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Fabig S, Weigert N, Migliorini F, Kleeff J, Hofmann GO, Schenk P, Hilbert-Carius P, Kobbe P, Mendel T. Predictive parameters for early detection of clinically relevant abdominal trauma in multiple-injury or polytraumatised patients: a retrospective analysis. Eur J Med Res 2024; 29:394. [PMID: 39080791 PMCID: PMC11288090 DOI: 10.1186/s40001-024-01969-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 07/10/2024] [Indexed: 08/03/2024] Open
Abstract
Diagnosis of relevant organ injury after blunt abdominal injury (AI) in multiple-injury/polytraumatised patients is challenging. AI can be distinguished between injuries of parenchymatous organs (POI) of the upper abdomen (liver, spleen) and bowel and mesenteric injuries (BMI). Still, such injuries may be associated with delays in diagnosis and treatment. The present study aimed to verify laboratory parameters, imaging diagnostics, physical examination and related injuries to predict intraabdominal injuries. This retrospective, single-centre study includes data from multiple-injury/polytraumatised patients between 2005 and 2017. Two main groups were defined with relevant abdominal injury (AI+) and without abdominal injury (AI-). The AI+ group was divided into three subgroups: BMI+, BMI+/POI+, and POI+. Groups were compared in a univariate analysis for significant differences. Logistic regression analysis was used to determine predictors for AI+, BMI+ and POI+. 26.3% (271 of 1032) of the included patients had an abdominal injury. Subgroups were composed of 4.7% (49 of 1032) BMI+, 4.7% (48 of 1032) BMI+/POI+ and 16.8% (174 of 1032) POI+. Pathological abdominal signs had a sensitivity of 48.7% and a specificity of 92.4% for AI+. Transaminases were significantly higher in cases of AI+. Pathological computed tomography (CT) (free fluid, parenchymal damage, Bowel Injury Prediction Score (BIPS), CT Grade > 4) was summarised and had a sensitivity of 94.8%, a specificity of 98%, positive predictive value (PPV) of 94.5% and, negative predictive value (NPV) of 98.2% for AI+. The detected predictors for AI+ were pathological abdominal findings (odds ratio (OR) 3.93), pathological multi-slice computed tomography (MSCT) (OR 668.9), alanine (ALAT) ≥ 1.23 µmol/ls (OR 2.35) and associated long bone fractures (OR 3.82). Pathological abdominal signs, pathological MSCT and lactate (LAC) levels ≥ 1.94 mmol/l could be calculated as significant risk factors for BMI+. For POI+ pathological abdominal MSCT, ASAT ≥ 1.73 µmol/ls and concomitant thoracic injuries had significant relevance. The study presents reliable risk factors for abdominal injury and its sub-entities. The predictors can be explained by the anatomy of the trunk and existing studies. Elevated transaminases predicted abdominal injury (AI+) and, specifically, the POI+. The pathological MSCT was the most reliable predictive parameter. However, it was essential to include further relevant parameters.
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Affiliation(s)
- Stefan Fabig
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Nadja Weigert
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
- Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy
| | - Jörg Kleeff
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Gunther Olaf Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, 74771, Jena, Germany
| | - Philipp Schenk
- Department of Science, Research and Education, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Philipp Kobbe
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany.
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany.
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Zarama V, Torres N, Duque E, Arango-Ibañez JP, Duran K, Azcárate V, Maya DA, Sánchez ÁI. Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department. BMC Emerg Med 2024; 24:103. [PMID: 38902603 PMCID: PMC11191214 DOI: 10.1186/s12873-024-01014-w] [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: 03/09/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVES Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period. METHODS We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death. RESULTS We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported. CONCLUSION The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.
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Affiliation(s)
- Virginia Zarama
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia.
- Department of Emergency Medicine, Fundación Valle del Lili, Cali, Colombia.
| | - Nicolás Torres
- Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Esteban Duque
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia
| | | | - Karina Duran
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia
| | - Valeria Azcárate
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia
| | - Duban A Maya
- Department of Emergency Medicine, Fundación Valle del Lili, Cali, Colombia
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Agri F, Pache B, Bourgeat M, Darioli V, Demartines N, Schmidt S, Zingg T. Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study. J Trauma Acute Care Surg 2024; 96:820-830. [PMID: 38111096 DOI: 10.1097/ta.0000000000004231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS). METHODS A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance. RESULTS The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively. CONCLUSION The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Fabio Agri
- From the Department of Visceral Surgery (F.A., M.B., N.D., T.Z.), Department of Administration and Finance (F.A.), Department of Women-Mother-Child (B.P.), Gynecology and Obstetrics Unit, Department of Emergency Medicine (V.D.), and Department of Diagnostic and Interventional Radiology (S.S.), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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O'Toole DM, Warrington NV, Matthees NG, Kupanoff KM, Bogert JN, Jones MD, Soe-Lin H, Huang DD, Weinberg JA. Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury. Emerg Radiol 2024; 31:193-201. [PMID: 38374481 PMCID: PMC10995023 DOI: 10.1007/s10140-023-02197-8] [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: 11/07/2023] [Accepted: 12/22/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE Blunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI. METHODS We conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI. RESULTS One hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67-0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64-0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75-0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55). CONCLUSION Radiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist's impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.
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Affiliation(s)
- Devin M O'Toole
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
| | | | | | - Kristina M Kupanoff
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - James N Bogert
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Michael D Jones
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Hahn Soe-Lin
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Dih-Dih Huang
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Jordan A Weinberg
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA.
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA.
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Zheng Y, Li Z, Zhou Q. Diagnosis of small intestinal microperforation by cell morphology detection in abdominal puncture fluid: A case report. Int J Surg Case Rep 2024; 115:109316. [PMID: 38306870 PMCID: PMC10847150 DOI: 10.1016/j.ijscr.2024.109316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Although abdominal computed tomography angiography (CTA) may be a gold standard for early diagnosis of small intestinal microperforation, early missed and delayed diagnosis are often important factors leading to poor prognosis. The cellular morphology diagnosis of abdominal puncture fluid (DAPF) or diagnostic peritoneal lavage (DPL) may have unexpected clinical outcomes. CASE PRESENTATION We report a case of small bowel microperforation which dues to BAT. A 39-year-old male with a chief complaint of "multiple injuries to the whole body from a car accident within 7 hours" was admitted to the trauma center. The first abdominal CTA ruled out perforation of abdominal parenchymatous organs and gastrointestinal tract. Subsequently, the patient underwent emergency surgery for traumatic shock, followed by clinical manifestations of persistent fever and septic shock. After diagnostic abdominal puncture fluid cell morphology examination, intestinal perforation was first considered. CLINICAL DISCUSSION Routine examination of abdominal puncture fluid can usually roughly determine the condition of visceral trauma, especially quickly and conveniently determine whether there is intra-peritoneal bleeding. However specific diagnostic components which were found in the cell images of abdominal puncture fluid also showed the clinical value of cellular morphology of DAPF. CONCLUSION The cellular morphology examination of DAPF/DPL may be the simplest, fastest, and most effective method for diagnosing small intestinal perforation due to blunt abdominal trauma(BAT). The value of DAPF /DPL in traumatic gastrointestinal injury cannot be ignored, especially for patients with BAT.
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Affiliation(s)
- Yaqin Zheng
- Clinical laboratory centre of Longquan People's Hospital Affiliated to Lishui University, Longquan City, Zhejiang Province, China
| | - Zijun Li
- Department of Obstetric and Gynecology of Longquan People's Hospital Affiliated to Lishui University, Longquan City, Zhejiang Province, China.
| | - Qinbing Zhou
- Imagning diagnosis center of Zhejiang Quhua Hospital, Quzhou city, Zhejiang province, China
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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.
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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.
