1
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Martinez B, Breeding T, Katz J, Patel H, Santos RG, Elkbuli A. Outcomes of Preperitoneal Packing and Angioembolization for Hemorrhage Control in Hemodynamically Unstable Pelvic Fractures: A Systematic Review and Meta-Analysis. Am Surg 2024; 90:455-464. [PMID: 37970830 DOI: 10.1177/00031348231216488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE). METHODS A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate. RESULTS Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = -1.0, 95% CI: -1.8 to -.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups. CONCLUSION The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.
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Affiliation(s)
- Brian Martinez
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Tessa Breeding
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Joshua Katz
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Heli Patel
- Dr. Kiran C. Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Radleigh G Santos
- Department of Mathematics, NSUNOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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2
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Anns KM, Khan F, Aman M, Shahid J, Haq TUI, Memon WA, Saeed MA, Khalid A, Abbasher Hussien Mohamed Ahmed K, Akram S. Pseudoaneurysm of cystic artery stump after laparoscopic cholecystectomy managed successfully with branch hepatic artery embolization using jail technique. J Surg Case Rep 2024; 2024:rjae152. [PMID: 38495041 PMCID: PMC10942811 DOI: 10.1093/jscr/rjae152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/21/2024] [Indexed: 03/19/2024] Open
Abstract
An unusual manifestation caused by cholecystitis, infection, or iatrogenic damage after cholecystectomy is a pseudoaneurysm of the cystic artery. We report this rare illness in a 64-year-old man who visited the emergency room with hematemesis and anemia. The patient initially experienced acute cholecystitis and then underwent a laparoscopic cholecystectomy following which he developed a cystic artery pseudoaneurysm, secondary to infected fluid collection. Based on the patient's history and contrast-enhanced computer tomography abdomen, a diagnosis of pseudoaneurysm of the cystic artery was made. Angioembolization of the hepatic artery branch was performed to occlude the pseudoaneurysm.
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Affiliation(s)
| | - Faheemullah Khan
- Department of Radiology, The Aga Khan University Hospital, Karachi 74200, Pakistan
| | - Muhammad Aman
- Department of Radiology, The Aga Khan University Hospital, Karachi 74200, Pakistan
| | - Jehanzeb Shahid
- Department of Radiology, The Aga Khan University Hospital, Karachi 74200, Pakistan
| | - Tanveer U I Haq
- Department of Radiology, The Aga Khan University Hospital, Karachi 74200, Pakistan
| | - Wasim Ahmad Memon
- Department of Radiology, The Aga Khan University Hospital, Karachi 74200, Pakistan
| | - Muhammad Arif Saeed
- Department of Radiology, James Paget University Hospital, Great Yarmouth NR31 6BN, United Kingdom
| | - Amna Khalid
- Medical College, King Edward Medical University, Lahore, 54000, Pakistan
| | | | - Saba Akram
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi 74200, Pakistan
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3
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Sharma S, Ali I, Shetty V. Wunderlich Syndrome: A Seldom Presentation of a Relatively Ubiquitous Tumor. Cureus 2024; 16:e56126. [PMID: 38618421 PMCID: PMC11015358 DOI: 10.7759/cureus.56126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 04/16/2024] Open
Abstract
Wunderlich syndrome (WS) is characterized by spontaneous renal or perinephric hemorrhage in the absence of known trauma. WS is much rarer than haemorrhage caused by iatrogenic or traumatic conditions. The classic WS presentation of Lenk's triad of acute onset flank pain, flank mass, and hypovolemic shock is seen in less than a quarter of patients. The majority of patients present with only isolated flank pain and are frequently imaged in the emergency department with an unenhanced computed tomography (CT). The underlying aetiology varies, with the majority of cases attributed to neoplasms, vascular disease, cystic renal disease, and anticoagulation. We hereby present a case of an 80-year-old female who presented with severe discomfort in her left flank for three days in the absence of trauma. The patient was brought in a state of hypovolemic shock. After a thorough evaluation, a diagnosis of WS secondary to angiomyolipoma was made, for which selective angioembolization of the left renal artery was performed. However, due to further deterioration, a left nephrectomy had to be performed. The patient had an uneventful recovery and showed no deterioration on follow-up. The treatment modalities are vivid depending on the hemodynamic status of the patient, ranging from conservative management to operative intervention, and should be tailored to the vital state on admission.
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Affiliation(s)
- Sarthak Sharma
- Department of General Surgery, Dr. D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Pune, IND
| | - Iqbal Ali
- Department of General Surgery, Dr. D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Pune, IND
| | - Varun Shetty
- Department of General Surgery, Dr. D.Y. Patil Medical College Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Pune, IND
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4
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Abdel-Aziz H, Murray C, Roberts D, Capron G, Starr F, Bokhari F, Brigode W. The American Association for the Surgery of Trauma Organ Injury Scale for Spleen Does Not Equally Predict Interventions in Penetrating and Blunt Trauma. Am Surg 2023; 89:5782-5785. [PMID: 37159228 DOI: 10.1177/00031348231175495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the spleen (and other organs) was created in 1989. It has been validated to predict mortality, need for operation, length of stay (LOS), and intensive care unit (ICU) LOS. PURPOSE We aimed to determine if the Spleen OIS is applied equally to blunt and penetrating trauma. RESEARCH DESIGN/STUDY SAMPLE We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017-2019, including patients with spleen injuries. DATA COLLECTION Outcomes included the rates of mortality, operation, spleen-specific operation, splenectomy, and splenic embolization. RESULTS 60900 patients had a spleen injury with an OIS grade. Mortality rates increased in Grades IV and V for both blunt and penetrating trauma. In blunt trauma, the odds for any operation, spleen-specific operation, and splenectomy increased, for each increase in grade. Penetrating trauma showed similar trends in grades up to grade IV, but were statistically similar between grade IV and V. Splenectomy was higher in penetrating trauma for all grades. Splenic embolization peaked at 25% of grade IV trauma before decreasing in grade V. Rates in penetrating trauma were significantly lower in all grades, peaking at 2.5% of Grade III injuries. CONCLUSIONS The mechanism of trauma is a significant factor for all outcomes, independent of AAST-OIS. Hemostasis is predominantly surgical in penetrating trauma, achieved with angioembolization more frequently in blunt trauma. Penetrating trauma management is influenced by the potential for injury to peri-splenic organs.
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Affiliation(s)
- Hossam Abdel-Aziz
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Clark Murray
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Drew Roberts
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Gwenviere Capron
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Frederic Starr
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Faran Bokhari
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - William Brigode
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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5
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Rozycki GF, Sakran JV, Manukyan MC, Feliciano DV, Radisic A, You B, Hu F, Wooster M, Noll K, Haut ER. Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries. Am Surg 2023; 89:5492-5500. [PMID: 36786019 DOI: 10.1177/00031348231157416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries. METHODS Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS. RESULTS From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years. CONCLUSIONS AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.
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Affiliation(s)
- Grace F Rozycki
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariuxi C Manukyan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Shock Trauma Center/University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda Radisic
- Department of Surgery, School of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Bin You
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fang Hu
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan Wooster
- Southeast Iowa Regional Medical Center, Burlington, IA, USA
| | - Kathy Noll
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Baral P, Singh Bhandari R, Pradhan S, Maharjan N, Mainali P, Regmi D, Kandel K. A case report on enormous haemangioma of liver. Ann Med Surg (Lond) 2023; 85:5782-5784. [PMID: 37915671 PMCID: PMC10617932 DOI: 10.1097/ms9.0000000000001360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/17/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Hemangiomas are the most common benign liver tumour. These tumours arise from the proliferation of vascular endothelial cells and increase in size owing to dilation. If their diameter exceeds 5 cm, they are classified as giant hemangiomas, while those surpassing 15 cm are considered enormous hemangiomas. Case presentation A 38-year-old female patient presented with complaints of abdominal fullness for 18 months. Contrast-enhanced computed tomography was performed and two hemangiomas were diagnosed; the , larger one was an enormous hemangioma of size 20 × 16 cm. Non-anatomical hepatic resection was performed to remove the hemangiomas. The patient recovered well, without any complications. Clinical discussion Hepatic hemangiomas are common, but hemangiomas greater than 15 cm in size are rare. They usually require no treatment unless the patient is symptomatic. Hepatectomy and enucleation of hemangioma are the most common surgical procedure for such hemangioma. Conclusions Rarely, large hepatic hemangioma can be the cause of abdominal fullness lasting for months. Often, surgical intervention is required.
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Affiliation(s)
- Pratik Baral
- Tribhuvan University Teaching hospital, Maharajgunj, Nepal
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7
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Krishnamurthi JSM, Verma S, David Johnson Bismy J. Delayed Hemobilia: A Rare Case of Biliary Bleeding One Year After Metallic Stent Placement. Cureus 2023; 15:e47790. [PMID: 38021587 PMCID: PMC10676568 DOI: 10.7759/cureus.47790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Hemobilia is a rare cause of upper GI bleed. This case report discusses hemobilia caused as a delayed complication of self-expanding metallic stent (SEMS) placement in a 65-year-old male. Our patient had a history of hepatitis C and an unresectable hepatocellular carcinoma, treated with chemotherapy and radiation therapy, which caused obstructive jaundice, which in turn led to the placement of SEMS. This case highlights the challenges in managing late-onset biliary bleeding, especially in patients with underlying malignancies. Detection of bleeding in a timely manner is crucial in devising the treatment plan. Angiographic occlusion is the first line of management to stop the bleed followed by definitive surgery or stent revision. Severe complications can occur in patients with poor general health. This case report addresses the importance of monitoring the patient and the need for collaborative efforts across specialties in managing complex cases. Despite the best efforts of the medical team, this case serves as a reminder of the complex and twisted nature of medical conditions, telling us the importance of developing suitable treatment strategies for each patient's needs and healthcare requirements.
