Faisal J Almalki
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulah Alhusain
- Plastic and Reconstructive Surgery, King Abdulaziz Medical City, Riyadh, SAU
| | - Faris Alsalamah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | | | - Hani Alkhulaiwi
- Trauma and Acute Care Surgery, King Abdulaziz Medical City, Riyadh, SAU
| |
Collapse
|
4
|
Use of minimally invasive surgery for the management of hollow viscus traumatic injuries. Surg Endosc 2022; 36:8421-8429. [PMID: 35229212 DOI: 10.1007/s00464-022-09102-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The objective of this study is to assess surgical outcomes following the initial use of laparoscopy versus laparotomy when managing patients with hollow viscus injuries due to trauma. METHODS Using the database from the American College of Surgeons Trauma Quality Improvement Program we identified all patients from 2015-2017 with ICD-10 Diagnosis codes for hollow viscus trauma. Types of procedures were identified by ICD-10 PCS codes. Patient outcomes were stratified by major trauma(ISS > 15) and minor trauma. Continuous variables were compared by ANOVA and categorical variables compared by Chi-Square. Analysis performed using STATA 16. RESULTS We identified 16,284 patients that matched inclusion criteria within the study time frame. Of those, 1986 patients received a surgical intervention, 1911(96%) were open and 75(4%) were laparoscopic. In blunt trauma there were 106 diagnostic procedures, 87(82%) were open and 19(18%) were laparoscopic. There were 574 therapeutic procedures, 543(95%) were open and 31(5%) were laparoscopic. In penetrating trauma there were 223 diagnostic procedures, 215(96%) were open and 8(4%) were laparoscopic. There were 1039 therapeutic procedures for penetrating trauma, 1023(98%) were open and 16(2%) were laparoscopic. For minor trauma, mean length of stay(days) after open surgery was 5 while for laparoscopy it was 2 (p = 0.04). There were 203 complications noted in the open group and 7 in the laparoscopic group (p = 0.19). For major trauma, mean length of stay(days) after open surgery was 5 and 6 for laparoscopy p = 0.54). There were 242 complications in the open group and 1 in the laparoscopic group (p = 0.07). There was no noted significant difference noted in the disposition at discharge in either group in both major and minor trauma. CONCLUSIONS For those that required surgery for hollow viscous injury, laparoscopy appeared to be safe, had less adverse outcomes and was underutilized, particularly when only a diagnostic procedure was required.
Collapse
|
5
|
Kim HW, Park BR, Hong TH. Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.
Collapse
|
6
|
Butler EK, Groner JI, Vavilala MS, Bulger EM, Rivara FP. Surgeon choice in management of pediatric abdominal trauma. J Pediatr Surg 2021; 56:146-152. [PMID: 33139031 PMCID: PMC7855195 DOI: 10.1016/j.jpedsurg.2020.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND No guidelines exist for management of hemodynamically stable children with suspected hollow viscus injury. We sought to determine factors contributing to surgeon management of these patients. METHODS Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury. RESULTS Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1-3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively. CONCLUSIONS Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care. TYPE OF STUDY Cross-Sectional Survey. LEVEL OF EVIDENCE N/A.
Collapse
Affiliation(s)
- Elissa K Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195, USA; Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Jonathan I Groner
- Center for Pediatric Trauma Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Monica S Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Eileen M Bulger
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195, USA
| | - Frederick P Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Pediatrics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| |
Collapse
|
7
|
Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic-therapeutic algorithm. Updates Surg 2020; 73:703-710. [PMID: 33340338 PMCID: PMC8005390 DOI: 10.1007/s13304-020-00929-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/11/2020] [Indexed: 11/23/2022]
Abstract
Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.