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Lamoshi A, Lay R, Wakeman D, Edwards M, Wallenstein K, Fabiano T, Singh Z, Zipkin J, Park S, Yu J, Chess M, Vali K. Validation of the predictive model for operative intervention after blunt abdominal trauma in children with equivocal computed tomography findings: a multi-institutional study. Pediatr Surg Int 2024; 40:39. [PMID: 38270628 DOI: 10.1007/s00383-023-05616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND We recently developed a preliminary predictive model identifying clinical and radiologic factors associated with the need for surgery following blunt abdominal trauma (BAT) in children. Our aim in this study was to further validate the factors in this predictive model in a multi-institutional study. METHODS A retrospective chart review of pediatric patients from five pediatric trauma centers who experienced BAT between 2011 and 2020 was performed. Patients under 18 years of age who had BAT and computed tomography (CT) abdomen imaging were included. Children with evidence of pneumoperitoneum, and hemodynamic instability were excluded. Fisher's exact test was used for statistical analysis of the association between the following risk factors and need for laparotomy: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture (TLF), presence of free fluid (FF), presence of solid organ injury (SOI). A predictive logistic regression model was then estimated employing these factors. FINDINGS Seven hundred thirty-four patients were identified in this multi-institutional dataset with BAT and abdominal CT imaging, and 726 were included. Of those, 59 underwent surgical intervention (8.8%). Univariate analysis of association between the studied factors and need for surgical management showed that the presence of TLF (p < 0.01), APT (p < 0.01), FF (p < 0.01), and SOI (p < 0.01) were significantly associated. A predictive model was created using the 5 factors resulting in an area under the curve (AUC) of 0.80. For the motor vehicle collisions (MVC) group, only FF, SOI, and TLF are significantly associated with the need for surgical intervention. The AUC for the MVC group was 0.87. CONCLUSIONS A clinical and radiologic prediction rule was validated using a large multi-institutional dataset of pediatric BAT patients, demonstrating a high degree of accuracy in identifying children who underwent surgery. FF, SOI, and TLF are the most important factors associated with the need for surgical intervention. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Raymond Lay
- University of Rochester Medical Center, Rochester, NY, USA
| | - Derek Wakeman
- University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Edwards
- Albany Medical College and Center, Albany, NY, USA
| | | | | | | | - Jacob Zipkin
- Albany Medical College and Center, Albany, NY, USA
| | | | | | - Mitchell Chess
- University of Rochester Medical Center, Rochester, NY, USA
| | - Kaveh Vali
- John R. Oishei Children's Hospital, Buffalo, NY, USA
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Hsieh TM, Chuang PC, Liu CT, Wu BY, Wu CH, Cheng FJ. Impact of Pelvic Fracture on Patients with Blunt Bowel Mesenteric Injury: Is Immediate Laparotomy Warranted? Life (Basel) 2023; 14:16. [PMID: 38276266 PMCID: PMC10821033 DOI: 10.3390/life14010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
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.
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Affiliation(s)
- Ting-Min Hsieh
- Division of Trauma, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Po-Chun Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Chun-Ting Liu
- Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (C.-T.L.); (B.-Y.W.)
| | - Bei-Yu Wu
- Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (C.-T.L.); (B.-Y.W.)
| | - Chien-Hung Wu
- Department of Emergency Medicine, Yunlin Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Yunlin 638, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
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Dhanasekara CS, Marschke B, Morris E, Bashrum BS, Shrestha K, Richmond R, Dissanaike S, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner J, Keith SL, Mcnutt MK, Kregel H, Gandhi R, Schroeppel T, Margulies DR, Hashim Y, Herrold J, Goetz M, Simpson L, Xuan-Lan D. Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study. Am J Surg 2023; 226:770-775. [PMID: 37270399 DOI: 10.1016/j.amjsurg.2023.05.032] [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: 03/24/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.
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Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Bryan S Bashrum
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Ara Ko
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Frank C Wood
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Maggie Brandt
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Justin Regner
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Michelle K Mcnutt
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Rajesh Gandhi
- Department of Surgery, JPS Health Network, Ft. Worth, TX, USA
| | - Thomas Schroeppel
- Department of Surgery, UCHealth, Memorial Hospital, Colorado Springs, CO, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - LeRone Simpson
- McAllen Medical Center Trauma Department, McAllen, TX, USA
| | - Doan Xuan-Lan
- McAllen Medical Center Trauma Department, McAllen, TX, USA
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10
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Grossman H, Dhanasekara CS, Shrestha K, Marschke B, Morris E, Richmond R, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner JL, Keith SL, McNutt MK, Kregel H, Gandhi RR, Schroeppel TJ, Margulies DR, Hashim YM, Herrold J, Goetz M, Simpson L, Doan XL, Dissanaike S. Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study. Trauma Surg Acute Care Open 2023; 8:e001178. [PMID: 38020867 PMCID: PMC10668238 DOI: 10.1136/tsaco-2023-001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence III.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ara Ko
- Department of Surgery, Stanford Medicine, Stanford, California, USA
| | | | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Frank C Wood
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maggie Brandt
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rajesh R Gandhi
- Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - LeRone Simpson
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Xuan-Lan Doan
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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11
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Jakob DA, Müller M, Jud S, Albrecht R, Hautz W, Pietsch U. The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:37. [PMID: 37550763 PMCID: PMC10405424 DOI: 10.1186/s13049-023-01107-8] [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: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies. METHODS This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI). RESULTS Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group. CONCLUSION Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.
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Affiliation(s)
- Dominik A Jakob
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Sebastian Jud
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Roland Albrecht
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Urs Pietsch
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
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12
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Winicki NM, Florissi IS, Nunez A, Santiago J, Burruss S, Srikureja DP. Influence of operative timing on perioperative outcomes of patients with the seatbelt sign. Surg Open Sci 2023; 13:48-53. [PMID: 37168241 PMCID: PMC10165162 DOI: 10.1016/j.sopen.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
Background The seatbelt sign (SBS) is a pattern of bruising/contusions on the chest and abdominal wall following motor vehicle collisions. The aim of this analysis is to investigate the influence of time to surgery following identification of the SBS on perioperative outcomes. Methods A retrospective review of the Trauma Quality Improvement Program database from 2017 to 2019 was performed. Patients included in this retrospective analysis were involved in motor vehicle collisions, experienced blunt abdominal trauma, presented with skin abrasions/contusions in the SBS distribution, were hemodynamically stable, and underwent laparotomy. Demographics, vital signs, injury severity score, Glasgow coma scale, preoperative CT scans (P-CT), and time from presentation to surgery were recorded. Time from presentation to surgery was subdivided by data quartiles as immediate (<1.3 h), early (1.3-4 h), and delayed (>4 h). The influence of operative timing on postoperative mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days was assessed in multivariate analyses. Results A total of 1523 patients were included; 280 underwent immediate, 610 early, and 633 delayed surgery. Patients undergoing surgery in the early and delayed groups who received P-CT scans had shorter mean times to operation (4.52 h vs 5.24 h, p < 0.01). In multivariate analysis, patients who underwent delayed surgery stayed in the hospital 2.5 days longer (p < 0.001), spent 2.8 additional days in the ICU (p < 0.001), and spent 3.75 additional days on a ventilator (p < 0.001) than patients who received early surgery. Within the early and delayed surgical groups, P-CT was associated with lower mortality (OR 0.46 95 % CI 0.24-0.88, p < 0.01) in multivariate analysis. Conclusions Early surgical intervention was associated with improved patient outcomes by reducing hospital and ICU LOS and ventilator days. Conducting P-CT reduced the time to surgery and mortality. Utilization of P-CT for screening hemodynamically stable patients with the SBS upon admission may expedite identification of the potential need for surgical management of abdominal injury.
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Affiliation(s)
- Nolan M. Winicki
- University of California Riverside, School of Medicine, Riverside, CA, United States of America
- Loma Linda University, Department of Surgery, Loma Linda, CA, United States of America
- Laboratory of Cardiovascular Science, National Institute of Health, Baltimore, MD, United States of America
| | - Isabella S. Florissi
- Johns Hopkins University, School of Medicine, Baltimore, MD, United States of America
| | - Alberto Nunez
- University of California Riverside, School of Medicine, Riverside, CA, United States of America
| | - Jeremy Santiago
- University of California Riverside, School of Medicine, Riverside, CA, United States of America
| | - Sigrid Burruss
- Loma Linda University, Department of Surgery, Loma Linda, CA, United States of America
| | - Daniel P. Srikureja
- Beacon Medical Group Trauma & Surgical Services, South Bend, IN, United States of America
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13
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Abdelrahman H, El-Menyar A, Peralta R, Al-Thani H. Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients. World J Gastrointest Surg 2023; 15:757-775. [PMID: 37342859 PMCID: PMC10277941 DOI: 10.4240/wjgs.v15.i5.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/18/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023] Open
Abstract
Background: Modern surgical medicine strives to manage trauma while improving outcomes using functional imaging. Identification of viable tissues is crucial for the surgical management of polytrauma and burn patients presenting with soft tissue and hollow viscus injuries. Bowel anastomosis after trauma-related resection is associated with a high rate of leakage. The ability of the surgeon’s bare eye to determine bowel viability remains limited, and the need for a more standardized objective assessment has not yet been fulfilled. Hence, there is a need for more precise diagnostic tools to enhance surgical evaluation and visualization to aid early diagnosis and timely management to minimize trauma-associated complications. Indocyanine green (ICG) coupled with fluorescence angiography is a potential solution for this problem. ICG is a fluorescent dye that responds to near-infrared irradiation. Methods: We conducted a narrative review to address the utility of ICG in the surgical management of patients with trauma as well as elective surgery. Discussion: ICG has many applications in different medical fields and has recently become an important clinical indicator for surgical guidance. However, there is a paucity of information regarding the use of this technology to treat traumas. Recently, angiography with ICG has been introduced in clinical practice to visualize and quantify organ perfusion under several conditions, leading to fewer cases of anastomotic insufficiency. This has great potential to bridge this gap and enhance the clinical outcomes of surgery and patient safety. However, there is no consensus on the ideal dose, time, and manner of administration nor the indications that ICG provides a genuine advantage through greater safety in trauma surgical settings. Conclusions: There is a scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy to facilitate intraoperative decisions and to limit the extent of surgical resection. This review will improve our understanding of the utility of intraoperative ICG fluorescence in guiding and assisting trauma surgeons to deal with the intraoperative challenges and thus improve the patients’ operative care and safety in the field of trauma surgery.