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8
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Kumar D, Mittal A, Panwar V, Talwar H, Singh GJ. Small Tumor, Major Complication: A Case of Spontaneous Perinephric Hematoma From a Small Renal Angiomyolipoma. Cureus 2023; 15:e44761. [PMID: 37809192 PMCID: PMC10556976 DOI: 10.7759/cureus.44761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
A renal angiomyolipoma is a benign kidney tumor composed of muscle, fat, and blood vessels. It is the most common benign kidney tumor, and it affects women more frequently than men. Angiomyolipomas can be small and asymptomatic, or they can be large, presenting with symptoms such as discomfort, hematuria, and hypertension. Occasionally, the rupture of an angiomyolipoma can cause a perinephric hematoma. This case report discusses a patient who developed a spontaneous large perinephric hematoma alongside a small renal angiomyolipoma. Aneurysm was seen on imaging. Angioembolization was successfully used for treatment. We explore the significance of the presence or absence of an aneurysm in predicting the risk of hemorrhage, particularly in association with small lesions. Angioembolization is an excellent choice for treating angiomyolipomas associated with significant hematomas.
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Affiliation(s)
- Deepak Kumar
- Urology, All India Institute of Medical Sciences (AIIMS) Rishikesh, Rishikesh, IND
| | - Ankur Mittal
- Urology, All India Institute of Medical Sciences (AIIMS) Rishikesh, Rishikesh, IND
| | - Vikas Panwar
- Urology, All India Institute of Medical Sciences (AIIMS) Rishikesh, Rishikesh, IND
| | - Harkirat Talwar
- Urology, All India Institute of Medical Sciences (AIIMS) Rishikesh, Rishikesh, IND
| | - Gurpremjit J Singh
- Urology, All India Institute of Medical Sciences (AIIMS) Rishikesh, Rishikesh, IND
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9
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Hanaki T, Tokuyasu N, Yata S, Kishino M, Murakami Y, Shishido Y, Miyatani K, Kihara K, Matsunaga T, Yamamoto M, Sakamoto T, Hasegawa T, Fujiwara Y. Hepatectomy for massive hepatic necrosis after transcatheter arterial embolization hemostasis for hepatic hemorrhage following hepatic trauma: A case report. Clin Case Rep 2023; 11:e7888. [PMID: 37731968 PMCID: PMC10507280 DOI: 10.1002/ccr3.7888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
Key Clinical Message Although partial hepatic necrosis often occurs following endovascular treatment for bleeding associated with hepatic trauma, it is relatively rare that additional treatment is required. However, invasive procedures such as hepatic resection should sometimes be considered when infection occurs over massive hepatic necrosis. Abstract Although partial hepatic necrosis following endovascular treatment for bleeding associated with hepatic trauma is occasionally experienced, it is relatively rare for the necrotic area of the liver to require additional treatment. However, invasive procedures such as hepatic resection should sometimes be considered when infection occurs over massive hepatic necrosis.
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Affiliation(s)
- Takehiko Hanaki
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Naruo Tokuyasu
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Shinsaku Yata
- Department of Multidisciplinary Internal Medicine, Division of Radiology, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Mikiya Kishino
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Yuki Murakami
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Yuji Shishido
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Kozo Miyatani
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Kyoichi Kihara
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Tomoyuki Matsunaga
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Manabu Yamamoto
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Teruhisa Sakamoto
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Toshimichi Hasegawa
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, School of Medicine, Faculty of MedicineTottori UniversityYonagoJapan
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Minici R, Mercurio M, Guzzardi G, Venturini M, Fontana F, Brunese L, Guerriero P, Serra R, Piacentino F, Spinetta M, Zappia L, Costa D, Coppola A, Galasso O, Laganà D. Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients. Tomography 2023; 9:1660-1682. [PMID: 37736986 PMCID: PMC10514840 DOI: 10.3390/tomography9050133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability. METHODS In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury. RESULTS In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality. CONCLUSIONS Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Pasquale Guerriero
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy;
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Marco Spinetta
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Lorenzo Zappia
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Davide Costa
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - MGJR Research Team
- Magna Graecia Junior Radiologists Research Team, 88100 Catanzaro, Italy;
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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11
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Wycoff M, Hoag TP, Okeke RI, Culhane JT. Association of Time to Definitive Hemostasis With Mortality in Patients With Solid Organ Injuries. Cureus 2023; 15:e45401. [PMID: 37854760 PMCID: PMC10581328 DOI: 10.7759/cureus.45401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.
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Affiliation(s)
- Michaela Wycoff
- General Surgery, MercyOne Des Moines Medical Center, Des Moines, USA
| | - Thomas P Hoag
- General Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| | - Raymond I Okeke
- General Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| | - John T Culhane
- General Surgery, Saint Louis University School of Medicine, Saint Louis, USA
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Jang H, Jeong ST, Park YC, Kang WS. Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis. Medicina (Kaunas) 2023; 59:1492. [PMID: 37629782 PMCID: PMC10456831 DOI: 10.3390/medicina59081492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I2 = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I2 = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.
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Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Soon Tak Jeong
- Department of Physical Medicine and Rehabilitation, Ansanhyo Hospital, Ansan-si 15457, Republic of Korea;
| | - Yun Chul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Wu Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Republic of Korea
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13
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Das S, Prakash S, Singh S, Shaikh O, Balasubramanian G. Spontaneous Rectus Sheath Hematoma. Cureus 2023; 15:e44138. [PMID: 37753012 PMCID: PMC10519645 DOI: 10.7759/cureus.44138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Rectus sheath hematoma (RSH) is one of the surgical emergencies that mimics peritonitis or other causes of acute abdominal pain. It is usually seen in old age, post-trauma, anticoagulation therapy pregnancy, chronic cough, and liver disease. Nevertheless, RSHs can be spontaneous without any underlying predisposing factors. Here, we present a 51-year-old female with sudden onset abdominal pain, abdominal distention, hypotension, and severe pallor. After initial resuscitation, the patient underwent radiological imaging. This suggested an RSH with active bleeding from the inferior epigastric artery or profunda femoris artery. The patient underwent digital subtraction angiography and angioembolization of the profunda femoris branch. After a few days, the patient continued deteriorating and succumbed to acute respiratory distress syndrome (ARDS).
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Affiliation(s)
- Snehasis Das
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Sagar Prakash
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Shweta Singh
- Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Oseen Shaikh
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gopal Balasubramanian
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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14
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Abstract
Introduction Pelvic hematomas are a rare complication of prostatic urethral lift. We would like to report the first case of massive pelvic hematoma after prostatic urethral lift that was successfully managed by selective angioembolization. Case presentation An 83-year-old gentleman with benign prostatic hyperplasia underwent prostatic urethral lift. Although the procedure was uneventful, he developed shock while in the recovery room. Urgent contrast computed tomography scan showed a large heterogenous hematoma at the right pelvis extending to the right retroperitoneum with contrast extravasation noted. Urgent angiogram confirmed extravasation from the right prostatic artery. Angioembolization with coils and 33% N-butyl cyanoacrylate glue was successfully performed. Conclusion Prostatic urethral lift can be complicated by the rare massive pelvic hematoma, possibly more common in small prostates. With a prompt contrast computed tomography scan, pelvic hematomas can be managed with angioembolization first and hopefully prevent open exploratory surgery.
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Affiliation(s)
- Brian Sze Ho Ho
- Division of Urology, Department of SurgeryQueen Mary HospitalHong Kong
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15
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Pal AK, Kalra S, Sreenivasan SK, Dorairajan LN, Manikandan R, Sah SK. Management Outcomes of Large Renal Angiomyolipoma Presenting with Wunderlich Syndrome-Experience from a Tertiary Center. J Kidney Cancer VHL 2023; 10:21-28. [PMID: 37303946 PMCID: PMC10256953 DOI: 10.15586/jkcvhl.v10i2.265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/19/2023] [Indexed: 06/13/2023] Open
Abstract
Renal angiomyolipoma is an uncommon, benign-mixed mesenchymal tumor consisting of thick-walled blood vessels, smooth muscles, and mature adipose tissues. Twenty percent of these tumors are associated with tuberous sclerosis. Wunderlich syndrome (WS), an acute nontraumatic spontaneous perirenal hemorrhage, can be a presentation of large angiomyolipoma. This study evaluated the presentation, management, and complications of renal angiomyolipoma with WS in eight patients who presented to the emergency department between January 2019 and December 2021. The presenting symptoms included flank pain, palpable mass, hematuria, and bleeding in the perinephric space on computerized tomography. Demographic data, symptoms at presentation, comorbidities, hemodynamic parameters, the association with tuberous sclerosis, transfusion requirements, need for angioembolization, surgical management, Clavien-Dindo complication, duration of hospital stay, and 30-day readmission rates were evaluated. The mean age of presentation was 38 years. Of the eight patients, five (62.5%) were females and 3(37.5%) were males. Two (25%) patients had tuberous sclerosis with angiomyolipoma, and three (37.5%) patients presented with hypotension. The mean packed cell transfusion was three units, and the mean tumor size was 7.85 cm (3.5-25 cm). Three of them (37.5%) required emergency angioembolization to prevent exsanguination. Embolization was unsuccessful in one patient (33%) who underwent emergency open partial nephrectomy, and one (33%) patient developed post-embolization syndrome. A total of six patients underwent elective surgery-four underwent partial nephrectomy (laparoscopic - 1, robotic - 1, open - 2) and two underwent open nephrectomy. Three patients encountered Clavien-Dindo complications (Grade 1, n = 2 and IIIA, n = 2). WS is a rare, life-threatening complication in patients with large angiomyolipoma. Judicious optimization, angioembolization, and prompt surgical intervention will help deliver better outcomes.
