Differences in outcomes of patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation between day-time and night-time.

Although patients who underwent night-time resuscitation for out-of-hospital cardiac arrest (OHCA) had worse clinical outcomes than those who underwent day-time resuscitation, the differences between the outcomes of patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR) in the day-time and night-time remain unclear. We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan. Patients were categorized according to whether they received treatment during the day-time or night-time. The primary outcomes were survival to hospital discharge and favorable neurological outcome at discharge, and the secondary outcomes were estimated low-flow time, implementation time of ECPR, and complications due to ECPR. A multivariate logistic regression model adjusted for confounders was used for comparison. Among the 1644 patients, the night-time patients had a significantly longer ECMO implementation time and estimated low-flow time than the day-time patients, along with a significantly higher number of complications than the day-time patients. However, the survival and neurologically favorable survival rates did not differ significantly between the groups. Thus, although patients who underwent ECPR at night had an increased risk of longer implementation time and complications, their clinical outcomes did not differ from those who underwent day-time ECPR.

Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review.

BACKGROUND: The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach. CASE PRESENTATION: A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma. CONCLUSIONS: We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

Perihepatic Abscess due to a Liver Suture with Pledgets Used to Treat a Penetrating Liver Injury.

BACKGROUND: Selective nonoperative management has become the standard for liver injuries. Accordingly, we cannot perform surgery for liver injuries as frequently as in the past. This report is aimed at sharing a valuable experience of postoperative complications after surgery for a liver injury. Case Presentation. A 40-year-old man was stabbed in his abdomen and underwent an emergency laparotomy for a severe liver injury. Five months after the operation, he developed fever, and purulent discharge was observed from an abdominal fistula. He was diagnosed with a perihepatic abscess and duodenal perforation due to the pledgets used for the operation. He underwent a second surgery to remove the pledgets and the abscess cavity for infection control and was discharged in good condition. CONCLUSION: The intra-abdominal environment should be considered contaminated due to bile leakage in surgeries following liver injury. Furthermore, nonabsorbable agents should not be used in these contaminated areas.

[A Case of Intrahepatic Cholangiocarcinoma Confused with a Recurrent Hepatocellular Carcinoma Treated by RFA at Diagnosis].

Intrahepatic cholangiocarcinoma(ICC)is the second most common malignant liver tumor after hepatocellular carcinoma (HCC). ICC is usually ischemic; however, it has variable findings and may be difficult to differentiate from HCC. We report about a case of ICC that was difficult to distinguish from HCC treated by radiofrequency ablation(RFA). A 79‒year‒old woman underwent RFA for HCC of the caudate lobe. Two years after RFA, a spindle‒shaped tumor was identified near the previous treatment site using contrast‒enhanced MRI. Images showed posterior segment bile duct dilation, posterior segment atrophy of the liver parenchyma, and posterior segmental portal vein disruption. We performed surgery because of the suspicion of a recurrent HCC invading into the bile duct. Intraoperative findings showed posterior segment atrophy. Intraoperative echocardiography could not identify the tumor but revealed a tumor plug and portal vein disruption in the posterior segment. The patient underwent post‒enlargement segmentectomy, caudate lobectomy of the liver, and biliary neoplastic resection. Histopathological findings showed no malignant findings in the hepatocytes. A moderately differentiated adenocarcinoma was found in the expanded bile duct, which was diagnosed as an intrahepatic cholangiocarcinoma. Here, we report about the case along with a discussion and a bibliographical consideration.

[A Case of Internal Hernia into a Reconstructed Pelvic Floor and Torsion of Jejunum near the Treitz Ligament after Laparoscopic Abdominoperineal Resection].

A 50s women underwent laparoscopic abdominoperineal resection(APR)for rectal cancer. Laparotomy was performed on the 8th postoperative day because of intestinal obstruction. An internal hernia was observed at the pelvic floor and the hernia orifice was found at the retroperitoneum that was sutured in the initial operation. On the other hand, the jejunum near the Treitz ligament was twisted, resulting in ischemic necrosis. The reason of the internal hernia is considered that a suction drain placed during the initial operation may have caused the rupture of the fragile part of the sutured peritoneum. Furthermore, increase of intra-abdominal pressure due to the internal hernia may have exacerbated the torsion of the jejunum near the Treitz ligament. This is probably due to the failure to the adequate reposition of the small intestine at the end of the initial operation. There is no consensus of the need for retroperitoneal sutures for APR. Currently, we only spray anti-adhesion agents on the pelvic floor without retroperitoneal reconstruction. Although the mobilization of small intestine is important to provide a good operative view in laparoscopic colorectal surgery, it is also important to confirm the reposition of the small intestine at the end of surgery.