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Affiliation(s)
| | - Ayman El-Menyar
- Trauma and Vascular Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Ruben Peralta
- Trauma Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Hassan Al-Thani
- Trauma and Vascular Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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14
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Blackley SK, Smith WC, Lee YL, Kinnard C, Williams AY, Butts CC, Mbaka MI, Haiflich A, Bright A, Simmons JD, Polite NM. Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury. Am Surg 2023:31348231174009. [PMID: 37115715 DOI: 10.1177/00031348231174009] [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: 04/29/2023]
Abstract
BACKGROUND Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI. METHODS Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention. RESULTS 1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention. CONCLUSION In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.
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Affiliation(s)
- Shem K Blackley
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - William C Smith
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Yann-Leei Lee
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | | | | | - Charles C Butts
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Maryann I Mbaka
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Andrew Haiflich
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Andrew Bright
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Jon D Simmons
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Nathan M Polite
- Department of Surgery, University of South Alabama, Mobile, AL, USA
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15
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Jang H, An S, Lee N, Jeong E, Park Y, Kim J, Jo Y. Factors associated with enteral nutrition tolerance after trauma laparotomy of the small bowel and mesenteric injuries by blunt trauma. BMC Surg 2023; 23:61. [PMID: 36959602 PMCID: PMC10037781 DOI: 10.1186/s12893-023-01955-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/07/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND In patients with blunt injury due to abdominal trauma, the common cause for laparotomy is damage to the small bowel and mesentery. Recently, postoperative early enteral nutrition (EEN) has been recommended for abdominal surgery. However, EEN in patients with blunt bowel and/or mesenteric injury (BBMI) has not been established. Therefore, this study aimed to identify the factors that affect early postoperative small bowel obstruction (EPSBO) and the date of tolerance to solid food and defecation (SF + D) after surgery in patients with BBMI. METHODS We retrospectively reviewed patients who underwent laparotomy for BBMI at a single regional trauma center between January 2013 and July 2021. A total of 257 patients were included to analyze the factors associated with enteral nutrition tolerance in patients with EPSBO and the postoperative day of tolerance to SF + D. RESULTS The incidence of EPSBO in patients with BBMI was affected by male sex, small bowel organ injury scale (OIS) score, mesentery OIS score, amount of crystalloid, blood transfusion, and postoperative drain removal date. The higher the mesentery OIS score, the higher was the EPSBO incidence, whereas the small bowel OIS did not increase the incidence of EPSBO. The amount of crystalloid infused within 24 h; the amount of packed red blood cells, fresh frozen plasma, and platelet concentrate transfused; the time of drain removal; Injury Severity Score; and extremity abbreviated injury scale (AIS) score were correlated with the day of tolerance to SF + D. Multivariate analysis between the EPSBO and non-EPSBO groups identified mesentery and small bowel OIS scores as the factors related to EPSBO. CONCLUSION Mesenteric injury has a greater impact on EPSBO than small bowel injury. Further research is needed to determine whether the mesentery OIS score should be considered during EEN in patients with BBMI. The amount of crystalloid infused and transfused blood components within 24 h, time of drain removal, injury severity score, and extremity AIS score are related to the postoperative day on which patients can tolerate SF + D.
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Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, 61469, Gwangju, Republic of Korea
| | - Sangyun An
- Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Naa Lee
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, 61469, Gwangju, Republic of Korea
| | - Euisung Jeong
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, 61469, Gwangju, Republic of Korea
| | - Yunchul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, 61469, Gwangju, Republic of Korea
| | - Jungchul Kim
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, 61469, Gwangju, Republic of Korea
| | - Younggoun Jo
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, 42 Jebong-ro, Dong-gu, 61469, Gwangju, Republic of Korea.
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16
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Adenuga AT, Adeyeye A. Pattern of Presentation and Outcome of Adult Patients with Abdominal Trauma - A 7-Year Retrospective Study in a Nigerian Tertiary Hospital. J Emerg Trauma Shock 2023; 16:8-12. [PMID: 37181742 PMCID: PMC10167826 DOI: 10.4103/jets.jets_91_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/06/2022] [Accepted: 09/28/2022] [Indexed: 03/29/2023] Open
Abstract
Introduction Abdominal trauma is a major cause of morbidity and mortality in low- and middle-income countries. There is a paucity of trauma data in this region and this study aimed to show the pattern of presentation and outcome of patients with abdominal trauma at a North-Central Nigerian Teaching Hospital. Methods This was a retrospective, observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from January 2013 to December 2019. Patients with clinical and/or radiological evidence of abdominal trauma were identified, and data extracted and analyzed. Results A total of 87 patients were included in the study. There were 73 males and 14 females (5.2:1) with a mean age of 34.2 years. Blunt abdominal injury occurred in 53 (61%) patients with 10 patients (11%) having concomitant extra-abdominal injuries. A total of 105 abdominal organ injuries occurred in 87 patients with the small bowel being the most frequently injured organ in penetrating trauma, while in blunt abdominal injury, the spleen was most commonly injured. A total of 70 patients (80.5%) had emergency abdominal surgery with a morbidity rate of 38.6% and negative laparotomy rate of 2.9%. There were 15 deaths in the period accounting for 17% of patients with sepsis as the most common cause of death (66%). Shock at presentation, late presentation >12 h, need for perioperative intensive care unit admission, and repeat surgery were associated with a higher risk of mortality (P < 0.05). Conclusion Abdominal trauma in this setting is associated with a significant amount of morbidity and mortality. Typical patients present late and with poor physiologic parameters often resulting in an undesirable outcome. There should be steps targeted at preventive policies focused on reducing the incidence of road traffic crashes, terrorism, and violent crimes as well as improving health care infrastructure to cater to this specific group of patients.
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Affiliation(s)
| | - Ademola Adeyeye
- Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
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17
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Kremser A, Németh D, Oláh A, Molnár FT. [Furtive small bowel perforation after blunt abdominal trauma]. Magy Seb 2022; 75:214-217. [PMID: 36006766 DOI: 10.1556/1046.2022.30002] [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: 05/18/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
A rare case of delayed jejunal perforation is reported, with a time window of approximately five hours. The diagnosis is challenging: there are no proper protocols, planned early physical examination checkups are advised. The forensic medical aspects of the occasional therapeutical delays are remarkable.
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Affiliation(s)
- Adriána Kremser
- 1 Petz Aladár Egyetemi Oktató Kórház, Érsebészeti Osztály, Győr, Magyarország
| | - Dávid Németh
- 2 Petz Aladár Egyetemi Oktató Kórház, Sebészeti Osztály, Győr, Magyarország
| | - Attila Oláh
- 2 Petz Aladár Egyetemi Oktató Kórház, Sebészeti Osztály, Győr, Magyarország
| | - F Tamás Molnár
- 2 Petz Aladár Egyetemi Oktató Kórház, Sebészeti Osztály, Győr, Magyarország
- 3 Pécsi Tudományegyetem, Általános Orvosi Kar, Orvosi Készségfejlesztő és Innovációs Központ, Műveleti Medicina Tanszék, Pécs, Magyarország
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18
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A Retrospective Cohort Study on the Clinical Characteristics of Patients with Surgical Blunt Bowel and/or Mesenteric Injuries among Motorcyclists and Car Occupants. Healthcare (Basel) 2022; 10:healthcare10071323. [PMID: 35885849 PMCID: PMC9323956 DOI: 10.3390/healthcare10071323] [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] [Received: 06/16/2022] [Revised: 07/04/2022] [Accepted: 07/14/2022] [Indexed: 12/04/2022] Open
Abstract
(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.