Collapse
|
8
|
Pham J, Kemp J, Pruitt J. Acute Abdomen in Adult Trauma. Semin Roentgenol 2020; 55:385-399. [PMID: 33220785 DOI: 10.1053/j.ro.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John Pham
- Department of Radiology, Division of Abdominal Imaging, UT Southwestern Medical Center, Dallas, TX
| | - Justine Kemp
- Department of Radiology, Division of Abdominal Imaging, UT Southwestern Medical Center, Dallas, TX
| | - Jeffrey Pruitt
- Department of Radiology, Division of Abdominal Imaging, UT Southwestern Medical Center, Dallas, TX.
| |
Collapse
|
9
|
Stern J, Anand RJ. Traumatic Decompression of the Jejunum: A Case of Small Bowel Perforation From High-Speed Motor Vehicle Crash. Am Surg 2020; 86:1535-1537. [PMID: 32683937 DOI: 10.1177/0003134820933611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We present a rare case of a focal perforation of the jejunum after a high-speed motor vehicle crash. A 60-year-old restrained rear seat passenger presented with severe abdominal pain. She was hemodynamically stable and underwent the traditional trauma workup. CT scan of the abdomen showed large-volume free intraperitoneal air and L4/L5 compression fractures. Given the peritoneal physical exam finding and free air on CT scan she was taken emergently to the operating room. Operative exploration revealed free intraperitoneal air upon entry into the abdominal cavity as well as murky fluid throughout the mid abdomen. A focal perforation was discovered on the antimesenteric surface of a segment of jejunum. The perforation was repaired primarily in two layers and the abdomen was closed. Postoperative course was uncomplicated. Antibiotics were continued for 4 days. Focal perforation of the small bowel from high-speed blunt trauma is a rare isolated injury. Close attention to physical exam and radiologic findings allows for early diagnosis and treatment of these injuries.
Collapse
Affiliation(s)
- Jeffrey Stern
- 72054Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Rahul J Anand
- 72054Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
10
|
Blunt Isolated Small Bowel Perforation Intervention: Does a Delay in Management Matter? Emerg Med Int 2020; 2020:7478485. [PMID: 32566306 PMCID: PMC7292993 DOI: 10.1155/2020/7478485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/24/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose Blunt small bowel injury is rare, and its timely diagnosis may be difficult. The effects of a delayed intervention on prognosis are unclear. We aimed to determine whether the time to surgical intervention affects outcomes in patients with blunt small bowel perforation. Methods The study was performed between March 2010 and December 2018 in adults (age >18 years) who initially underwent computed tomography and small bowel surgery only and survived more than one day postoperatively. They were categorized into three groups based on injury-to-surgery time intervals: ≤8, 8-24, and >24 h; similarly, they were also categorized into two groups of ≤24 and >24 h. Results Bowel resection, length of stay (LOS), intensive care unit (ICU) LOS, morbidity, and mortality were analyzed as outcomes in 52 patients. The number of patients in the three groups (≤8, 8-24, and >24 h) based on the time-to-surgery was 33, 13, and 6, respectively. On comparing the three groups, there were no significant differences in LOS (24 [18-35], 21 [10-40], and 28 [20-98] days, respectively; p=0.321), ICU LOS (2 [1-12], 4 [2-26], and 11 [7-14] days; respectively, p=0.153), mortality (3% (n = 1), 15% (n = 2), and 0%, respectively; p=0.291), and morbidity (46% (n = 15), 39% (n = 5), and 50% (n = 3), respectively; p=0.871). However, there was a significant difference between the groups in bowel resection (67% (n = 22), 31% (n = 4), and 83% (n = 5), respectively; p=0.037). Additionally, there was no significant difference in outcomes between the two groups (≤24 and >24 h) with small bowel perforation. Conclusions Delay in surgical intervention following blunt abdominal trauma may not affect the outcomes of patients with small bowel injuries, such as LOS, ICU LOS, morbidity, and mortality, except bowel resection.