Age-related differences in the impact of coagulopathy in patients with isolated traumatic brain injury: An observational cohort study.

BACKGROUND: Although age and coagulopathy are well-known predictors of poor outcome after traumatic brain injury (TBI), the interaction effect of these two predictors remains unclear. OBJECTIVES: We assessed age-related differences in the impact of coagulopathy on the outcome following isolated TBI. METHODS: We conducted a retrospective observational study in two tertiary emergency critical care medical centers in Japan from 2013 to 2018. A total of 1036 patients with isolated TBI (head Abbreviated Injury Scale ≥ 3 and other Abbreviated Injury Scale < 3) were selected and divided into the nonelderly (n = 501, 16-64 years) and elderly group (n = 535, age ≥65 years). We further evaluated the impact of coagulopathy (international normalized ratio, >1.2) on the outcomes (Glasgow Outcome Scale-Extended [GOS-E] scores, in-hospital mortality, and ventilation-free days) in both groups using univariate and multivariate models. Further, we conducted an age-based assessment of the impact of TBI-associated coagulopathy on GOS-E using a generalized additive model. RESULTS: The multivariate model showed a significant association of age and TBI-associated coagulopathy with lower GOS-E scores, in-hospital mortality, and shorter ventilation-free days in the nonelderly group; however, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. There was a decrease in the correlation degree between coagulopathy and GOS-E scores decreased with those older than 65 years. CONCLUSION: There was a low impact of coagulopathy on functional and survival outcomes in geriatric patients with isolated TBI. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

[Gastric Complications in Stomach-Preserving Procedures on Total Pancreatectomy].

Whether the stomach should be preserved during total pancreatectomy(TP)is controversial. Therefore, we examined the correlation between stomach-preserving procedures on TP and postoperative gastric complications. Seven consecutive cases underwent TP(standard TP: 1 case, SSPTP: 3 cases, PPTP: 3 cases)for pancreatic cancer during the time period 2011-2019 at our hospital. There was no clinical case of postoperative gastric ulcer nor bleeding. Delayed gastric emptying(DGE)was observed in 4 cases of Grade A and 2 cases of Grade C. One of the Grade C cases was considered to be secondary DGE due to postoperative intestinal necrosis. The other was SSPTP case whose left gastric artery(LGA)was ligated. The patient had difficulty of food intake after the surgery and gastrointestinal endoscopy showed widespread hemorrhage and erosion of the gastric mucosa, considered to be ischemic gastropathy. Regarding primary DGE, most of cases were within Grade A even in stomach-preserving cases. Whereas, stomach-preserving procedure should be avoided when the LGA is ligated, because ischemic gastropathy may occur.

Differences in durations, adverse events, and outcomes of in-hospital cardiopulmonary resuscitation between day-time and night-time: An observational cohort study.

BACKGROUND: Although patients with out-of-hospital cardiac arrest (OHCA) have a lower survival rate during night-time than during day-time, the cause of this difference remains unclear. We aimed to assess CPR parameters according to time period based on in-hospital cardiopulmonary resuscitation (IHCPR) duration and the frequency of iatrogenic chest injuries among OHCA patients. METHODS: This two-centre observational cohort study evaluated non-traumatic OHCA patients who were transferred between 2013-2016. These patients were categorised according to whether they received day-time treatment (07:00-22:59) or night-time treatment (23:00-06:59). Differences in IHCPR duration, CPR-related chest injuries, return of spontaneous circulation, and survivals to emergency department and hospital discharge were compared using a generalised estimating equation model adjusted for pre-hospital confounders. Sensitivity analysis was also performed using a propensity score matching method. RESULTS: Among 1254 patients (day-time: 948, night-time: 306), the night-time patients had a significantly shorter IHCPR duration (27.8 min vs. 23.6 min, adjusted difference: -5.1 min, 95% confidence interval [CI]: -6.7, -3.4), a higher incidence of chest injuries (40.4% vs. 67.0%, adjusted odds ratio [AOR]: 1.27, 95% CI: 1.20, 1.35), and a lower rate of return of spontaneous circulation (38.4% vs. 26.5%, AOR: 0.93, 95% CI: 0.88, 0.98). No significant differences were observed in the rates of survival to emergency department and hospital discharge. The propensity score-matched analysis revealed similar results. CONCLUSIONS: Patients who underwent night-time treatment for OHCA had an increased risk of CPR-related chest injuries despite their shorter resuscitation duration. Further studies are needed to clarify the underlying mechanism(s).

[A Case of Pancreatic Mixed Acinar-Neuroendocrine Carcinoma with Main Pancreatic Duct Development].