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Kuhlenschmidt KM, Choi E, Moonmoon K, Blackwell J, Comish PB, Balentine C, Grant J, Park C, Dultz LA, Shoultz T, Cripps MW, Dumas RP. Provider Perception of Time During Trauma Resuscitation: A Prospective Quantitative Trauma Video Review Analysis. J Surg Res 2022; 274:207-212. [DOI: 10.1016/j.jss.2021.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 11/20/2021] [Accepted: 12/27/2021] [Indexed: 11/29/2022]
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Basukala S, Tamang A, Sharma S, Bhusal U, Pathak B. Successful conservative management of a large traumatic mesenteric hematoma: A case report. Int J Surg Case Rep 2022; 93:106930. [PMID: 35286983 PMCID: PMC8921292 DOI: 10.1016/j.ijscr.2022.106930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE In blunt abdominal trauma, small bowel and mesentery injury (SBMI) is the third most common organ injury with an estimated incidence of 1-5%. Traumatic mesenteric injuries are difficult to diagnose and their undiagnosed complications are severe with high mortality rates. CASE PRESENTATION A 21-year-old male presented to the emergency room with severe colicky pain in the right-hypochondrium 2 h after dinner. He gave history of nausea, vomiting and diarrhea after dinner and before the pain started. The morning after admission, a Contrast Enhanced Computed Tomography (CECT) scan was done which showed a large mesenteric hematoma. On subsequent questioning, the patient then recalled a blow to the abdomen while playing basketball two days ago. Since the patient was hemodynamically stable, non-operative management (NOM) was chosen with close monitoring. Regular follow-up ultrasonography (USG) scans showed progressive spontaneous resolution of the hematoma. CLINICAL DISCUSSION Nonspecific symptoms of mesenteric hematoma make it difficult to reach a diagnosis. It is usually identified by history or medical imaging. Mesenteric hematoma can be managed conservatively if there is no active bleeding. In stable patients, selective visceral angiography should be performed and bleeding vessels should be embolized where possible. CONCLUSION This case highlights a successful conservative management of a large traumatic mesenteric hematoma. It also emphasizes the importance of eliciting a detailed history of major or minor trauma for any patient with abdominal pain. Previous cases have also highlighted the importance of non-operative management and avoidance of emergency laparotomy in stable patients.
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Affiliation(s)
- Sunil Basukala
- Department of Surgery, Shree Birendra Hospital (SBH), Kathmandu, Nepal
| | - Ayush Tamang
- College of Medicine, Nepalese Army Institute of Health Sciences (NAIHS), Kathmandu, Nepal.
| | - Shriya Sharma
- College of Medicine, Nepalese Army Institute of Health Sciences (NAIHS), Kathmandu, Nepal
| | - Ujwal Bhusal
- College of Medicine, Nepalese Army Institute of Health Sciences (NAIHS), Kathmandu, Nepal
| | - Bishnu Pathak
- Department of Surgery, Shree Birendra Hospital (SBH), Kathmandu, Nepal
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21
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Smyth L, Bendinelli C, Lee N, Reeds MG, Loh EJ, Amico F, Balogh ZJ, Di Saverio S, Weber D, Ten Broek RP, Abu-Zidan FM, Campanelli G, Beka SG, Chiarugi M, Shelat VG, Tan E, Moore E, Bonavina L, Latifi R, Hecker A, Khan J, Coimbra R, Tebala GD, Søreide K, Wani I, Inaba K, Kirkpatrick AW, Koike K, Sganga G, Biffl WL, Chiara O, Scalea TM, Fraga GP, Peitzman AB, Catena F. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 2022; 17:13. [PMID: 35246190 PMCID: PMC8896237 DOI: 10.1186/s13017-022-00418-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023] Open
Abstract
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
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Affiliation(s)
- Luke Smyth
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Lee
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Matthew G Reeds
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Eu Jhin Loh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dieter Weber
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Fikri M Abu-Zidan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Solomon Gurmu Beka
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Massimo Chiarugi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vishal G Shelat
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Edward Tan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ernest Moore
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Luigi Bonavina
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Rifat Latifi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andreas Hecker
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jim Khan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Giovanni D Tebala
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kjetil Søreide
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Imtiaz Wani
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenji Inaba
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Kaoru Koike
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gabriele Sganga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gustavo P Fraga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew B Peitzman
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Fausto Catena
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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22
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Wandling M, Cuschieri J, Kozar R, O'Meara L, Celii A, Starr W, Burlew CC, Todd SR, de Leon A, McIntyre RC, Urban S, Biffl WL, Bayat D, Dunn J, Peck K, Rooney AS, Kornblith LZ, Callcut RA, Lollar DI, Ambroz E, Leichtle SW, Aboutanos MB, Schroeppel T, Hennessy EA, Russo R, McNutt M. Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries. Injury 2022; 53:122-128. [PMID: 34380598 DOI: 10.1016/j.injury.2021.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 06/25/2021] [Accepted: 07/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. MATERIALS AND METHODS Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. RESULTS Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively. CONCLUSION This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.
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Affiliation(s)
- Michael Wandling
- McGovern Medical School at UT Health, 6410 Fannin St, Houston, TX 77030, USA
| | - Joseph Cuschieri
- University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Rosemary Kozar
- University of Maryland School of Medicine, 655 W Baltimore St S, Baltimore, MD 21201, USA
| | - Lindsay O'Meara
- University of Maryland School of Medicine, 655 W Baltimore St S, Baltimore, MD 21201, USA
| | - Amanda Celii
- Oklahoma University Health Science Center, 865 Research Pkwy, Oklahoma, OK 73104, USA
| | - William Starr
- Oklahoma University Health Science Center, 865 Research Pkwy, Oklahoma, OK 73104, USA
| | | | - S Rob Todd
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | | | | | - Shane Urban
- University of Colorado, 13001 E 17(th) Pl, Aurora, CO 80045, USA
| | - Walt L Biffl
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, San Diego, CA 92037, USA
| | - Dunya Bayat
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, San Diego, CA 92037, USA
| | - Julie Dunn
- UC Health Medical Center of the Rockies, 2500 Rocky Mountain Ave, Loveland, CO 80538, USA
| | - Kimberly Peck
- Scripps Mercy Hospital San Diego, 4077 Fifth Ave, San Diego, CA 92103, USA
| | - Alexandra S Rooney
- Scripps Mercy Hospital San Diego, 4077 Fifth Ave, San Diego, CA 92103, USA
| | - Lucy Z Kornblith
- University of California San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Rachael A Callcut
- University of California San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Daniel I Lollar
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA
| | - Eric Ambroz
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, USA
| | - Stefan W Leichtle
- Virginia Commonwealth University Medical Center, 1204 E Marshal St #4-100, Richmond, VA 23298, USA
| | - Michel B Aboutanos
- Virginia Commonwealth University Medical Center, 1204 E Marshal St #4-100, Richmond, VA 23298, USA
| | - Thomas Schroeppel
- UCHealth Memorial Hospital Central, 1400 E Boulder St, Colorado Springs, CO 80909, USA
| | - Elizabeth A Hennessy
- UCHealth Memorial Hospital Central, 1400 E Boulder St, Colorado Springs, CO 80909, USA
| | - Rachel Russo
- University of Michigan, 1301 Catherine St, Ann Arbor, MI 48109, USA
| | - Michelle McNutt
- McGovern Medical School at UT Health, 6410 Fannin St, Houston, TX 77030, USA.
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23
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Diagnostic Accuracy of Computed Tomography for the Prediction of the Need for Laparotomy for Traumatic Hollow Viscus Injury: Systematic Review and Meta-Analysis. J Pers Med 2021; 11:jpm11121269. [PMID: 34945741 PMCID: PMC8708608 DOI: 10.3390/jpm11121269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI. METHOD A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models. RESULTS Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501-0.809) and 0.969 (95% CI: 0.920-0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011-0.071). CONCLUSION In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.