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Affiliation(s)
| | - Sidhartha Kalra
- Author for correspondence: Sidhartha Kalra*, Department of Urology & Renal Transplantation, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), An Institute of National Importance, Govt. of India, JIPMER Campus Road, Gorimedu, Puducherry 605006, India.
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16
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Daché A, Fatica R, Herts BR, McLennan G, Remer EM, Haber GP, Ouzaid I. Factors predicting the active treatment of renal angiomyolipoma: 30 years of experience in two tertiary referral centers. Front Surg 2023; 10:1094806. [PMID: 37251582 PMCID: PMC10210137 DOI: 10.3389/fsurg.2023.1094806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/27/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction and objective This study aimed to identify clinical features representing predictive factors of active treatment (AT) compared to active surveillance (AS) for renal angiomyolipoma (AML). Patients and methods From 1990 to 2020, patients referred to two institutions for a renal mass and diagnosed with an AML based on typical features on CT were included in the analysis. The study population was divided into two groups based on the treatment received: active surveillance (AS) or active treatment (AT). Age, gender, tuberous sclerosis syndrome, tumor size, contralateral kidney disease, renal function, year of diagnosis, and symptoms at presentation were assessed as potential predictive factors of active treatment using a logistic regression model in univariate and multivariate analyses. Results In total, 253 patients (mean age 52.3 ± 15.7 years; 70% women; 70.9% incidentally diagnosed) were included in the analysis. One hundred and nine (43%) received AS, whereas 144 (57%) were actively treated. For univariate analysis, age, tuberous sclerosis complex syndrome, tumor size, symptoms at presentation, and contralateral kidney disease were found to be predictors of AT. Only tumor size (p < 0.001) and the year of diagnosis (p < 0.001) remained significant for multivariable analyses. The likelihood of being managed with AS evolved over the study period and was 50% and 75% when diagnosed before and after 2010, respectively. With respect to size, 4-cm and 6-cm tumors had a probability of 50% and 75% of being treated with AS, respectively. Conclusion The present analysis from a high-volume institution provides evidence that the management of renal masses with typical radiological features of AML has markedly changed over the last three decades with a trend toward AS over AT. Tumor size and the year of diagnosis were significant factors for the treatment strategies.
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Affiliation(s)
- Arnaud Daché
- Department of Urology, Bichat Claude Bernard Hospital, University Paris-Cité, Paris, France
| | - Richard Fatica
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, United States
| | - Brian R. Herts
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, United States
| | - Gordon McLennan
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, United States
| | - Erick M. Remer
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, United States
| | - Georges-Pascal Haber
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, United States
| | - Idir Ouzaid
- Department of Urology, Bichat Claude Bernard Hospital, University Paris-Cité, Paris, France
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17
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Safar O, Al-Qahtani A, Al-Qahtani S. Urinary Bladder Hemangioma Successfully Treated by Angioembolization with Long-Term Follow-Up: Case Report and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13050875. [PMID: 36900025 PMCID: PMC10001091 DOI: 10.3390/diagnostics13050875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Hemangiomas are benign blood vessel and capillary tumor growths which are widespread in many organs but extremely rare in the bladder, making up just 0.6% of all bladder tumors. To the best of our knowledge, few cases of bladder hemangioma are associated with pregnancy in the literature, and no bladder hemangiomas have been discovered incidentally after abortion. The use of angioembolization is well established; however, postoperative follow-up is crucial to identify tumor recurrence or residual disease. Case presentation: In 2013, a 38-year-old female was referred to a urology clinic with an incidental finding after an abortion of a large bladder mass identified incidentally using ultrasound (US). The patient was recommended for CT, which reported a polypoidal hypervascular lesion, as previously described arising from the urinary bladder wall. Diagnostic cystoscopy showed a large, bluish-red, pulsatile, vascularized submucosal mass with large dilated submucosal vessels, a wide-based stalk, and no active bleeding in the posterior wall of the urinary bladder, measuring about 2 × 3 cm, with negative urine cytology. Due to the vascular nature of the lesion and no active bleeding, the decision was made not to biopsy. The patient underwent angioembolization and scheduled for US every six months with regular diagnostic cystoscopy. In 2018, at 5 years of follow-up, the patient developed recurrence after a successful pregnancy. The angiography revealed recanalization of the previously embolized left superior vesical arteries from the anterior division of the left internal iliac artery, resulting in arteriovenous malformation (AVM). The second angioembolization was performed, with the total exclusion of AVM without residual. By the end of 2022, the patient had remained asymptomatic and without recurrence. Conclusion: Angioembolization is a safe treatment technique, minimally invasive, and has less effect on the quality of life, especially in young patients. Long-term follow-up is essential for detecting tumor recurrence or residual disease.
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Affiliation(s)
- Omar Safar
- Urology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte P.O. Box 101, Saudi Arabia
- Correspondence:
| | - Abdulhadi Al-Qahtani
- Urology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte P.O. Box 101, Saudi Arabia
| | - Saad Al-Qahtani
- Radiology Department, Armed Forces Hospitals Southern Region, Khamis Mushayte P.O. Box 101, Saudi Arabia
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18
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Yoo R, Gaziano MD, Cortes V, Chauhan N, Bamberger PK, Reilly EF, Geng T, Butts CA, Ong A. Distal Pancreatic Necrosis After Splenic Angioembolization. Am Surg 2023:31348231157839. [PMID: 36803024 DOI: 10.1177/00031348231157839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Pancreatic ischemia with necrosis is an extremely rare complication of splenic angioembolization (SAE). A 48-year-old male with a grade IV blunt splenic injury underwent angiography which demonstrated no active bleeding or pseudoaneurysm. Proximal SAE was performed. One week later, he developed severe sepsis. Repeat CT imaging showed nonperfusion of the distal pancreas, and laparotomy found necrosis of approximately 40% of the pancreas. Distal pancreatectomy and splenectomy were performed. He endured a prolonged hospital course with multiple complications. Clinicians should have a high index of suspicion for ischemic complications after SAE when sepsis develops.
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Affiliation(s)
- Rachel Yoo
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | | | - Vicente Cortes
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | - Nikunj Chauhan
- Department of Interventional Radiology, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | - Peter K Bamberger
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | - Eugene F Reilly
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | - Thomas Geng
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | - Christopher A Butts
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
| | - Adrian Ong
- Department of Surgery, Division of Acute Care Surgery/Trauma, Reading Hospital, 419713Tower Health System, Reading, PA, USA
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19
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Mbengue M, Bigirimana B, Diagne S, Niang A. Renal angiomyolipoma in tuberous sclerosis complex: Case series and literature review. Clin Nephrol Case Stud 2023; 11:29-34. [PMID: 36896137 DOI: 10.5414/CNCS110768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/30/2022] [Indexed: 03/07/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a genetic disease characterized by the growth of numerous noncancerous tumors in many parts of the body mainly the skin, brain, kidneys. The prevalence of the disease is estimated to be 7 - 12 in 100,000. We report the cases of two black African women diagnosed with TSC at age 25 and 54. They both had renal angiomyolipoma, facial angiofibroma and diffuse hypochromic macules. The older patient remained stable for the 11 years following her diagnosis. But, in the second patient, the disease was more severe with a giant angiomyolipoma, complicated by renal intracystic hemorrhage leading to the patient's death 1 month after diagnosis. Renal involvement can be life-threatening in patients with TSC. The risk of fatal bleeding increases with the size of the tumor. The mTOR inhibitors and angioembolization can improve the prognosis of this disease.
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20
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Muacevic A, Adler JR, Binyousef BH, Munshi A, AlMutawa AM, Alkhaibari R, Zia Z, Junaid I. Renal Angiomyolipoma Causing Inferior Vena Cava Thrombus in a Young Girl With Tuberous Sclerosis. Cureus 2023; 15:e33244. [PMID: 36741628 PMCID: PMC9890403 DOI: 10.7759/cureus.33244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/03/2023] Open
Abstract
Angiomyolipomas (AML), also known as hamartomas, are benign mesenchymal tumors of the kidneys which consist of vascular tissue, smooth muscles, and adipose tissue, with a higher prevalence in females than males. AML may be associated with tuberous sclerosis, and the growth of the mass may present as hematuria or flank pain. We present a case of a 14-year-old female patient who had a known case of tuberous sclerosis since early childhood. She has a history of numerous bilateral renal masses radiographically consistent with AML. A special and unique entity of our case is the age of presentation which is 14 years and the presence of TSC. In contrast to our case, which was invading the right renal vein and IVC at a young age, AML is well known for its benign nature. According to a recent literature review, the youngest patient reported was 16 years old. Typically, non-complicated AMLs less than 4 cm in size are managed by annual radiological imaging which is preferably a CT scan, while larger AMLs of more than 4 cm that present with perinephric hemorrhages or intralesional aneurysms are treated by partial nephrectomy or selective angioembolization. A radical nephrectomy and IVC thrombectomy are typically necessary due to the risks that the IVC thrombus carries as well as the AML itself and its unpredictable behavior. In cases like ours with the extension into the renal vein and IVC, the surgical approach is similar to the venous invasion of renal cell carcinomas.