Collapse
|
11
|
Lethal mesenteric perforation by osteophytes after blunt abdominal trauma. Forensic Sci Med Pathol 2020; 16:535-539. [PMID: 32239426 DOI: 10.1007/s12024-020-00238-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
A 50 year-old homeless man was found dead the day after he had sustained blunt abdominal trauma during a physical assault. Autopsy revealed no apparent injury to the abdominal wall, but showed a massive hemoperitoneum resulting from a large (8 cm) tear of the mesenteric root. It also revealed prominent and diffuse spinal osteophytes predominating in the lumbar region, where they were fused and formed a large anterior ossified excrescence. The diagnosis of diffuse idiopathic skeletal hyperostosis was established in the presence of continuous ossification along the anterior aspect of five contiguous vertebral bodies, without any additional features of degenerative disease on imaging. Death was attributed to intra-abdominal hemorrhage due to mesenteric perforation caused by blunt abdominal trauma in the context of diffuse idiopathic skeletal hyperostosis. This pre-existing condition was considered an aggravating factor, as anterior lumbar osteophytosis had made the mesentery more vulnerable to blunt trauma by reducing both the space separating the abdominal wall from the spine and the surface of interaction between the spine and the mesentery. Only a few cases of osteophyte-related visceral injury have been described in the literature. To our knowledge, this is the first reported case of lethal abdominal injury caused by osteophytes after blunt trauma.
Collapse
|
12
|
Acceleration–Deceleration Injury. Indian J Surg 2020. [DOI: 10.1007/s12262-019-01942-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
13
|
Goedecke M, Kühn F, Stratos I, Vasan R, Pertschy A, Klar E. No need for surgery? Patterns and outcomes of blunt abdominal trauma. Innov Surg Sci 2019; 4:100-107. [PMID: 31709301 PMCID: PMC6817729 DOI: 10.1515/iss-2018-0004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 09/03/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction The management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM). Materials and methods Analysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury. Results Patients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001). Conclusion NOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.
Collapse
Affiliation(s)
- Maximilian Goedecke
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany.,Department of Oral and Maxillofacial Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universitätzu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Munich, Munich, Germany
| | - Ioannis Stratos
- Department of Trauma, Hand and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Robin Vasan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Annette Pertschy
- Department of General, Visceral, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Ernst Klar
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany
| |
Collapse
|
14
|
Otsuka H, Fukushima T, Tsubouchi Y, Sakurai K, Inokuchi S. Current strategy for hollow viscus injury with active bleeding: A case report. SAGE Open Med Case Rep 2019; 7:2050313X18824816. [PMID: 30728979 PMCID: PMC6350135 DOI: 10.1177/2050313x18824816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/20/2018] [Indexed: 12/30/2022] Open
Abstract
Despite rapid advancements in medical technologies, the use of interventional
radiology in a patient with hemodynamic instability or hollow viscus injury
remains controversial. Here, we discuss important aspects regarding the use of
interventional radiology for such patients. A 74-year-old Japanese male climber
was injured following a 10 m fall. On admission, his systolic blood pressure was
40 mmHg. He had disturbance of consciousness and mild upper abdominal pain
without peritoneal irritation. Focused assessment sonography for trauma
indicated massive hemorrhage in the intra-abdominal cavity. Plain radiographs
revealed hemopneumothorax with right-side rib fractures. Thoracostomy to the
right thoracic cavity and massive transfusion were immediately performed.
Consequently, a sheath catheter was inserted into the common femoral artery for
interventional radiology. His systolic blood pressure increased to 80 mmHg owing
to rapid transfusion. In the computed tomography scan room, based on computed
tomography findings, we judged that it was possible to achieve hemostasis by
interventional radiology. The time from hospital admission to entering the
angiography suite was 38 min. Transcatheter arterial embolization for hemorrhage
control was performed without complications. Following transcatheter arterial
embolization, he was admitted to the intensive care unit. All injuries could be
treated conservatively without surgery. His post-interventional course was
uneventful, and he recovered completely after rehabilitation. Hemorrhage control
using interventional radiology should be assessed as a first-line treatment,
even in hemodynamically unstable patients having a hollow viscus injury with
active bleeding, without obvious findings that indicate surgical repair.