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24
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Chen SA, Wang CY, Hsu CP, Lin JY, Cheng CT, Ouyang CH, Huang JF, Liao CH. The Current Diagnostic Accuracy on Free Peritoneal Fluid in Computed Tomography to Determinate the Necessity of Surgery in Blunt Bowel and Mesenteric Trauma-Systemic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11112028. [PMID: 34829375 PMCID: PMC8620381 DOI: 10.3390/diagnostics11112028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
Traumatic bowel mesenteric injury (TBMI) is a challenge in trauma care. The presence of free peritoneal fluid (FF) in computed tomography (CT) was considered the indication for surgical intervention. However, conservative treatment should be applied for minor injuries. We conduct a systematic review to analyze how reliable the FF is to assess the TBMI. Publications were retrieved by structured searching among databases, review articles and major textbooks. For statistical analysis, summary receiver operating characteristic curves (SROCs) were computed using hierarchical models. Fourteen studies enrolling 4336 patients were eligible for final qualitative analysis. The SROC line was created by a hierarchical summary receiver operating characteristic model. The summary sensitivity of FF to predict surgical TBMI was 0.793 (95% CI: 0.635-0.894), and the summary specificity of FF to predict surgical TBMI was 0.733 (95% CI: 0.468-0.896). The diagnostic odds ratio was 10.531 (95% CI: 5.556-19.961). This study represents the most robust evidence (level 3a) to date that FF is not the absolute but an acceptable indicator for surgically important TBMI. However, there is still a need for randomized controlled trials to confirm.
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Affiliation(s)
- Szu-An Chen
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chen-Yu Wang
- Department of Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan;
| | - Chih-Po Hsu
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Jia-Yen Lin
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chi-Tung Cheng
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Jen-Fu Huang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chien-Hung Liao
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
- Correspondence: ; Tel.: +886-3281200 (ext. 3651)
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25
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Weinberg JA, Peck KA, Ley EJ, Brown CV, Moore EE, Sperry JL, Rizzo AG, Rosen NG, Brasel KJ, Hartwell JL, de Moya MA, Inaba K, Martin MJ. Evaluation and management of bowel and mesenteric injuries after blunt trauma: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2021; 91:903-908. [PMID: 34162796 DOI: 10.1097/ta.0000000000003327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jordan A Weinberg
- From the Department of Surgery, Creighton University School of Medicine Phoenix Regional Campus (J.A.W.), Phoenix, Arizona; Department of Surgery, Scripps Mercy Hospital (K.A.P., M.J.M.), San Diego; Department of Surgery, Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Department of Surgery, Dell Medical School, University of Texas (C.V.B.), Austin, Texas; Department of Surgery, Ernest E. Moore Shock Trauma Center (E.E.M.), Denver, Colorado; Department of Surgery, University of Pittsburgh School of Medicine, (J.L.S.), Pittsburgh, Pennsylvania; Department of Surgery, Inova Trauma Center (A.G.R.), Falls Church, Virginia; Department of Surgery, Cincinnati Children's Hospital (N.G.R.), Cincinnati, Ohio; Department of Surgery, Oregon Health Science University (K.J.B.), Portland, Oregon; Department of Surgery, Indiana University School of Medicine (J.L.H.), Indianapolis, Indiana; Department of Surgery, Medical College of Wisconsin (M.A.d.M.), Milwaukee, Wisconsin; Department of Surgery, University of Southern California (K.I.), Los Angeles, California
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26
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Keller N, Zingg T, Agri F, Denys A, Knebel JF, Schmidt S. Significant blunt bowel and mesenteric injury - Comparison of two CT scoring systems in a trauma registry cohort. Eur J Radiol Open 2021; 8:100380. [PMID: 34646913 PMCID: PMC8496098 DOI: 10.1016/j.ejro.2021.100380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study evaluated and compared two imaging-based scoring systems for the detection of significant blunt bowel and mesenteric injury (sBBMI) by emergency computed tomography (CT). METHODS AND MATERIALS We included all consecutive adult polytrauma patients admitted to our emergency department following a road traffic accident from January 2008 to June 2015, provided that intravenously contrast-enhanced whole-body CT examination was performed immediately after hospital admission. Two radiologists, blinded to patients' outcome, reviewed the CT examinations for distinctive direct intestinal or mesenteric vascular injury and indirect signs of abdominal injury. These findings were correlated with the patients' surgical or interventional radiology findings, autopsy, or clinical follow-up (>24 h). Two previously validated imaging-based bowel-injury scoring systems, the CT-based Faget score and the clinically and radiologically based Mc Nutt score (BIPS), were compared by applying each to our trauma cohort. Student t-test, chi-squared, and logistic regression were used in analyses. RESULTS Twenty-one of 752 analysed patients (2.8 %) had confirmed sBBMI. Active mesenteric bleeding, mesenteric and free pneumoperitoneum, small haemoperitoneum, non-focal bowel wall thickening, mesenteric/pericolic fat stranding, and anterior abdominal wall injury were significantly correlated with sBBMI, as did the two evaluated scoring systems (p < 0.001). However, multivariate logistic regression revealed the superiority of the Faget score to the McNutt score. CONCLUSION The prevalence of sBBMI among polytrauma patients is low. Early diagnosis is necessary to avoid increased mortality. Certain CT features are pathognomic of sBBMI and must not be overlooked. Scoring systems are helpful, especially when they are based on radiological signs.
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Key Words
- AAWI, Anterior abdominal wall injury
- AMB, Active mesenteric bleeding
- ATMV, Abrupt termination of mesenteric vessels
- BIPS, Bowel Injury Prediction Score
- BWD, Bowel wall discontinuity
- BWT, Bowel wall thickening
- CT, Multidetector computed tomography
- DBWE, Decreased bowel wall enhancement
- FF, (Non-haematic) free fluid
- FPP, Free pneumoperitoneum
- HP, Haemoperitoneum
- IBMV, Irregular beading of mesenteric vessels
- Intestine, large
- Intestine, small
- MFS, Mesenteric (pericolic) fat stranding
- MPP, Mesenteric pneumoperitoneum
- Mesentery
- Multidetector computed tomography
- Polytrauma
- SB, Small bowel
- WBC, White blood cell
- sBBMI, Significant blunt bowel and mesenteric injury
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Affiliation(s)
- Nathalie Keller
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Francois Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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27
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Tominaga GT, Crandall M, Cribari C, Zarzaur BL, Bernstein M, Kozar RA. Organ Injury Scaling 2020 update: Bowel and mesentery. J Trauma Acute Care Surg 2021; 91:e73-e77. [PMID: 34137742 DOI: 10.1097/ta.0000000000003319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gail T Tominaga
- From the Department of Surgery (G.T.T.), Scripps Memorial Hospital La Jolla, La Jolla, California; Department of Surgery (M.C.), University of Florida College of Medicine Jacksonville, Jacksonville, Florida; Department of Surgery (C.C.), University of Colorado, Denver, Colorado; Department of Surgery (B.L.Z.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Trauma & Emergency Radiology (M.B.), NYU Lagone Health Medical Centers/Bellvue Hospital, New York, New York; and Shock Trauma (R.A.K.), University of Maryland School of Medicine, Baltimore, Maryland
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28
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Suda AJ, Baran K, Brunnemer S, Köck M, Obertacke U, Eschmann D. Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk. Eur J Trauma Emerg Surg 2021; 48:2183-2188. [PMID: 34327544 PMCID: PMC9192381 DOI: 10.1007/s00068-021-01754-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/18/2021] [Indexed: 11/28/2022]
Abstract
Purpose Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries. Methods In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed. Results In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053). Conclusion Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey. Level of evidence Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).
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Affiliation(s)
- Arnold J Suda
- Department of Orthopaedics and Trauma Surgery, AUVA Trauma Center Salzburg, Academic Teaching Hospital of Paracelsus Medical University, Dr. Franz-Rehrl-Platz 5, 5010, Salzburg, Austria.