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21
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Lata T, Peacock T, Limmer A, Tan JE, Wu S, Yeh D. Impact of inter-hospital transfer on success of angioembolization for lower gastrointestinal bleeding. ANZ J Surg 2022; 92:3242-3246. [PMID: 36117456 DOI: 10.1111/ans.18054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Angioembolization is a useful therapeutic tool for lower gastrointestinal bleeding (LGIB) however is only available at centres with specialist interventional radiology departments. Delay in angioembolization of greater than 120-150 minutes is associated with higher rates of non-therapeutic angioembolization. METHODS This retrospective review analysed the impact of interhospital transfer on timing and success of angioembolization in adults with LGIB. RESULTS Of the 121 patients who underwent CTMA at a peripheral hospital for LGIB, only 20.7% had positive CTMA (n = 25). Of the 24 patients who were transferred for the purpose of angioembolization, only five ultimately had successful embolisation (20.1%). Patients who had unsuccessful angioembolization had a significantly longer mean time from arrival at the tertiary hospital to angioembolization compared to patients who had successful angioembolization (mean 375 versus 175 min, P = 0.001). There was no association of patient haemodynamics, use of anticoagulant or antiplatelet therapy, and transfusion requirement with success of angioembolization. CONCLUSION Interhospital transfer is associated with delay in angioembolization. Delay after arrival at the receiving hospital is associated with unsuccessful angioembolization.
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Affiliation(s)
- Tahmina Lata
- Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Timothy Peacock
- Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Alexandra Limmer
- Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ju-En Tan
- Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Sara Wu
- Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Dean Yeh
- Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
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22
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McDonogh JM, Lewis DP, Tarrant SM, Balogh ZJ. Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:931-939. [PMID: 34991126 PMCID: PMC9038232 DOI: 10.1097/ta.0000000000003528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/15/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemodynamically unstable pelvic fracture patients are challenging to manage. Preperitoneal packing (PPP) and angioembolization (AE) are two interventions commonly used to help gain hemorrhage control. Recently, there has been a tendency to support PPP in hemodynamically unstable pelvic fracture seemingly in direct comparison with AE. However, it seems that key differences between published cohorts exist that limits a comparison between these two modalities. METHODS A systematic literature search of the MEDLINE, CINAHL, and EMBASE databases was conducted. Prospective and retrospective studies were eligible. No limitation was placed on publication date, with only manuscripts printed in English eligible (PROSPERO CRD42021236219). Included studies were retrospective and prospective cohort studies and a quasirandomized control trial. Studies reported demographic and outcome data on hemodynamically unstable patients with pelvis fractures that had either PPP or AE as their initial hemorrhage control intervention. The primary outcome was in-hospital mortality rate. Eighteen studies were included totaling 579 patients, of which 402 were treated with PPP and 177 with AE. RESULTS Significant differences were found between AE and PPP in regard to age, presence of arterial hemorrhage, Injury Severity Score, and time to intervention. The crude mortality rate for PPP was 23%, and for AE, it was 32% (p = 0.001). Analysis of dual-arm studies showed no significant difference in mortality. Interestingly, 27% of patients treated with PPP did not get adequate hemorrhage control and required subsequent AE. CONCLUSION Because of bias, heterogeneity, and inadequate reporting of physiological data, a conclusive comparison between modalities is impossible. In addition, in more than a quarter of the cases treated with PPP, the patients did not achieve hemorrhage control until subsequent AE was performed. This systematic review highlights the need for standardized reporting in this high-risk group of trauma patients. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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23
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Heidorn EF, Xiao G, Sacks D, Moshkovsky F. Resection for Chronic Hepatic Abscess due to Infected Embolization Coils After Liver Injury. Am Surg 2022:31348221091942. [PMID: 35483376 DOI: 10.1177/00031348221091942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Liver injuries after blunt abdominal trauma are very common. Non-operative approaches to management are now the standard of care for many patients with up to and including grade V liver injuries. However, the long-term complications associated with coil embolization can be challenging to manage. We present the case of a 29-year-old male who presented with a chronic liver abscess which contained the coils following embolization of a grade IV liver injury and the subsequent transhepatic embolization of the pseudoaneurysm. In addition, the patient developed a fistula draining the abscess through the previously placed drain site that traversed the diaphragm. A multidisciplinary discussion was held between trauma surgery, hepatobiliary surgery, thoracic surgery, and interventional radiology to discuss the best treatment plan. The patient subsequently underwent liver resection, fistula tract resection, and diaphragm repair. This case presents a definitive management strategy for these complex patients.
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Affiliation(s)
- Elise F Heidorn
- Department of Surgery, Tower Health, 6823Reading Hospital, Reading, PA, USA
| | - Gary Xiao
- Department of Surgery, 419713Tower Health, Reading, PA, USA
| | - David Sacks
- Department of Interventional Radiology, Tower Health, 6823Reading Hospital, Reading, PA, USA
| | - Filip Moshkovsky
- Department of Trauma Surgery, Tower Health, 6823Reading Hospital, Reading, PA, USA
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24
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Nam IC, Won JH, Kim S, Bae K, Jeon KN, Moon JI, Cho E, Park JE, Jang JY, Park SE. Transcatheter Arterial Embolization for Spontaneous Hepatic Rupture Associated with HELLP Syndrome: A Case Report. Medicina (Kaunas) 2021; 57:medicina57101055. [PMID: 34684092 PMCID: PMC8538371 DOI: 10.3390/medicina57101055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 11/16/2022]
Abstract
Background: Spontaneous hepatic rupture associated with the syndrome characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome) is a rare and life-threatening condition, and only a few cases regarding the management of this condition through transcatheter arterial embolization (TAE) have been previously reported. Case summary: Herein, we report a case involving a 35-year-old pregnant woman who presented at 28 weeks of gestation with right upper quadrant pain, hypotension, and elevated levels of liver enzymes. Transabdominal ultrasound revealed fetal death. She required an emergency cesarean section, and hepatic rupture was identified after the fetus had been delivered. Hepatic packing and TAE were performed. The postprocedural course was uneventful, and the patient was discharged 14 days after she had been admitted to our hospital. Conclusions: Spontaneous hepatic rupture associated with HELLP syndrome is a very serious condition that requires prompt and decisive management. The high maternal and fetal mortality rates associated with this condition can be reduced through early accurate diagnosis and adequate management. The findings in the reported case indicate that TAE may be an attractive alternative to surgery for the management of spontaneous hepatic rupture associated with HELLP syndrome.
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Affiliation(s)
- In-Chul Nam
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
| | - Jung-Ho Won
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju 52727, Korea;
| | - Sungbin Kim
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
| | - Kyungsoo Bae
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
| | - Kyung-Nyeo Jeon
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
| | - Jin-Il Moon
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
| | - Eun Cho
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
| | - Ji-Eun Park
- Department of Obstetrics and Gynecology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Jae-Yool Jang
- Department of General Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Sung-Eun Park
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon 51472, Korea; (I.-C.N.); (S.K.); (K.B.); (K.-N.J.); (J.-I.M.); (E.C.)
- Correspondence: ; Tel.: +82-55-214-3145
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25
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Malik AR, Ali S, Kumar V, Sharma M, Rawat V, Agarwal A. Outcome of simultaneous angioembolization and nephron sparing surgery in large renal angiomyolipomas. Urologia 2021; 89:500-505. [PMID: 34346257 DOI: 10.1177/03915603211036428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To study the outcome of simultaneous angioembolization and nephron sparing surgery in large renal angiomyolipomas. MATERIALS AND METHODS A prospective study of carried out from 2016 to 2019. A total of 15 patients were included in the study with a lesion (angiomyolipoma) more than 10 cm in size, suitable for nephron sparing surgery. The workup of the patients included history, baseline blood investigations, ultrasonography, and CT urography including angiographic films. All the patients were taken up for selective of angioembolization of the feeding vessels of the AML carried out by the interventional radiologist followed by nephron sparing surgery in the same sitting. The short term outcomes studied were warm ischemia time, average blood loss, and length of post-operative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen and functional outcome by assessing the function of the preserved renal parenchyma. RESULTS Twelve out of fifteen cases were female. The mean age was 42.25 years. All the patients had lesion more than 10 cm with seven tumors located at the lower pole, four at mid-pole, and four at upper pole. Eight patients had low complexity score on RENAL score (i.e. 4-6), five patients medium complexity score (i.e. 7-9), and two had high complexity score (i.e. ⩾10). Average blood loss was 200 ml, warm ischemia time was 18.46 min and postoperative stay was 3.55 days. All the 15 specimens sent for histopathology were confirmed as AML (angiomyolipomas) with margins free of tumor. Follow up CECT done at 4 months postoperatively revealed functioning residual renal parenchyma with prompt excretion of contrast. CONCLUSION Large AML's are also amenable to nephron sparing surgery. However patient should always be warned about the possibility of total nephrectomy. Selective angioembolization helps in reducing the blood supply and risk of torrential bleeding thus facilitates in the removal of the tumor and increasing the chances of nephron sparing surgery.
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Affiliation(s)
| | | | | | | | - Vijay Rawat
- Indraprastha Apollo Hospital, New Delhi, India
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26
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Yashavanth HS, Jagtap N, Singh JR, Ramchandani M, Lakhtakia S, Tandan M, Gupta R, Vamsi M, Bhaware B, Rao GV, Reddy DN. Hemosuccus Pancreaticus: A systematic approach. J Gastroenterol Hepatol 2021; 36:2101-2106. [PMID: 33445212 DOI: 10.1111/jgh.15404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/27/2020] [Accepted: 01/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management. METHODS We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019. RESULTS Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7 ± 11.7 years with 89.7% men. Median duration of bleeding before diagnosis was 10 days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12 months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post-endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%. CONCLUSIONS Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases.