Collapse
Affiliation(s)
- Hiroyuki Otsuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Tomokazu Fukushima
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Youhei Tsubouchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Keiji Sakurai
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| |
Collapse
|
15
|
Edwards MK, Kuppler CS, Croft CA, Eason-Bates HM. Adhesive Closed-loop Small Bowel Obstruction. Clin Pract Cases Emerg Med 2018; 2:31-34. [PMID: 29849259 PMCID: PMC5965135 DOI: 10.5811/cpcem.2017.10.35927] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/04/2017] [Accepted: 10/16/2017] [Indexed: 12/29/2022] Open
Abstract
Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands that form following iatrogenic peritoneal injury. Rarely, adhesive SBO may arise without previous intra-abdominal surgery through other modes of peritoneal trauma. We present the case of a male evaluated in the emergency department for a closed-loop small bowel obstruction due to an adhesive band that likely formed after blunt abdominal trauma over two decades earlier. We review the epidemiology, pathophysiology, and treatment options for similar cases of adhesive SBO.
Collapse
Affiliation(s)
- Matthew K Edwards
- University of Florida Health, Department of Emergency Medicine, Gainesville, Florida
| | - Christopher S Kuppler
- University of Florida Health, Department of Emergency Medicine, Gainesville, Florida
| | - Chasen A Croft
- University of Florida Health, Department of Emergency Medicine, Gainesville, Florida
| | - Hannah M Eason-Bates
- University of Florida Health, Department of Emergency Medicine, Gainesville, Florida
| |
Collapse
|
16
|
Taylor A, Cooper E, Ham K. Delayed intestinal perforation secondary to blunt force abdominal trauma in a cat. JFMS Open Rep 2018; 4:2055116918763410. [PMID: 29662682 PMCID: PMC5894924 DOI: 10.1177/2055116918763410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Case summary A 7-month-old intact male domestic shorthair cat was presented 4 h after being hit by a car. It had bilateral inguinal hernias and a mesenteric rent that were repaired surgically and a hematoma in the left retroperitoneal space. No other intra-abdominal abnormalities were identified on abdominal surgical exploration. Approximately 72 h after presentation, the cat started vomiting and developed severe abdominal discomfort. A sudden decrease in mentation and elevation of respiratory rate and effort ensued. Abdominal radiographs showed loss of detail in the abdominal cavity, and abdominocentesis confirmed septic peritonitis. The cat was euthanized, and post-mortem evaluation of the bowel revealed two 1 cm perforations of the jejunum. Relevance and novel information To our knowledge, delayed intestinal perforation secondary to blunt force abdominal trauma has not previously been reported in cats. It has been reported in dogs, but the pathophysiology resulting in perforation is poorly understood. Delayed intestinal injury secondary to blunt force abdominal trauma has been reported in people, especially in children, as a result of motor vehicle accidents.
Collapse
Affiliation(s)
- A Taylor
- Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA, USA
| | - E Cooper
- Department of Emergency and Critical Care, The Ohio State University, Columbus, OH, USA
| | - K Ham
- Department of Veterinary Clinical Sciences - Small Animal Surgery, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
17
|
Ladic A, Petrovic I, Gojevic A, Kinda E, Coza I. Salmonella enterica Serovar Enteritidis Liver Abscess after Blunt Abdominal Trauma. Balkan Med J 2017; 34:469-472. [PMID: 28443586 PMCID: PMC5635636 DOI: 10.4274/balkanmedj.2016.1199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Salmonella enterica serovar Enteritidis is among the most reported serotypes of Salmonella species worldwide, but is rarely reported as the causative agent of a liver abscess. Case Report: We present a patient with an abdominal blunt trauma. An initial abdominal computed tomography scan revealed a rupture of the right kidney and of the liver. Two days later, his physical state deteriorated and a new computed tomography scan was obtained. An extremely large 8-centimetre liver abscess was verified. Due to the unsatisfying response to antibiotic therapy and percutaneous drainage, we operated on the patient. An appendectomy, cholecystectomy and bisegmental liver resection were performed. An intraoperative swab from the abscess was positive for Salmonella enterica serovar Enteritidis. The patient was given intravenous ciprofloxacine. The post-operative course was complicated by a Coagulase-negative Staphylococcus infection of the wound, which improved with antibiotic therapy. Conclusion: Blunt abdominal trauma may initiate an unpredictable course of the disease in chronic Salmonella carriers.