| | - Kristine Baran
- Department of Orthopaedics and Trauma, Medical Faculty, University Medical Center Mannheim, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Suna Brunnemer
- Department of Orthopaedics and Trauma, Medical Faculty, University Medical Center Mannheim, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manuela Köck
- Department of Orthopaedics and Trauma, Medical Faculty, University Medical Center Mannheim, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Udo Obertacke
- Department of Orthopaedics and Trauma, Medical Faculty, University Medical Center Mannheim, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - David Eschmann
- Department of Orthopaedics and Trauma, Medical Faculty, University Medical Center Mannheim, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Segmental Bowel Hypoenhancement on CT Predicts Ischemic Mesenteric Laceration After Blunt Trauma. AJR Am J Roentgenol 2021; 217:93-99. [PMID: 33909460 DOI: 10.2214/ajr.20.23108] [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: 11/18/2022]
Abstract
OBJECTIVE. The objectives of this study were to examine the performance of CT in the diagnosis of ischemic mesenteric laceration after blunt trauma and to assess the predictive value of various CT signs for this injury. MATERIALS AND METHODS. In this retrospective study, consecutive patients with bowel and mesenteric injury diagnosed by CT or surgery from January 2011 through December 2016 were analyzed. Two radiologists evaluated CT images for nine signs of bowel injury. The outcome evaluated was ischemic mesenteric laceration. Univariable analysis followed by logistic regression was performed. RESULTS. The study included 147 patients (96 men and 51 women; median age, 35 years; age range, 23-52 years). Thirty-three patients had surgically confirmed ischemic mesenteric lacerations. CT signs that correlated with ischemic mesenteric laceration were abdominal wall injury, mesenteric contusion, free fluid, segmental bowel hypoenhancement, and bowel hyperenhancement adjacent to a hypoenhancing segment. The regression model developed after inclusion of clinical variables identified two predictors: segmental bowel hypoenhancement (adjusted odds ratio, 22.9 [95% CI, 7.9-66.2; p < .001] for reviewer 1 and 20.7 [95% CI, 7.2-59.0; p < .001] for reviewer 2) and abdominal wall injury (adjusted odds ratio, 5.26 [95% CI, 1.7-15.9; p = .003] for reviewer 1 and 5.3 [95% CI, 1.9-15.0; p = .002] for reviewer 2), which yielded an AUC of 0.87 for predicting injury. For reviewer 1 and reviewer 2, the sensitivities of CT in detecting the injury were 72.3% (95% CI, 54.5-86.7%) and 78.8% (95% CI, 61.0-91.0%), respectively, whereas the specificities were 94.7% (95% CI, 88.9-98.0%), and 92.1% (95% CI, 85.5-96.3%), respectively. CONCLUSION. CT has limited sensitivity but good specificity for detecting ischemic mesenteric laceration, with segmental bowel hypoenhancement considered the most predictive imaging sign.
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Wadhwa M, Kumar R, Trehan M, Singla S, Sharma R, Ahmed A, Sharma R. Blunt Abdominal Trauma With Hollow Viscus and Mesenteric Injury: A Prospective Study of 50 Cases. Cureus 2021; 13:e13321. [PMID: 33738164 PMCID: PMC7957336 DOI: 10.7759/cureus.13321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Hollow viscus injury following blunt abdominal trauma is an infrequent diagnosis. Blunt hollow viscus and mesenteric injury (HVMI) is not only an uncommon finding but its timely diagnosis is also difficult. Due to its less frequency, this injury has not been studied in detail prospectively. Aims and objectives The aim of this study is to determine the causes, pattern, management, and outcome of HVMI following blunt abdominal trauma. Methodology This study was conducted from January 2015 to June 2016 in a high-volume tertiary care trauma center and teaching hospital in North India. All patients with blunt HVMI admitted during this period were included in this study. Data were collected regarding medical history, physical findings, demographics, injury dates and times, laboratory results, diagnostic tests, delay in surgical intervention, type of surgical procedure performed, site of injury, complications, and mortality. Results Out of a total of 6,570 trauma admissions, 465 blunt abdominal injuries were identified, and HVMI was found only in 50 patients. The small bowel was the most common injury, with the jejunum being the most commonly involved segment. All patients were managed surgically. The mean time to operative intervention after hospital admission was 4.5 hours (IQR: 2-8 hours). Primary repair was performed in 54% of patients. Mortality rate was high in patients with HVMI (22% patients). Septic shock was the most common cause of death. Conclusion Hollow viscus injury in blunt abdominal trauma is not so common finding. Early diagnosis and treatment is an important but difficult task. Prognosis depends on age, associated injuries, co-morbid conditions, and delay in operative intervention.
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Affiliation(s)
- Manish Wadhwa
- Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Rajesh Kumar
- Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Munish Trehan
- Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Sanjeev Singla
- Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
| | - R Sharma
- Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Asma Ahmed
- General Surgery, Ramaiah Medical College and Hospital, Bangalore, IND
| | - Renuka Sharma
- Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
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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: 6] [Impact Index Per Article: 2.0] [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.
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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
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Ahmadinejad M, Mohammadzadeh S, Shirzadi A, Soltanian A, Ahmadinejad I, Pouryaghobi SM. Trauma factors among adult and geriatric blunt trauma patients. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Goh B, Soundappan SSV. Traumatic duodenal injuries in children: a single-centre study. ANZ J Surg 2020; 91:95-99. [PMID: 33369841 DOI: 10.1111/ans.16502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/07/2020] [Accepted: 11/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. METHODS Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. RESULTS Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. CONCLUSION In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.
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Affiliation(s)
- Barnabas Goh
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Emergency Department Versus Operating Suite Intubation in Operative Trauma Patients: Does Location Matter? World J Surg 2020; 44:780-787. [PMID: 31741071 DOI: 10.1007/s00268-019-05296-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Decreasing the time from patient arrival to definitive surgical care in injured patients requiring an operation improves outcomes. We sought to study the effect of intubation location (emergency department versus operating suite) on time to definitive surgical care. We hypothesized that patients requiring emergency surgical interventions intubated in the emergency department would have shorter times to definitive care when compared to patients intubated in the operating suite. METHODS All injured patients with a preoperative emergency department dwell time of less than 30 min and undergoing emergency operative procedures with the trauma surgery service at an urban Level I center (2010-2017) were analyzed. Demographics, clinical variables, and outcomes were assessed in relation to emergency department intubation versus operating suite intubation. The primary study endpoint was time to initiation of definitive surgical care, defined as the total elapsed time from emergency department arrival until operating room incision time. To investigate the relationship between clinical variables and time, multivariable regression was performed. RESULTS In total, 241 patients were included. In total, 138 patients were intubated in the emergency department and 103 patients were intubated in the operative suite. There was no difference between patients intubated in the emergency department and those intubated in the operating room with respect to age, gender, injury mechanism, initial heart rate or systolic blood pressure. Emergency department patients were more likely to sustain post-intubation, traumatic cardiopulmonary arrest (8.0 vs. 0.9%; p = 0.014). No statistical difference in total elapsed time from arrival to definitive surgical care was appreciated between study groups (41 vs. 43 min; p = 0.064). After controlling for clinical variables, emergency department intubation was not associated with time to definitive care (p = 0.386) in the multiple variable regression analysis. CONCLUSION When emergency department and operative suite intubation patients were compared, emergency department intubation did not decrease total elapsed time until definitive surgery but was associated with post-intubation, traumatic cardiopulmonary arrest.
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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.
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Jagjit SD, Rupp J, Ferre RM, Jordan MK, Bales B. Systematic Sonography Looking for Occult Wounds: accuracy of an abdominal ultrasound adjunct in penetrating trauma. Ultrasound J 2020; 12:48. [PMID: 33242102 PMCID: PMC7691400 DOI: 10.1186/s13089-020-00194-3] [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] [Received: 05/14/2020] [Accepted: 11/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic Sonography Looking for Occult Wounds (SSLOW) in trauma is a novel technique for the evaluation of intra-abdominal wounds in penetrating trauma. No data exist regarding the effectiveness. The objective of this study was to evaluate the accuracy of the SSLOW exam. METHODS This is a prospective collected case series conducted over a period of 10 months and took place at the Accident and Emergency Department (A&E) of the Georgetown Public Hospital Corporation (GPHC). The study enrolled patients presenting to the A&E who were 16 years old or greater with penetrating abdominal trauma. All patients with penetrating trauma received an E-FAST examination. If the E-FAST examination was negative, a SSLOW examination was completed. The sonographer evaluated for free fluid collection between the loops of bowel. The results of the SSLOW were compared to usual care (surgery consult, serial abdominal and E-FAST exams, laparotomy, and 7-day follow-up) and then categorized into four groups: true positive, false positive, true negative, and false negative. These results lead to four categorical values. From these results, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios were calculated. RESULTS There were 5 (12%) true positives, 1 (2%) false positive, 37 (86%) true negatives, and zero (0%) false negative. The SSLOW was 100% sensitive (95% CI 5-100%) and 97% specificity (95% CI 74-96%). There was an 80% positive predictive value (95% CI 1.0-64% 95% CI) and 100% negative predictive value (95% CI 88-100%). The positive likelihood ratio was 8.4 (95% CI 3.69-19.1) and negative likelihood ratio was 0. CONCLUSION The SSLOW examination may be a useful tool in the evaluation of penetrating abdominal injuries.