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Affiliation(s)
- H S Yashavanth
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jagadeesh Rampal Singh
- Department of Interventional Radiology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manu Tandan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Gupta
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Vamsi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Bhushan Bhaware
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - G V Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D N Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Al-Thani H, Abdelrahman H, Barah A, Asim M, El-Menyar A. Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center. Ther Clin Risk Manag 2021; 17:333-343. [PMID: 33907407 PMCID: PMC8064722 DOI: 10.2147/tcrm.s303518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center. Methods We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry. Results A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%. Conclusion Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma&Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ali Barah
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
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28
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Murao S, Yamakawa K, Kabata D, Kinoshita T, Umemura Y, Shintani A, Fujimi S. Effect of Earlier Door-to-CT and Door-to-Bleeding Control in Severe Blunt Trauma: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10071522. [PMID: 33917338 PMCID: PMC8038745 DOI: 10.3390/jcm10071522] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023] Open
Abstract
Blunt trauma is a potentially life-threatening injury that requires prompt diagnostic examination and therapeutic intervention. Nevertheless, how impactful a rapid response time is on mortality or functional outcomes has not been well-investigated. This study aimed to evaluate effects of earlier door-to-computed tomography time (D2CT) and door-to-bleeding control time (D2BC) on clinical outcomes in severe blunt trauma. This was a single-center, retrospective cohort study of patients with severe blunt trauma (Injury Severity Score > 16). To assess the effect of earlier D2CT and D2BC on clinical outcomes, we conducted multivariable regression analyses with a consideration for nonlinear associations. Among 671 patients with severe blunt trauma who underwent CT scanning, 163 patients received an emergency bleeding control procedure. The median D2CT and D2BC were 19 min and 57 min, respectively. In a Cox proportional hazard regression model, earlier D2CT was not associated with improved 28-day mortality (p = 0.30), but it was significantly associated with decreased mortality from exsanguination (p = 0.003). Earlier D2BC was significantly associated with improved 28-day mortality (p = 0.026). In conclusion, earlier time to a hemostatic procedure was independently associated with decreased mortality. Meanwhile, time benefits of earlier CT examination were not observed for overall survival but were observed for decreased mortality from exsanguination.
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Affiliation(s)
- Shuhei Murao
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
- Department of Emergency Medicine, Osaka Medical College, Takatsuki 569-8686, Japan
- Correspondence: ; Tel.: +81-6-6692-1201; Fax: +81-6-6692-1155
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Takahiro Kinoshita
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita 565-0871, Japan;
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
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29
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Joh D, Sharma M, Taj M, Surani S. An infrequently encountered case of spontaneous subcapsular liver hematoma with hepatic artery pseudoaneurysm. J Community Hosp Intern Med Perspect 2021; 11:81-84. [PMID: 33552423 PMCID: PMC7850349 DOI: 10.1080/20009666.2020.1821468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Hepatic artery pseudoaneurysm (HAP) is a rare complication of liver trauma and liver transplant, and spontaneous subcapsular liver hematoma is not frequently encountered outside the setting of preeclampsia and hemolysis, elevated liver enzyme and low platelet (HELLP) syndrome. We report a rare case of spontaneous subcapsular liver hematoma with hepatic artery pseudoaneurysm without any apparent liver trauma or recent interventional procedures of the hepatobiliary system. Although subcapsular hepatic hematoma and HAP are uncommon diagnoses, clinicians should be aware of these diagnoses to promptly diagnose and effectively treat them. Clinicians should also not forget these diseases could be masked by other common etiologies, such as gastritis.
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Affiliation(s)
- Daniel Joh
- Department of Internal Medicine, Corpus Christi Medical Center - Bay Area, Corpus Christi, TX, USA
| | - Munish Sharma
- Department of Pulmonary Medicine, Corpus Christi Medical Center, Corpus Christi, TX, USA
| | - Mehrunissa Taj
- Department of Nursing, John Hopkins University School of Nursing, Baltimore, MD, USA
| | - Salim Surani
- Department of Internal Medicine, Corpus Christi Medical Center - Bay Area, Corpus Christi, TX, USA.,Department of Pulmonary Medicine, Corpus Christi Medical Center, Corpus Christi, TX, USA.,Department of Internal Medicine, University of North Texas, Dallas, TX, USA
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30
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Keshmiri MS, Shafaghi S, Sharif-Kashani B, Sadoughi A, Ghorbani F, Naghashzadeh F, Abedini A. Preemptive non-selective bronchial artery angioembolization to reduce recurrence rate of hemoptysis. Multidiscip Respir Med 2020; 15:723. [PMID: 33456774 PMCID: PMC7802011 DOI: 10.4081/mrm.2020.723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/30/2020] [Indexed: 11/23/2022] Open
Abstract
Background Massive hemoptysis which is presented in advanced lung diseases is a life-threatening condition. Bronchial artery embolization as a minimally invasive procedure is the treatment of choice either in first or recurrent hemoptysis. This study aimed to assess the early and late efficacy of bronchial angioembolization (BAE) without microcatheter. Methods In this prospective cohort study, all patients with hemoptysis who had undergone BAE from August 2018 to March 2019 were included. Angiographic patterns including bleeding sources, number of involved vessels, the underlying etiology, and recurrence rate were evaluated in a one-year follow up. Results 153 patients were included with mean age of 55 ±16 years. 68% of them were male and 58% had life-threatening massive hemoptysis. Three distinct angiographic patterns were recognized. The culprit bleeding vessel was bronchial in 126 (92%), intercostal in 4 (3%), and both vessels in 7 (5%) of cases (p<0.05). One vessel involvement was seen in 56 patients; however it was observed in 69% of non-cystic fibrosis lobar bronchiectasis patients. In 1, 3 and 12 months follow up, recurrent hemoptysis was reported in 15 (11%), 4 (2.5%), and 24 (15.5%), respectively. In 52% of cases, no abnormal vessels were observed during aorta injection, but culprit bronchial or intercostal arteries were found in selective investigational angiography. Conclusion BAE was successful in the control of hemoptysis and resulted in a low rate of recurrence in different types of lung diseases. This could be due to the embolization of all pathological arteries found during angiography which might have prevented recurrent bleeding.
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Affiliation(s)
- Mohammad Sadegh Keshmiri
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shadi Shafaghi
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Sharif-Kashani
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Sadoughi
- Divisions of Pulmonary and Critical Care, Albert Einstein College of Medicine, New York, USA
| | - Fariba Ghorbani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Farah Naghashzadeh
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atefeh Abedini
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.
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Affiliation(s)
- Ali Cadili
- Department of Surgery, University of Connecticut, CT, USA
| | - Jonathan Gates
- Department of Surgery, University of Connecticut, CT, USA
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32
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Abstract
Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm.
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Affiliation(s)
- Kim E M Benders
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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33
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Marmor M, El Naga AN, Barker J, Matz J, Stergiadou S, Miclau T. Management of Pelvic Ring Injury Patients With Hemodynamic Instability. Front Surg 2020; 7:588845. [PMID: 33282907 PMCID: PMC7688898 DOI: 10.3389/fsurg.2020.588845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/12/2020] [Indexed: 12/28/2022] Open
Abstract
Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.
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Affiliation(s)
- Meir Marmor
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ashraf N El Naga
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jordan Barker
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jacob Matz
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | | | - Theodore Miclau
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
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34
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Desai D, Ong M, Lah K, Clouston J, Pearch B, Gianduzzo T. Outcome of angioembolization for blunt renal trauma in haemodynamically unstable patients: 10-year analysis of Queensland public hospitals. ANZ J Surg 2020; 90:1705-1709. [PMID: 32783322 DOI: 10.1111/ans.16204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/10/2020] [Accepted: 07/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of the study was to evaluate whether angioembolization is an appropriate alternative method for the management of blunt renal trauma in haemodynamically unstable patients. METHODS A retrospective analysis was conducted from 2002 to 2012 at three tertiary trauma hospitals in the state of Queensland. Patients who had blunt renal trauma and underwent renal angioembolization or had a trauma nephrectomy were identified using patient records and operating theatre and interventional radiology databases. The inclusion criteria were - haemodynamically unstable patients with blunt renal trauma treated with angioembolization, above the age of 16 years. Patients who underwent angioembolization for other causes such as: penetrating renal trauma, post-procedure, renal tumours, renal angiomyolipomas or arteriovenous malformations were excluded. Patients below the age of 16 were also excluded. Post-embolization renal function, blood pressure, morbidity and mortality were analysed using the paired t2 test. RESULTS A total of 668 renal trauma patients were identified during this period. Sixteen patients underwent angioembolization for blunt renal trauma. Post-procedure renal function normalized without any hypertension with the median follow up being 4 months. Four patients had post-embolization complications including a urinoma, two devascularized kidneys and one ureteric stricture requiring nephrectomy. There was no mortality. CONCLUSION Selective angioembolization, where feasible, is an alternative method in the management of haemodynamically stable patients with blunt renal trauma maximizing nephron sparing and producing acceptable long-term outcomes with avoidance of the morbidity of trauma nephrectomy. This is the first study that we know of in Australia analysing the outcome of angioembolization for blunt renal trauma.
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Affiliation(s)
- Devang Desai
- Department of Urology, Toowoomba Hospital, Toowoomba, Queensland, Australia.,Interventional Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michelle Ong
- Department of Urology, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Kevin Lah
- Interventional Radiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - John Clouston
- Interventional Radiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Ben Pearch
- Interventional Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Troy Gianduzzo
- Interventional Radiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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35
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Kurahachi T, Hashizume N, Asagiri K, Asakawa T, Tanaka H, Yoshida M, Tsuru T, Yagi M. The management and outcome of pediatric blunt chest-abdominal injuries. Pediatr Int 2020; 62:834-839. [PMID: 32048772 DOI: 10.1111/ped.14195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 01/08/2020] [Accepted: 02/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to determine the frequency and nature of pediatric blunt chest-abdominal injuries (BCAIs) and to summarize their management, ranging from non-operative management (NOM), with or without angioembolization (AE), to surgical treatment. METHODS This retrospective study included patients admitted to our hospital for BCAIs from January 1996 to December 2017. The age, injury pattern, organs of injury, outcome, and treatment were summarized. RESULTS One hundred and thirty-two patients (98 males, 34 females, mean age 7.68 years ± 3.58, range 1-15 years) were included in the study. Their injuries resulted from motor-vehicle traffic incidents (n = 60), single-bicycle injuries (n = 16), falls (n = 33), sports (n = 10), assault (n = 6), abuse (n = 3), and others (n = 4). There were no injured organs in 31 cases, while there were 130 injured organs in 101 cases, including the liver (n = 42), spleen (n = 35), lung (n = 23), kidney (n = 13), intestine (n = 10), pancreas (n = 5), and adrenal gland (n = 2). Angiography (AG) was performed in 20 cases, and NOM with AE was performed in 16 cases, including 17 organs (liver injury [n = 9], splenic injury [n = 5], and kidney injury [n = 4]). Surgical treatment was performed in eight cases (splenic injury in one, pancreas injury in one, and intestinal injury in six). NOM without AE was performed in the other cases. CONCLUSIONS The management of organ injury must take into consideration the management of integrated bleeding. It is recommended that children with severe organ injury are treated in dedicated trauma centers in which AE is available.