Collapse
Affiliation(s)
- Agata Ladic
- Division of Gastroenterology and Hepatology, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Igor Petrovic
- Division of Abdominal Surgery, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Ante Gojevic
- Division of Abdominal Surgery, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Emil Kinda
- Division of Abdominal Surgery, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Ivo Coza
- Department Abdominal Surgery, Zadar General Hospital, Zadar, Croatia
| |
Collapse
|
18
|
Kleanthis A, Mouravas V, Lampropoulos V, Babatseva E, Spyridakis I. Laparoscopic evaluation and management of isolated gastric rupture in a boy after blunt abdominal injury. Pan Afr Med J 2017; 27:173. [PMID: 28904701 PMCID: PMC5579448 DOI: 10.11604/pamj.2017.27.173.12430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/28/2017] [Indexed: 12/18/2022] Open
Abstract
Blunt abdominal injury in children can be a significant diagnostic and therapeutic challenge. The extent and localization of organ damage cannot be always thoroughly investigated noninvasively and in spite of modern imaging techniques and a laparotomy may be necessary for diagnosis, even though it carries a significant morbidity. We present a rare case of isolated gastric rupture after blunt abdominal injury in a 12 year old boy that sustained a bicycle accident. He was hemodynamically stable, had signs of acute abdomen and axial tomography was inconclusive as of the site of visceral perforation. Definitive diagnosis and treatment were carried out laparoscopically with excellent results. Laparoscopic surgery in cases of blunt abdominal injury with gastric rupture can serve both as a diagnostic and therapeutic modality with the additional advantage of being less traumatic. The accumulation of relevant experience is mandatory in order to establish this modality in the diagnostic and therapeutic protocols.
Collapse
Affiliation(s)
- Anastasiadis Kleanthis
- Paediatric Surgeon, 2 Department of Paediatric Surgery, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Vasilis Mouravas
- Paediatric Surgeon, 2 Department of Paediatric Surgery, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Vasilis Lampropoulos
- Paediatric Surgeon, 2 Department of Paediatric Surgery, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Evgenia Babatseva
- Paediatrician, Neonatologist, 2 Department of Neonatal Intensive Care, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Ioannis Spyridakis
- Assistant Professor, Chief of the 2 Department of Paediatric Surgery, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| |
Collapse
|
19
|
Massalou D, Masson C, Foti P, Afquir S, Baqué P, Berdah SV, Bège T. Dynamic biomechanical characterization of colon tissue according to anatomical factors. J Biomech 2016; 49:3861-3867. [PMID: 27789033 DOI: 10.1016/j.jbiomech.2016.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 10/13/2016] [Accepted: 10/16/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The aim of this study was to determine the mechanical response of colonic specimens retrieved from the entire human colon and placed under dynamic solicitation until the tissue ruptured. MATERIAL AND METHODS Specimens were taken from 20 refrigerated cadavers from different locations of the colonic frame (ascending, transverse, descending and sigmoid colon) in two different directions (longitudinal and circumferential), with or without muscle strips (taenia coli). A total of 120 specimens were subjected to tensile tests, after preconditioning, at the speed of 1m/s. RESULTS High-speed video analysis showed a bilayer injury process with an initial rupture of the serosa / external muscular layer followed by a second rupture of the inner layer consisting of the internal muscle / submucosa / mucosa. The mechanical response was biphasic, with a first point of initial damage followed by a complete rupture. The levels of stress and strain at the failure site were statistically greater in terms of circumferential stress (respectively 69±22% and 1.02±0.50MPa) than for longitudinal stress (respectively 55±32% and 0.70±0.34MPa). The difference between longitudinal and circumferential stress was not statistically significant (3.17±2.05MPa for longitudinal stress and 3.15±1.73MPa for circumferential stress). The location on colic frame significantly modified the mechanical response both longitudinally and circumferentially, whereas longitudinal taenia coli showed no mechanical influence. CONCLUSION The mechanical response of the colon specimen under dynamic uniaxial solicitation showed a bilayer and biphasic injury process depending on the direction of solicitation and colic localization. Furthermore these results could be integrated into a numeric model reproducing abdominal trauma to better understand and prevent intestinal injuries.