A 78-year-old man was referred to our hospital owing to a pancreatic tumor detected on ultrasonography. He showed weight loss, and his diabetes mellitus had worsened over 3 months. Abdominal contrast-enhanced computed tomography revealed a 3 cm diameter pancreatic head tumor with peripheral enhancement and a dilated pancreatic duct. He underwent subtotal stomach-preserving pancreaticoduodenectomy. Examination of intraoperative frozen sections did not indicate cancer involvement at the edge of the resected pancreatic duct. The tumor was histologically diagnosed as mixed acinar-neuroendocrine carcinoma(MANEC). It was mainly detected in the pancreatic head and was accompanied by intra-ductal growth in the pancreatic duct. The patient has survived for 21 months without recurrence. MANEC is a rare disease associated with intraductal growth. Intraoperative diagnosis of tumor involvement at the edge of the pancreatic duct may be useful for R0 resection in surgery for MANEC.

The impact of blood type O on mortality of severe trauma patients: a retrospective observational study.

BACKGROUND: Recent studies have implicated the differences in the ABO blood system as a potential risk for various diseases, including hemostatic disorders and hemorrhage. In this study, we evaluated the impact of the difference in the ABO blood type on mortality in patients with severe trauma. METHODS: A retrospective observational study was conducted in two tertiary emergency critical care medical centers in Japan. Patients with trauma with an Injury Severity Score (ISS) > 15 were included. The association between the different blood types (type O versus other blood types) and the outcomes of all-cause mortality, cause-specific mortalities (exsanguination, traumatic brain injury, and others), ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate competing-risk regression models. Moreover, the impact of blood type O on the outcomes was assessed using regression coefficients in the multivariate analysis adjusted for age, ISS, and the Revised Trauma Score (RTS). RESULTS: A total of 901 patients were included in this study. The study population was divided based on the ABO blood type: type O, 284 (32%); type A, 285 (32%); type B, 209 (23%); and type AB, 123 (13%). Blood type O was associated with high mortality (28% in patients with blood type O versus 11% in patients with other blood types; p <  0.001). Moreover, this association was observed in a multivariate model (adjusted odds ratio = 2.86, 95% confidence interval 1.84-4.46; p <  0.001). The impact of blood type O on all-cause in-hospital mortality was comparable to 12 increases in the ISS, 1.5 decreases in the RTS, and 26 increases in age. Furthermore, blood type O was significantly associated with higher cause-specific mortalities and shorter VFD compared with the other blood types; however, a significant difference was not observed in the transfusion volume between the two groups. CONCLUSIONS: Blood type O was significantly associated with high mortality in severe trauma patients and might have a great impact on outcomes. Further studies elucidating the mechanism underlying this association are warranted to develop the appropriate intervention.

The Association between Cardiopulmonary Resuscitation in Out-of-Hospital Settings and Chest Injuries: A Retrospective Observational Study.

OBJECTIVES: The aim of this study was to assess the risk of cardiopulmonary resuscitation (CPR) performed in out-of-hospital settings for chest injuries in patients with out-of-hospital cardiac arrest (OHCA). METHODS: This retrospective, observational study was conducted in an emergency critical care medical center in Japan. Non-traumatic OHCA patients transferred to the hospital from April 2013 through August 2016 were analyzed. The outcome was defined by chest injuries related to CPR, which is composite of rib fractures, sternal fractures, and pneumothoraces. A multivariate logistic regression analysis was performed to assess the independent risk factors for chest injuries related to CPR. The threshold of out-of-hospital CPR duration that increased risk of chest injuries was also assessed. RESULTS: A total of 472 patients were identified, of whom 233 patients sustained chest injuries. The multivariate logistic regression model showed that the independent risk factors for chest injuries were age and out-of-hospital CPR duration (age: AOR=1.06 [95% CI, 1.04 to 1.07]; out-of-hospital CPR duration: AOR=1.03 [95% CI, 1.01 to 1.05]). In-hospital CPR duration was not an independent risk factor for chest injuries. When the duration of out-of-hospital CPR extended over 15 minutes, the likelihood of chest injuries increased; however, this association was not statistically significant. CONCLUSIONS: Long duration of out-of-hospital CPR was an independent risk factor for chest injuries, possibly due to the difficulty of maintaining adequate quality of CPR. Further investigations to assess the efficacy of alternative CPR devices are expected in cases requiring long transportation times. Takayama W , Koguchi H , Endo A , Otomo Y . The association between cardiopulmonary resuscitation in out-of-hospital settings and chest injuries: a retrospective observational study. Prehosp Disaster Med. 2018;33(2):171-175.