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Affiliation(s)
- Tomohiro Kurahachi
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Naoki Hashizume
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan.,Department of Pediatric Surgery, Kurume University School of Medicine Japan, Kurume, Fukuoka, Japan
| | - Kimio Asagiri
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Takahiro Asakawa
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Hiroaki Tanaka
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Motomu Yoshida
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Tomomitsu Tsuru
- Department of Pediatric Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine Japan, Kurume, Fukuoka, Japan
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Dreizin D, Zhou Y, Chen T, Li G, Yuille AL, McLenithan A, Morrison JJ. Deep learning-based quantitative visualization and measurement of extraperitoneal hematoma volumes in patients with pelvic fractures: Potential role in personalized forecasting and decision support. J Trauma Acute Care Surg 2020; 88:425-433. [PMID: 32107356 PMCID: PMC7830753 DOI: 10.1097/ta.0000000000002566] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Admission computed tomography (CT) is a widely used diagnostic tool for patients with pelvic fractures. In this pilot study, we hypothesized that pelvic hematoma volumes derived using a rapid automated deep learning-based quantitative visualization and measurement algorithm predict interventions and outcomes including (a) need for angioembolization (AE), pelvic packing (PP), or massive transfusion (MT), and (b) in-hospital mortality. METHODS We performed a single-institution retrospective analysis of 253 patients with bleeding pelvic fractures who underwent admission abdominopelvic trauma CT between 2008 and 2017. Included patients had hematoma volumes of 30 mL or greater, were 18 years and older, and underwent contrast-enhanced CT before surgical or angiographic intervention. Automated pelvic hematoma volume measurements were previously derived using a deep-learning quantitative visualization and measurement algorithm through cross-validation. A composite dependent variable of need for MT, AE, or PP was used as the primary endpoint. The added utility of hematoma volume was assessed by comparing the performance of multivariable models with and without hematoma volume as a predictor. Areas under the receiver operating characteristic curve (AUCs) and sensitivities, specificities, and predictive values were determined at clinically relevant thresholds. Adjusted odds ratios of automated pelvic hematoma volumes at 200 mL increments were derived. RESULTS Median age was 47 years (interquartile range, 29-61), and 70% of patients were male. Median Injury Severity Score was 22 (14-36). Ninety-four percent of patients had injuries in other body regions, and 73% had polytrauma (Injury Severity Score, ≥16). Thirty-three percent had Tile/Orthopedic Trauma Association type B, and 24% had type C pelvic fractures. A total of 109 patients underwent AE, 22 underwent PP, and 53 received MT. A total of 123 patients received all 3 interventions. Sixteen patients died during hospitalization from causes other than untreatable (abbreviated injury scale, 6) head injury. Variables incorporated into multivariable models included age, sex, Tile/Orthopedic Trauma Association grade, admission lactate, heart rate (HR), and systolic blood pressure (SBP). Addition of hematoma volume resulted in a significant improvement in model performance, with AUC for the composite outcome (AE, PP, or MT) increasing from 0.74 to 0.83 (p < 0.001). Adjusted unit odds more than doubled for every additional 200 mL of hematoma volume. Increase in model AUC for mortality with incorporation of hematoma volume was not statistically significant (0.85 vs. 0.90, p = 0.12). CONCLUSION Hematoma volumes measured using a rapid automated deep learning algorithm improved prediction of need for AE, PP, or MT. Simultaneous automated measurement of multiple sources of bleeding at CT could augment outcome prediction in trauma patients. LEVEL OF EVIDENCE Diagnostic, level IV.
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Affiliation(s)
- David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Yuyin Zhou
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University
| | - Tina Chen
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Guang Li
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Alan L. Yuille
- Department of Computer Science, Head, Center for Cognition Vision and Learning, Johns Hopkins University
| | - Ashley McLenithan
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan J. Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Abstract
Lower gastrointestinal bleeding (LGIB) is a common entity encountered by the surgeon. Though most LGIB stops on its own, familiarity with the diagnoses and their treatments is critical to optimal patient care. Even in 2016, surgery may be required. Advances in imaging have led to an enhanced ability to localize bleeding. Newer anticoagulants have developed which provide ease of use to the patient, but challenges to caregivers when bleeding arises.
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Affiliation(s)
- Laura Greco
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Pennsylvania
| | - Jeanette Zhang
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Pennsylvania
| | - Howard Ross
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Pennsylvania
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Self D, Reece M, Dilernia S. Predicting the need for transfer and interventional angiography for patients with acute colonic haemorrhage in a regional setting. ANZ J Surg 2019; 89:E109-E112. [PMID: 30856681 DOI: 10.1111/ans.15064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 11/07/2018] [Accepted: 12/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Radiological angioembolization is an important strategy in management of acute colonic bleeding. Due to requirement for specialized interventional radiology, many hospitals rely on transfer for this service. This study aimed to identify patient and clinical factors associated with positive (blush) computed tomography mesenteric angiogram (CTMA) or need for invasive angiography. The secondary aim was to identify a patient population who may forego transfer and be safely managed in a regional centre. METHODS All presentations to Central Coast Local Health District with colonic bleeding from June 2013-June 2017 were included. A guideline for transfer of patients with positive CTMA from Central Coast Local Health District to Royal North Shore Hospital had been established prior to the study period. Demographics, medical background, transfusion requirement, presentation details and mortality data were collected on all patients. RESULTS Of 2378 patients presenting with colonic bleeding, 71 of 247 patients investigated with CTMA had a blush. Forty-six patients were transferred to Royal North Shore Hospital. Of these, 28 proceeded to interventional angiography with 19 undergoing angioembolization. Acute transfusion ≥5 units (odds ratio 6.78, P < 0.01) was the only significant predictor of needing interventional angiography. There was no association between age, bleeding site (right or left), use of antiplatelet or anticoagulation, diverticular disease or chronic kidney disease and identification of arterial bleeding on interventional angiography. There was no mortality or significant procedure-related morbidity. CONCLUSION A patient's medical background demonstrates a lack of correlation to identification of active bleeding on interventional angiography. Patients requiring ≥5 units blood transfusion should be considered for transfer and interventional angiography.
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Affiliation(s)
- Duncan Self
- Department of General Surgery, Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Mifanwy Reece
- Department of General Surgery, Concord Repatriation Hospital, Sydney, New South Wales, Australia
| | - Shannon Dilernia
- Department of General Surgery, Central Coast Local Health District, Gosford, New South Wales, Australia
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Yanagi M, Suzuki Y, Hamasaki T, Mizunuma K, Arai M, Yokota H, Murata S, Kondo Y, Nishimura T. Early Transcatheter Arterial Embolization for the American Association for the Surgery of Trauma Grade 4 Blunt Renal Trauma in Two Institutions. J NIPPON MED SCH 2018; 85:204-207. [PMID: 30259888 DOI: 10.1272/jnms.jnms.2018_85-31] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the efficacy of early transcatheter arterial embolization for hemodynamically stable patients with The American Association for the Surgery of Trauma (AAST) grade 4 blunt renal trauma. MATERIALS AND METHODS The medical records of consecutive patients with grade 4 blunt renal trauma who were transported to our two critical care centers in Japan and treated with early transcatheter arterial embolization (TAE) between 2001 and 2013 were retrospectively reviewed. Treatment failure was defined as the need for further surgical intervention or re-embolization after initial embolization. We divided these cases into two groups, a group who survived and a group who died, investigating the factors that led to death. RESULTS Seventeen patients underwent early TAE, with an average time between presentation and embolization for renal trauma of 125 minutes (66-214 minutes). There was no case of treatment failure. Three of the patients died, but none solely because of renal injury. Significant factors associated with patient death were the number of concomitant injured organs (p=0.04), the presence of pelvic fractures (p<0.01), and the presence of visceral injuries (p<0.01). The presence of lumber fractures (p=0.09) also tended to be associated with patient death. CONCLUSIONS Early TAE is an effective treatment and should be actively performed for hemodynamically stable patients with grade 4 blunt renal injuries without multiple concomitant organ injuries.