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Affiliation(s)
- Sri Devi Jagjit
- Georgetown Public Hospital Corporation, New Market St., Georgetown, Guyana
| | - Jordan Rupp
- Vanderbilt Medical Center, 1313 21st Avenue South, Oxford House 703, Nashville, TN, 37212, USA.
| | | | - Mary Kate Jordan
- Vanderbilt Medical Center, 1313 21st Avenue South, Oxford House 703, Nashville, TN, 37212, USA
| | - Brian Bales
- Vanderbilt Medical Center, 1313 21st Avenue South, Oxford House 703, Nashville, TN, 37212, USA
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Hatchimonji JS, Sharoky CE, Kaufman EJ, Ma LW, Garcia Whitlock AE, Smith BP, Holena DN. A Contemporary Analysis of Delayed Diagnoses After Traumatic Injury : The Role of Operative Therapy. Am Surg 2020; 87:384-389. [PMID: 32993352 DOI: 10.1177/0003134820951458] [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] [Indexed: 01/09/2023]
Abstract
BACKGROUND Factors associated with delayed injury diagnosis (DID) have been examined, but incompletely researched. METHODS We evaluated demographics, mechanism, and measures of mental status and injury severity among 10 years' worth of adult trauma patients at our center for association with DID in a multivariable regression model. Descriptions of DID injuries were reviewed to highlight characteristics of these injuries. RESULTS We included 13 509 patients, 89 (0.7%) of whom had a recognized DID. In regression analysis, ISS (OR 1.04 per point, 95% CI 1.02-1.06) and number of injuries (OR 1.08 per injury, 95% CI 1.04-1.11) were associated with DID. Operative patients had twice the odds of DID (OR 2.02, 95% CI 1.18-3.44). The most common category of DID was orthopedic extremity injury (22/89). CONCLUSION DID is associated with injury severity and operative intervention. This suggests that the presence of an injury requiring operation may distract the trauma team from additional injuries.
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Affiliation(s)
- Justin S Hatchimonji
- 6572 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine E Sharoky
- 6572 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- 14640 Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lucy W Ma
- 6572 College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna E Garcia Whitlock
- 6572 Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian P Smith
- 14640 Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel N Holena
- 14640 Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Evans S, Talbot E, Hellenthal N, Monie D, Campbell P, Cooper S. Mesenteric Vascular Injury in Trauma: An NTDB Study. Ann Vasc Surg 2020; 70:542-548. [PMID: 32898654 DOI: 10.1016/j.avsg.2020.08.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/30/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although abdominal trauma remains a major cause of morbidity and mortality, there has not been a large-scale multicenter study regarding outcomes in patients who incur mesenteric vascular injuries. The goal of this retrospective analysis was to investigate the factors associated with outcomes in patients with trauma diagnosed with mesenteric vascular injuries. METHODS A retrospective database analysis was performed on patients who sustained a mesenteric vascular injury (MVI, ICD-9 902.20-902.29) identified by the 2012 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, emergency room (ER) and final hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score (ISS), and injury type (blunt or penetrating). RESULTS Of the 1,133 total patients included, blunt trauma accounted for 740 (65%) of the injuries, whereas penetrating trauma accounted for 364 of the injuries (32%). Patients with penetrating injuries were 1.43 times more likely to die from their injuries than those suffering from blunt trauma (95% CI 1.04-1.98, P < 0.05). Patients with a higher ISS (>16) were 5.39 times more likely to die from their injuries than those with a lower ISS (95% CI 1.89-15.4, P = 0.002); if ISS was >25, the patient was 15.1 times more likely to die (95% CI 5.5-41.7, P < 0.001). Men were more likely to suffer from penetrating injuries than women (37% vs. 13%, P < 0.001), and African Americans were nearly 4 times more likely to present with penetrating injuries (69% vs 17%, P < 0.001). Age was also associated with mortality as patients >65 years and between 21 and 44 years were more likely to die from their injuries than patients in other age categories. Of the 740 patients with blunt MVIs, 326 (44%) were taken directly from the ER to the operating room (OR) and 306 (41%) to the intensive care unit (ICU), whereas with penetrating MVIs, 311 (85%) were taken to the OR from the emergency department and 18 (5%) to the intensive care unit. Of the 740 blunt MVIs, 115 died (16%), compared with 76 (21%) of the penetrating MVIs (P < 0.001). Injuries to the hepatic and superior mesenteric arteries were associated with higher mortality, with OR 2.03 and 3.03, respectively (P < 0.001). CONCLUSIONS The presence of mesenteric arterial injury warrants rapid identification and management as these injuries are associated with significant morbidity and mortality, with penetrating mechanism, injury to large mesenteric vessels, and increased ISS associated with increased mortality.
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Durrant E, Abu Mughli R, O’Neill SB, Jiminez-Juan L, Berger FH, Ezra O’Keeffe M. Evaluation of Bowel and Mesentery in Abdominal Trauma. Can Assoc Radiol J 2020; 71:362-370. [DOI: 10.1177/0846537120908132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Since the advent of multidetecter computed tomography (CT), radiologist sensitivity in detection of traumatic bowel and mesenteric abnormalities has significantly improved. Although several CT signs have been described to identify intestinal injury, accurate interpretation of these findings can remain challenging. Early detection of bowel and mesenteric injury is important as it alters patient management, disposition, and follow-up. This article reviews the common imaging findings of traumatic small bowel and mesenteric injury.
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Affiliation(s)
- Eric Durrant
- Department of Emergency and Trauma Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rawan Abu Mughli
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Siobhán B. O’Neill
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Laura Jiminez-Juan
- Department of Cardiothoracic Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ferco H. Berger
- Department of Emergency and Trauma Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael Ezra O’Keeffe
- Department of Emergency and Trauma Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Cohan CM, Beattie G, Tang A, Mazzolini K, Farzaneh N, Senekjian L, Victorino GP. Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis. J Surg Res 2020; 255:619-626. [PMID: 32653694 DOI: 10.1016/j.jss.2020.05.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.
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Affiliation(s)
- Caitlin M Cohan
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California.
| | - Genna Beattie
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Kirea Mazzolini
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | | | - Lara Senekjian
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
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Lamoshi A, Wagner N, Chen Z, Fabiano T, Wilding GE, Rothstein DH, Bass K. Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study. J Surg Res 2020; 255:449-455. [PMID: 32619860 DOI: 10.1016/j.jss.2020.05.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To study the clinical and radiologic factors predicting the need for surgical intervention after blunt abdominal trauma (BAT) in children with equivocal computed tomography (CT) scan findings. METHODS We performed a retrospective review of the trauma database at our level I pediatric trauma center between 2011 and 2019. We selected patients with BAT and equivocal findings for surgical intervention on CT scan. We studied five factors: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture, the presence of free fluid (FF), and the presence of solid organ injury, all previously reported in the literature to predict the need for operative intervention. We used t-test, the Kruskal-Wallis test and logistic regression to study the association of these factors with the need for operation in our pediatric cohort. RESULTS Of 3044 blunt trauma patients, 288 had abdominal CT scans with 61 patients demonstrating equivocal findings. Operation was performed for 12 patients (19.7%) confirming surgically correctable traumatic injuries. The need for surgical intervention was significantly associated with the age of the patients (P = 0.03), the presence of APT (P = 0.001), AWB (P = 0.01), and FF (P = 0.04). The presence of thoracolumbar fracture and solid organ injury were not significantly associated with the need for operation. For the subset of 37 patients who were injured in a motor vehicle crash, five (13.5%) required surgical intervention, which was significantly associated with the presence of AWB (P = 0.04), APT (P = 0.01), and FF (P = 0.03). A predictive model that used these factors produced a receiver operating characteristic curve of 0.86. CONCLUSIONS In cases of equivocal abdominal CT scan findings to evaluate BAT in children, the presence of abdominal wall tenderness, AWB, or FF may be significant factors predicting more accurately the need for operative intervention. A predictive model using the combination of clinical and image findings might determine with more certainty, the need for surgical intervention in children with BAT and equivocal CT findings. Validation on a larger multi-institutional data set should be done.
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Affiliation(s)
- Abdulraouf Lamoshi
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York.
| | - Nicole Wagner
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York
| | - Ziqiang Chen
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
| | - Tiffany Fabiano
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York
| | - Gregory E Wilding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Kathyrn Bass
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Lapointe L, Lavallee-Bourget MH, Pichard-Jolicoeur A, Turgeon-Pelchat C, Fleet R. Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review. CANADIAN JOURNAL OF RURAL MEDICINE 2020; 25:31-40. [PMID: 31854340 DOI: 10.4103/cjrm.cjrm_8_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients. Materials and Methods A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies. Results The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients. Conclusions The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.
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Affiliation(s)
- Luc Lapointe
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Marie-Helene Lavallee-Bourget
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Alexia Pichard-Jolicoeur
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Catherine Turgeon-Pelchat
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis, Canada
| | - Richard Fleet
- Research Chair in Emergency Medicine, CISSS Chaudière-Appalaches, Laval University, Centre De Recherche Du CISSS Chaudière-Appalaches Lévis; Department of Family and Emergency Medicine, Laval University; Centre De Recherche Sur Les Soins Et Services De Première Ligne Université Laval, Québec, Canada
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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.