Collapse
Affiliation(s)
- D Massalou
- Emergency Surgery Unit, Universitary Hospital of Nice, Hôpital Pasteur 2, Nice Sophia-Antipolis University, France; Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, France.
| | - C Masson
- Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, France
| | - P Foti
- Emergency Surgery Unit, Universitary Hospital of Nice, Hôpital Pasteur 2, Nice Sophia-Antipolis University, France
| | - S Afquir
- Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, France
| | - P Baqué
- Emergency Surgery Unit, Universitary Hospital of Nice, Hôpital Pasteur 2, Nice Sophia-Antipolis University, France
| | - S-V Berdah
- Department of Visceral Surgery, AP-HM Hôpital Nord, Aix-Marseille University, France; Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, France
| | - T Bège
- Department of Visceral Surgery, AP-HM Hôpital Nord, Aix-Marseille University, France; Biomechanical Applied Laboratory, UMRT24, IFSTTAR, Aix-Marseille University, France
| |
Collapse
|
20
|
Verma N, Pham JD, Linnau KF. Core curriculum illustration: blunt trauma to the bowel. Emerg Radiol 2016; 24:109-111. [PMID: 27757729 DOI: 10.1007/s10140-016-1455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/11/2016] [Indexed: 12/01/2022]
Abstract
This is the 22nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .
Collapse
Affiliation(s)
- Nupur Verma
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, FL, 32610-0374, USA.
| | - John D Pham
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, FL, 32610-0374, USA
| | - Ken F Linnau
- Department of Radiology, University of Washington, Seattle, WA, USA
| |
Collapse
|
21
|
Pande R, Saratzis A, Winter Beatty J, Doran C, Kirby R, Harmston C. Contemporary characteristics of blunt abdominal trauma in a regional series from the UK. Ann R Coll Surg Engl 2016; 99:82-87. [PMID: 27490986 DOI: 10.1308/rcsann.2016.0223] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Blunt abdominal trauma (BAT) is a common injury in recent trauma series. The characteristics of patients with BAT have changed following the reconfiguration of UK trauma services. The aim of this study was to build a new profile for BAT patients undergoing immediate or delayed laparotomy. METHODS All 5,401 consecutive adults presenting with major trauma between April 2012 and April 2014 in the 3 major trauma centres in the West Midlands were analysed to identify all patients with BAT. A total of 2,793 patients with a mechanism of injury or symptomatology consistent with BAT were identified (52%). Outcomes were analysed using local electronic clinical results systems and notes. RESULTS Of the 2,793 patients, 179 (6.4%) had a mesenteric or hollow viscus injury, 168 (6.0%) had a hepatobiliary injury, 149 (5.4%) had a splenic injury and 46 (1.6%) had a vascular injury. Overall, 103 patients (3.7%) underwent an early (<12 hours) laparotomy while 30 (1.1%) underwent a delayed (>12 hours) laparotomy. Twenty (66.7%) of those undergoing a delayed laparotomy had a hollow viscus injury. In total, 170 deaths occurred among the BAT patients (6.1%). In the early laparotomy group, 53 patients died (51.5%) whereas in the delayed laparotomy group, 6 patients died (20.0%). CONCLUSIONS This series has attempted to provide the characteristics of patients with BAT in a large contemporary UK cohort. BAT was found to be a common type of injury. Early and delayed laparotomy occurred in 3.7% and 1.1% of these patients respectively, mostly because of hollow viscus injury in both cases. Outcomes were comparable with those in the international literature from regions with mature trauma services.
Collapse
Affiliation(s)
- R Pande
- University Hospitals Coventry and Warwickshire NHS Trust , UK.,Contributed equally
| | - A Saratzis
- University of Leicester , UK.,Contributed equally
| | - J Winter Beatty
- University Hospitals Coventry and Warwickshire NHS Trust , UK
| | - C Doran
- University Hospitals Birmingham NHS Foundation Trust , UK
| | - R Kirby
- University Hospitals of North Midlands NHS Trust , UK
| | - C Harmston
- University Hospitals Coventry and Warwickshire NHS Trust , UK
| |
Collapse
|