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Affiliation(s)
- Masato Yanagi
- Department of Urology (Chief: Y. Suzuki), Nippon Medical School Chiba Hokusoh Hospital.,Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | - Yasutomo Suzuki
- Department of Urology (Chief: Y. Suzuki), Nippon Medical School Chiba Hokusoh Hospital.,Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | - Tsutomu Hamasaki
- Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | | | - Masatoku Arai
- Department of Emergency and Critical Care Medicine, (Chairman and Professor: H. Yokota), Nippon Medical School
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, (Chairman and Professor: H. Yokota), Nippon Medical School
| | - Satoru Murata
- Department of Radiology (Chairman and Professor: S. Kumita), Nippon Medical School
| | - Yukihiro Kondo
- Department of Urology (Chairman and Professor: Y. Kondo), Nippon Medical School
| | - Taiji Nishimura
- Department of Urology (Chief: S. Kurita), Tachikawa Sogo Hospital
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Chavali JSS, Bertolo R, Kara O, Garisto J, Mouracade P, Nelson RJ, Dagenais J, Kaouk JH. Renal Arterial Pseudoaneurysm After Partial Nephrectomy: Literature Review and Single-Center Analysis of Predictive Factors and Renal Functional Outcomes. J Laparoendosc Adv Surg Tech A 2018; 29:45-50. [PMID: 30300074 DOI: 10.1089/lap.2018.0364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Partial nephrectomy (PN) represents the current surgical standard for T1 tumors. Renal arterial pseudoaneurysm is a rare but potentially life-threatening complication reported after PN. The aim of this study was to identify the factors associated with the occurrence of pseudoaneurysm after PN, specifically focusing on those requiring management with selective embolization. A literature review of the topic was performed. METHODS A retrospective review of the institutional PN database was performed from January 2011 to December 2016. Patients who underwent embolization for pseudoaneurysm represented a separated cohort to be compared with other patients (controls). Patients' and tumors' characteristics were considered. Univariable and multivariable analyses were used to test their eventual association with the occurrence of pseudoaneurysm. RESULTS A total of 1417 cases were evaluated. At a median of 21 days (interquartile range = 10-34), 20 patients (1.4%) developed postoperative pseudoaneurysm. The majority of patients (70%) presented with gross hematuria. The clinical suspicion was confirmed by contrast-enhanced computed tomography scan with angiography. Selective embolization was performed using endovascular coils. Technical success and clinical success rates were 100% and 95%, respectively. No difference was found in percentage estimated glomerular filtration rate (eGFR) preserved between patients who underwent embolization versus controls (median 82.6% versus 86.3%, P = .35). No differences in age, baseline renal function (as assessed by glomerular filtration rate [GFR]), tumor size, and R.E.N.A.L. were found between patients who reported and did not report pseudoaneurysm. In patients who developed pseudoaneurysm, longer operative time (225.6 minutes versus 193 minutes, P = .04), and cold ischemia time (48 minutes versus 29 minutes, P = .03) were reported. CONCLUSION In our series, the occurrence of pseudoaneurysm was associated with longer operative and cold ischemia times. In patients who underwent selective embolization, renal function remained comparable with that of controls.
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Affiliation(s)
- Jaya Sai S Chavali
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Riccardo Bertolo
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Onder Kara
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Juan Garisto
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pascal Mouracade
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ryan J Nelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Julien Dagenais
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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Azeemuddin M, Sayani R, Turab N, Mustahsan SM, Hasan M, Khan DB, Mubarak F. Institutional Review of Hemorrhagic Pelvic Emergencies Effectively Managed with Percutaneous Arterial Embolization. Cureus 2018; 10:e2194. [PMID: 29662732 PMCID: PMC5898841 DOI: 10.7759/cureus.2194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Our aim was to review the results of pelvic arterial embolization (PAE) performed in the interventional radiology suite. METHOD The data of all patients in whom pelvic angioembolization was performed was collected from July 2011 to June 2017. Procedures were performed by an experienced interventional radiologist. The clinical and laboratory data, as well as the outcome data, were obtained from the medical records of our hospital. The following parameters were collected for each patient, including the age, gender, presenting symptoms, site of bleeding, catheters used for embolization, material used for embolization, previous computed tomography (CT) scan and/or focused assessment with sonography for trauma (FAST) ultrasound, average hemoglobin before the procedure, and patient clinical status on discharge. RESULT A total of 37 patients underwent pelvic angiography for acute hemorrhage at our institution. They had contrast blush, active extravasation, or abnormal vascularity from the branches of the internal iliac artery and underwent therapeutic transcatheter embolization. A total of 29 patients (78.3%) were male and 8 (21.7%) were female. The average age was 30.0 years (range: 6-90 year). Of these, 16 patients (43.2%) presented with road traffic accidents (RTAs), six with gunshot injuries (16.2%), six with iatrogenic injuries (16.2%), four with a history of a fall (10.8%), two with bomb blast injuries (5.4%), one with a history of a glass injury (2.7%), one had a history of a roof falling on her during an earthquake, and one patient had a pelvic pseudoaneurysm secondary to an abscess. The type of embolic material used for embolization included coils in 16 patients, polyvinyl alcohol (PVA) particles were used in eight patients, both PVA particles and coils were used in 11 patients, and glue was used in one patient. All were successfully embolized. Thirty-four were discharged while three patients expired during the course of hospital stay due to other coexisting morbidities. CONCLUSION The management of pelvic injuries has always been a topic of debate, with multiple methods reported to date but growing evidence supports the use of pelvic arterial embolization in hemorrhagic pelvic injuries. The formulation of a standardized protocol is the need of the day.
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Affiliation(s)
| | - Raza Sayani
- Department of Radiology, The Aga Khan University, Karachi
| | - Nauman Turab
- Radiology Department, Dow University of Health Sciences (DUHS), Karachi, Pakistan
| | | | | | - Dawar B Khan
- Department of Radiology, The Aga Khan University, Karachi
| | - Fatima Mubarak
- Department of Radiology, The Aga Khan University, Karachi
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Velez SE. [Simultaneous organ angioembolization in nonoperative treatment strategy of blunt abdominal trauma]. Rev Fac Cien Med Univ Nac Cordoba 2017; 74:207-13. [PMID: 29890095 DOI: 10.31053/1853.0605.v74.n3.14483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 12/05/2016] [Indexed: 11/21/2022] Open
Abstract
Background nonoperative treatment (TNO) is suggested in blunt abdominal trauma in stable patients without necessarily addressing surgical trauma injuries. Among the tools used, it has highlighted the angioembolization as a method of stopping bleeding or potentially bleeding lesions. The existence of more than one lesion may be possible to treat this way. Objectives: to show the experience of a hospital emergency department in the use of angioembolization in nonoperative management of more than one injured abdominal organ. Demonstrate utility of simultaneous angioembolization of more than one vascular territory or organ in the management of patients with blunt abdominal trauma who start a nonoperative treatmeant. Design: Retrospective observational study Methods: Between 2007 and 2014, patients with blunt abdominal trauma and active hemorrhage or potentially bleeding lesions demonstrated by computed tomography (CT) were evaluated. Those who underwent nonoperative treatment and embolized were included. Of these, those with more than one organ or vascular territory embolized were described. Results: 392 patients were admitted with blunt abdominal trauma. Of these, 281 (72 %) started TNO protocol. 225 with active bleeding on CT were found. 183 patients (80 %) underwent angiography and 166 need embolization. In 7 cases embolization of more than one organ or vascular territory was performed. Conclusion: angioembolization of organ with active bleeding is definitely accepted practice in trauma centers. The opportunity and need for more than one organ embolization or vascular territory is scarce, but it is doable when adjusted to existing protocols, respecting especially hemodynamic stability Objectives to show the experience of a hospital emergency department in the use of angioembolization in nonoperative management of more than one injured abdominal organ. Demonstrate utility of simultaneous angioembolization of more than one vascular territory or organ in the management of patients with blunt abdominal trauma who start a nonoperative treatmeant. Design: Retrospective observational study Methods: Between 2007 and 2014, patients with blunt abdominal trauma and active hemorrhage or potentially bleeding lesions demonstrated by computed tomography (CT) were evaluated. Those who underwent nonoperative treatment and embolized were included. Of these, those with more than one organ or vascular territory embolized were described. Results: 392 patients were admitted with blunt abdominal trauma. Of these, 281 (72 %) started TNO protocol. 225 with active bleeding on CT were found. 183 patients (80 %) underwent angiography and 166 need embolization. In 7 cases embolization of more than one organ or vascular territory was performed. Conclusion: angioembolization of organ with active bleeding is definitely accepted practice in trauma centers. The opportunity and need for more than one organ embolization or vascular territory is scarce, but it is doable when adjusted to existing protocols, respecting especially hemodynamic stability Design Retrospective observational study Methods: Between 2007 and 2014, patients with blunt abdominal trauma and active hemorrhage or potentially bleeding lesions demonstrated by computed tomography (CT) were evaluated. Those who underwent nonoperative treatment and embolized were included. Of these, those with more than one organ or vascular territory embolized were described. Results: 392 patients were admitted with blunt abdominal trauma. Of these, 281 (72 %) started TNO protocol. 225 with active bleeding on CT were found. 183 patients (80 %) underwent angiography and 166 need embolization. In 7 cases embolization of more than one organ or vascular territory was performed. Conclusion: angioembolization of organ with active bleeding is definitely accepted practice in trauma centers. The opportunity and need for more than one organ embolization or vascular territory is scarce, but it is doable when adjusted to existing protocols, respecting especially hemodynamic stability Methods Between 2007 and 2014, patients with blunt abdominal trauma and active hemorrhage or potentially bleeding lesions demonstrated by computed tomography (CT) were evaluated. Those who underwent nonoperative treatment and embolized were included. Of these, those with more than one organ or vascular territory embolized were described. Results: 392 patients were admitted with blunt abdominal trauma. Of these, 281 (72 %) started TNO protocol. 225 with active bleeding on CT were found. 183 patients (80 %) underwent angiography and 166 need embolization. In 7 cases embolization of more than one organ or vascular territory was performed. Conclusion: angioembolization of organ with active bleeding is definitely accepted practice in trauma centers. The opportunity and need for more than one organ embolization or vascular territory is scarce, but it is doable when adjusted to existing protocols, respecting especially hemodynamic stability Results 392 patients were admitted with blunt abdominal trauma. Of these, 281 (72 %) started TNO protocol. 225 with active bleeding on CT were found. 183 patients (80 %) underwent angiography and 166 need embolization. In 7 cases embolization of more than one organ or vascular territory was performed. Conclusion angioembolization of organ with active bleeding is definitely accepted practice in trauma centers. The opportunity and need for more than one organ embolization or vascular territory is scarce, but it is doable when adjusted to existing protocols, respecting especially hemodynamic stability
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Abstract
Aneurysm of gastroduodenal artery (GDA) is rare. Most reported cases are due to pancreatitis and atherosclerosis; however, those following pancreatic trauma have not been reported. We encoun- tered GDA aneurysm in a patient of blunt abdominal trauma, who had pancreatic contusion and retroduodenal air on contrast enhanced computed tomography of abdomen. Emergency laparotomy for suspected duodenal injury revealed duodenal wall and pancreatic head contusion, mild hemo- peritoneum and no evidence of duodenal perforation. In the postoperative period, the patient developed upper gastrointestinal hemorrhage on day 5. Repeat imaging revealed GDA aneurysm, which was managed successfully by angioembolization. This case highlights, one, delayed presen- tation of GDA aneurysm after blunt pancreatic trauma and two, its successful management using endovascular technique.