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Blunt small bowel perforation (SBP): An Eastern Association for the Surgery of Trauma multicenter update 15 years later. J Trauma Acute Care Surg 2020; 86:642-650. [PMID: 30633100 DOI: 10.1097/ta.0000000000002176] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Previous work demonstrated diagnostic delays in blunt small bowel perforation (SBP) with increased mortality and inability of scans to reliably exclude the diagnosis. We conducted a follow-up multicenter study to determine if these challenges persist 15 years later. METHODS We selected adult cases with blunt injury, International Classification of Diseases, Ninth Revision or current procedural terminology (CPT) indicating small bowel surgery, no other major injury and at least one abdominal computed tomography (CT) within initial 6 hours. Controls had blunt trauma with abdominal CT but not SBP. After institutional review board approval, data from each center were collected and analyzed. RESULTS Data from 39 centers (from October 2013 to September 2015) showed 127,919 trauma admissions and 94,743 activations. Twenty-five centers were Level 1. Centers submitted 77 patients (mean age, 39; male, 68%; mean length of stay, 11.3 days) and 131 controls (mean age, 44; male, 64.9%; length of stay, 3.6 days). Small bowel perforation cases were 0.06% of admissions and 0.08% of activations. Mean time to surgery was 8.7 hours (median, 3.7 hours). Initial CT showed free air in 31 cases (43%) and none in controls. Initial CT was within normal in three cases (4.2%) and 84 controls (64%). Five cases had a second scan; two showed free air (one had an initial normal scan). One death occurred among the patients (mortality, 1.4%; and time to surgery, 16.9 hours). Regression analysis showed sex, abdominal tenderness, distention, peritonitis, bowel wall thickening, free fluid, and contrast extravasation were significantly associated with SBP. CONCLUSIONS Blunt SBP remains relatively uncommon and continues to present a diagnostic challenge. Trauma centers have shortened time to surgery with decreased case mortality. Initial CT scans continue to miss a small number of cases with potentially serious consequences. We recommend (1) intraperitoneal abnormalities on CT scan should always evoke high suspicion and (2) strong consideration of additional diagnostic/therapeutic intervention by 8 hours after arrival in patients who continue to pose a clinical challenge. LEVEL OF EVIDENCE Observational study, level III.
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Filiberto DM, Afzal MO, Sharpe JP, Seger C, Shankar S, Croce MA, Fabian TC, Magnotti LJ. Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score. Eur J Trauma Emerg Surg 2020; 47:1813-1817. [PMID: 32300849 DOI: 10.1007/s00068-020-01371-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/06/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma. METHODS All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score. RESULTS 151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91). CONCLUSIONS CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.
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Affiliation(s)
- Dina M Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Muhammad O Afzal
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - John P Sharpe
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Catherine Seger
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sridhar Shankar
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Timothy C Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Isolated Jejunal Perforation and Mesentery Injury following a Kick on the Abdomen of a College Student: A Case Report from a District Hospital in Northern Ghana. Case Rep Crit Care 2020. [DOI: 10.1155/2020/3063472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction. Isolated jejunal perforation from blunt abdominal trauma is an extremely rare intra-abdominal injury that poses a huge diagnostic challenge. Delay in diagnosis and initiation of treatment often leads to significant morbidity and mortality. Diagnosis particularly in resource-poor settings may be extremely challenging and often relies on a high index of suspicion. This is due to lack of adequate diagnostic facilities and human resource to deal with the condition with resulting high occurrence of adverse outcomes. Case Presentation. We report a case of isolated jejunal perforation with associated mesentery injury in a young college student who sustained a kick to his abdomen while playing soccer. This is an unusual presentation since most reported cases often resulted from motor vehicular accidents, bicycle handlebar, and fall from a height. We emphasized the role of critical level of suspicion with a good history and physical examination as the major source of diagnosis since diagnostic procedures, such as abdominal ultrasonography and computed tomography, are largely unavailable in most resource-constraint settings. Early surgical intervention following diagnosis leads to good recovery and reduced mortality. Conclusion. Sufficient vigilance and suspicions of small bowel perforation should always be considered after blunt trauma even when symptoms and physical findings are minimal and when diagnostic capacity is limited.
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Alabousi M, Mellnick VM, Kashef Al-Ghetaa R, Patlas MN. Imaging of blunt bowel and mesenteric injuries: Current status. Eur J Radiol 2020; 125:108894. [PMID: 32092685 DOI: 10.1016/j.ejrad.2020.108894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/26/2022]
Abstract
Blunt abdominal trauma often presents a diagnostic challenge. Clinical examination demonstrates low reliability in detecting abdominal injury (16 %) when there is a history of head injury or loss of consciousness. This can prove detrimental, as delays in the diagnosis of traumatic bowel injury of 8 h or less can result in increased morbidity and mortality, as well as prolonged hospitalization. Although hemodynamically unstable patients will require an urgent laparotomy following clinical assessment, MDCT is the modality of choice for comprehensive imaging of blunt abdominal trauma in hemodynamically stable patients. Despite the use of MDCT, blunt injury to the bowel and mesentery, which accounts for up to 5% of injuries in cases of trauma, may be difficult to detect. The use of a constellation of direct and indirect signs on MDCT can help make the diagnosis and guide clinical management. Direct signs on MDCT, such as bowel wall discontinuity, and extraluminal gas may assist in the diagnosis of traumatic bowel injury. However, these signs are not sensitive. Therefore, the astute radiologist may have to rely on indirect signs of injury, such as free fluid, bowel wall thickening, and abnormal bowel wall enhancement to make the diagnosis. This review will focus on MDCT imaging findings of bowel and mesenteric injuries secondary to blunt abdominal trauma.
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Affiliation(s)
- Mostafa Alabousi
- Department of Radiology, McMaster University, Hamilton, ON, Canada.
| | - Vincent M Mellnick
- Abdominal Imaging Section, Mallinckrodt Institute of Radiology, Washington University, St Louis, MO, USA.
| | - Rayeh Kashef Al-Ghetaa
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Michael N Patlas
- Department of Radiology, McMaster University, Hamilton, ON, Canada.
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Abstract
OBJECTIVE To develop French guidelines on the management of patients with severe abdominal trauma. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. METHODS The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. RESULTS The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.
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Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Gustavo Pereira Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Grazia Sibilla
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Peter T. Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mazyr, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Rao Ivatury
- General and Trauma Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Francesco Favi
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Uruguay
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes, UGA-Université Grenoble Alpes, Grenoble, France
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
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Ahmed N, Kuo YH, Lepis G. Emergency Laparotomy and Outcomes in Penetrating Small Bowel Perforation in Unstable Patients. Cureus 2019; 11:e6022. [PMID: 31824790 PMCID: PMC6886658 DOI: 10.7759/cureus.6022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The purpose of the study was to evaluate the impact of emergency laparotomy (EL) on outcomes of patients who suffered from small bowel perforations following a penetrating mechanism and presented with initial systolic blood pressure (SBP) <90 mmHg. Methods Data from 2012-2014 from the National Trauma Data Bank (NTDB) data set was accessed for this study. All patients who presented with initial SBP <90 mmHg and sustained perforated small bowel injury after a penetrating mechanism and were taken for EL within four hours of the patient’s arrival to the hospital were included in the study. Data were categorized into early group, if the EL was performed within an hour and late group, and if EL was done 1-4 hours of patient arrival to the hospital. Results Out of 360, approximately 89% of patients underwent EL within an hour and 11% of patients underwent EL within 1-4 hours of hospital arrival. The median (IQR) time of the late laparotomy was two (2, 3) hours. After propensity matching, there were no significance differences found between the groups regarding in-hospital mortality (11 (26.8%) vs 8 (19.5%), P = 0.54), total hospital length of stay (median and IQR 20 (17, 25) vs 15 (11, 20), P = 0.117), discharge to home without services (67% vs. 82%, P = 0.28), and post-operative complications. Conclusion EL in perforated small bowel injury in unstable patients needs to be performed as soon as possible. EL performed within the median of two hours’ time may be acceptable in certain circumstances.
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Affiliation(s)
- Nasim Ahmed
- Surgery, Division of Trauma, Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, USA
| | - Yen-Hong Kuo
- Epidemiology and Public Health, Office of Research Administration, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, USA
| | - Grace Lepis
- Surgery, Monmouth Medical Center, Long Branch, USA
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