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Babu A, Gupta A, Sharma P, Ranjan P, Kumar A. Blunt traumatic superior gluteal artery pseudoaneurysm presenting as gluteal hematoma without bony injury: A rare case report. Chin J Traumatol 2016; 19:244-6. [PMID: 27578385 PMCID: PMC4992137 DOI: 10.1016/j.cjtee.2015.11.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Blunt traumatic injuries to the superior gluteal artery are rare in clinic. A majority of injuries present as aneurysms following penetrating trauma, fracture pelvis or posterior dislocation of the hip joint. We reported a rare case of superior gluteal artery pseudoaneurysm following blunt trauma presenting as large expanding right gluteal hematoma without any bony injury. The gluteal hematoma was suspected clinically, confirmed by ultrasound and the arterial injury was diagnosed by CT angiography that revealed a large right gluteal hematoma with a focal contrast leakage forming a pseudoaneurysm within the hematoma. Pseudoaneurysm arose from the superior gluteal branch of right internal iliac artery, which was successfully angioembolized. The patient was discharged on day 4 of hospitalization with resolving gluteal hematoma. This report highlighted the importance of considering an arterial injury following blunt trauma to the buttocks with subsequent painful swelling. Acknowledgment of this rare injury pattern was necessary to facilitate rapid diagnosis and appropriate treatment.
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Affiliation(s)
| | - Amit Gupta
- Corresponding author. Tel.: +91 9868397720.
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Değer KC, Gündeş E, Fedakar A. Surgical management of a splenic artery aneurysm. Clin Case Rep 2016; 4:524-5. [PMID: 27190621 PMCID: PMC4856251 DOI: 10.1002/ccr3.550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/26/2016] [Accepted: 03/09/2016] [Indexed: 11/15/2022] Open
Abstract
Aneurisms of the splenic artery are rare clinical findings. Surgeons and interventional radiologists should co‐operate in the management of this challenging disease; we describe here a surgical option.
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Affiliation(s)
- Kamuran Cumhur Değer
- Gastroenterological Surgery Department Kartal Koşuyolu High Speciality and Training Hospital Istanbul Turkey
| | - Ebubekir Gündeş
- Gastroenterological Surgery Department Kartal Koşuyolu High Speciality and Training Hospital Istanbul Turkey
| | - Ali Fedakar
- Cardiovascular Surgery Department Kartal Koşuyolu High Speciality and Training Hospital Istanbul Turkey
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Sur A, Manraj H, Lavoie PM, Lim K, Courtemanche D, Brooks P, Albersheim S. Multiple Successful Angioembolizations for Refractory Cardiac Failure in a Preterm with Rapidly Involuting Congenital Hemangioma. AJP Rep 2016; 6:e99-e103. [PMID: 26929881 PMCID: PMC4737636 DOI: 10.1055/s-0035-1570342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/22/2015] [Indexed: 11/06/2022] Open
Abstract
Rapidly involuting congenital hemangiomas (RICH) are the commonest variety of congenital hemangioma, often diagnosed antenatally as high-flow arteriovenous shunts causing hemodynamic compromise to the fetus. The postnatal management of such patients is often challenging. We present the case of an infant boy who was delivered prematurely at 29 weeks of gestation due to fetal compromise by a RICH, with features of high-output cardiac failure and major systemic hemodynamic steal from peripheral organs. Two early angioembolizations were required to manage his high-output cardiac failure. To our knowledge, this infant is the smallest and earliest newborn case of successful angioembolization for a complex, life-threatening vascular anomaly. We discuss the interventional dilemmas regarding the optimal timing of delivery and early embolization.
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Affiliation(s)
- Amitava Sur
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Heran Manraj
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Interventional Radiology, University of British Columbia, Vancouver, Canada
| | - Pascal M Lavoie
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Ken Lim
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Maternal and Fetal Medicine, University of British Columbia, Vancouver, Canada
| | - Douglas Courtemanche
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Plastic Surgery, University of British Columbia, Vancouver, Canada
| | - Paul Brooks
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Cardiology, University of British Columbia, Vancouver, Canada
| | - Susan Albersheim
- Children's and Women's Health Centre of British Columbia, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada
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Dalton BGA, Dehmer JJ, Gonzalez KW, Shah SR. Blunt Spleen and Liver Trauma. J Pediatr Intensive Care 2015; 4:10-15. [PMID: 31110844 DOI: 10.1055/s-0035-1554983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Blunt abdominal trauma is an important cause of pediatric morbidity and mortality. The spleen and liver are the most common abdominal organs injured. Trauma to either organ can result in life-threatening bleeding. Controversy exists regarding which patients should be imaged and the correct imaging modality depending on the level of clinical suspicion for injury. Nonoperative management of blunt abdominal trauma is the standard of care for hemodynamically stable patients. However, the optimal protocol to maximize patient safety while minimizing resource utilization is a matter of debate. Adjunctive therapies for pediatric spleen and liver trauma are also an area of ongoing research. A review of the current literature on the diagnosis, management, and follow-up of pediatric spleen and liver blunt trauma is presented.
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Affiliation(s)
- Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Jeff J Dehmer
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Katherine W Gonzalez
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Sohail R Shah
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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Abstract
The pediatric patient is especially prone to blunt renal trauma due to the size and location of pediatric kidneys. No clear guidelines have been established for the management of these injuries in children to achieve the highest rate of renal salvage with low morbidity. Wide-ranging literature exists on this subject, but consists of vastly different management strategies. This review is written to summarize the different approaches to blunt renal trauma and highlight opportunities for further research.
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Affiliation(s)
- Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jeff J Dehmer
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Sohail R Shah
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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Sosada K, Wiewióra M, Piecuch J. Literature review of non-operative management of patients with blunt splenic injury: impact of splenic artery embolization. Wideochir Inne Tech Maloinwazyjne 2014; 9:309-14. [PMID: 25337151 DOI: 10.5114/wiitm.2014.44251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 04/13/2014] [Accepted: 06/23/2014] [Indexed: 11/17/2022] Open
Abstract
Splenic injuries constitute the most common injuries accompanying blunt abdominal traumas. Non-operative treatment is currently the standard for treating hemodynamically stable patients with blunt splenic injuries. The introduction of splenic angiography has increased the possibility of non-operative treatment for patients who, in the past, would have qualified for surgery. This cohort includes mainly patients with severe splenic injuries and with active bleeding. The results have indicated that applying splenic angioembolization reduces the frequency of non-operative treatment failure, especially in severe splenic injuries; however, it is still necessary to perform prospective, randomized clinical investigations.
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Ouzaid I, Autorino R, Fatica R, Herts BR, McLennan G, Remer EM, Haber GP. Active surveillance for renal angiomyolipoma: outcomes and factors predictive of delayed intervention. BJU Int 2014; 114:412-7. [PMID: 24325283 DOI: 10.1111/bju.12604] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present the outcomes of active surveillance (AS) for renal angiomyolipomas (AMLs) and to assess the clinical features predicting delayed intervention of this treatment option. PATIENTS AND METHODS We retrospectively reviewed the outcomes of patients diagnosed with AMLs on computed tomography (CT) who were managed with AS at our institution. The AS protocol consisted of 6- and 12-month, then annual follow-up visits, each one including a physical examination and CT imaging. Discontinuation of AS was defined as the need or decision for an active procedure during the follow-up period. Causes of delayed intervention, as well as the type of active treatment (AT), were recorded. Clinical features at presentation of patients failing AS were compared with those who remained under AS at the time of the last follow-up. Predictive factors of delayed intervention were analysed using univariate and multivariate Cox regression models. RESULTS Overall, 130 patients were included in the analysis, of whom 102 (78.5%) were incidentally diagnosed, while 15 (11.5%) and 13 patients (10%) presented with flank pain and haematuria, respectively. After a mean (sd) follow-up of 49 (40) months, 17 patients (13%) discontinued AS and underwent AT. Patients who underwent delayed intervention were more likely to present with a higher body mass index, larger tumours and symptomatic disease. Angioembolization represented the first-line AT after AS (64.7%), whereas partial nephrectomy was adopted in 29.4% of patients. On the univariate analysis, risk factors for delayed intervention included tumour size ≥4 cm, symptoms at diagnosis, and history of concomitant or contralateral kidney disease. On the multivariate analysis, only tumour size and symptoms remained independently associated with discontinuation of AS. CONCLUSIONS Tumour size and symptoms at initial presentation were highly predictive of discontinuation of AS in the management of AMLs. Selective angioembolization was the first-line option used for AT after AS was discontinued.
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Affiliation(s)
- Idir Ouzaid
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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