Concurrent Thoracic Endovascular Aortic Repair and Liver Transplant: Multidisciplinary Management of Multiple Posttraumatic Lesions.

Association of thoracic and abdominal injuries in patients with major trauma is common. Under emergency conditions, it is often difficult to promptly perform a certain diagnosis and identify treatment priorities of life-threatening lesions. We present the case of a young man with combined thoracic and abdominal injuries after a motorcycle accident. Primary evaluation through echography and X-ray showed fluid within the hepatorenal recess and an enlarged mediastinum. Volume load, blood transfusions, and vasoactive agents were initiated to sustain circulation. Despite hemodynamic instability, we decided to perform computed tomographic angiography (CTA) scan that revealed a high-grade traumatic aortic pseudoaneurysm, multiple and severe areas of liver contusion, and a small amount of hemoperitoneum, without active bleeding spots. The patient was successfully submitted to thoracic endovascular aortic repair (TEVAR). Immediately after the end of the successful TEVAR, signs of massive abdominal bleeding revealed. Immediate explorative laparotomy was performed showing massive hepatic hemorrhage. After liver packing and Pringle's maneuver, control of bleeding was lastly obtained with hemostatic devices and selective cross-clamping of the right hepatic artery. The patient was then transferred to intensive care unit where, despite absence of further hemorrhage, hemodynamic instability, anuria, severe lactic acidosis together with liver necrosis indices appeared. A new CTA demonstrated massive parenchymal disruption within the right lobe of the liver and multiple hematomas in the left lobe. Considering the high-grade lesions of the hepatic vascular tree and liver failure, patient was listed for emergency liver transplantation (LT). LT occurred few hours later, and patient's clinical conditions rapidly improved even if the subsequent clinical course was characterized by a severe fungal infection because of immunosuppression. Evaluation of life-threatening lesions and treatment priorities, availability of different excellence skills, and multidisciplinary collaboration have a key role to achieve clinical success in such severe cases.

Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives.

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

Intra-abdominal pressure may be elevated in patients with open abdomen after emergent laparotomy.

PURPOSE: To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who were left with open abdomen and temporary abdominal closure after laparotomy, during the first 48 h after admission. METHODS: A cohort study in a single ICU in a tertiary care hospital. All adult patients admitted to the ICU after emergent laparotomy for acute abdomen or trauma, who were left with temporary abdominal closure (TAC), were included. Patients were followed up to 48 h. IAP was routinely measured at 0, 6, 12, 24, and 48 h after admission to ICU. RESULTS: Thirty-nine patients were included, 34 were operated due to acute abdomen and 5 due to abdominal trauma. Seventeen patients were treated with skin closure, 13 with Bogota bag, and 9 with negative pressure wound therapy (NPWT). Eleven patients (28.2%) had IAP of 15 mmHg or above at time 0, (mean pressure 19.0 ± 3.0 mmHg), and it dropped to 12 ± 4 mmHg within 48 h (p < 0.01). Reduction in lactate level (2.4 ± 1.0 to 1.2 ± 0.2 mmol/L, p < 0.01) and increase in PaO2/FiO2 ratio (163 ± 34 to 231 ± 83, p = 0.03) were observed as well after 48 h. CONCLUSIONS: This is the first large report of IAP in open abdomen. Elevated IAP may be measured in open abdomen and may subsequently relieve after 48 h.

Point-of Care Ultrasonographically Guided Proximal External Aortic Compression in the Emergency Department.

In cases of severe subdiaphragmatic vascular trauma, only in extremis interventions such as emergency thoracotomy with aortic cross clamping or resuscitative endovascular balloon occlusion of the aorta are available for temporization until definitive care. This case report proposes a noninvasive approach consisting of localizing the proximal aorta with ultrasonographic guidance and applying a compressive force to occlude the aorta and limit distal flow. Using point-of-care ultrasonography allows precise compression, continuous monitoring of its efficacy, and early detection of return of spontaneous circulation in arrest patients. We present the case of a patient who sustained a gunshot wound causing a left iliac artery injury and subsequent cardiac arrest while he was on route to the hospital. Point-of-care ultrasonographically guided proximal external aortic compression was attempted and return of spontaneous circulation was achieved and maintained, allowing transfer of the patient to the operating room. This single-case report suggests that point-of-care ultrasonographically guided proximal external aortic compression could be used as a bridge to definitive care or to more advanced techniques such as resuscitative endovascular balloon occlusion of the aorta and emergency department thoracotomy with aortic cross clamping.

Long-term Impact of Bile Duct Injury on Morbidity, Mortality, Quality of Life, and Work Related Limitations.

OBJECTIVE: Assessment of long-term comprehensive outcome of multimodality treatment of bile duct injury (BDI) in terms of morbidity, mortality, quality of life (QoL), survival, and work related limitations. BACKGROUND: The impact of BDI on work ability is scarcely investigated. METHODS: BDI patients referred to a tertiary center after BDI were included (n = 800). QoL and work related limitations (HLQ) were compared with 175 control patients after uncomplicated laparoscopic cholecystectomy. RESULTS: The mean survival after BDI was 17.6 years (95% confidence interval, CI, 17.2-18.0 years). BDI related mortality was 3.5% (28/800). Corrected for sex, ASA classification, treatment and type of injury, survival is worse in male patients (hazard ratio, HR 1.50, 95% CI 1.01-2.33) and progressively worse with higher ASA classification (ASA2: 5.25 (2.94-9.37), ASA3: 18.1 (9.79-33.3). Patients treated surgically had a significantly better survival (HR: 0.45 (95% CI: 0.25-0.80). BDI patients reported a significantly worse physical QoL compared with the control group and worse disease specific QoL. Loss of productivity of work was significantly higher among BDI patients. There also was a significant hindrance in unpaid work. A higher number of bile duct injury patients were receiving disability benefits after long-term follow-up (34.9% vs 19.6%, P = 0.004). CONCLUSIONS: Reconstructive surgery in BDI patients is associated with improved survival. Although the clinical outcome of multidisciplinary treatment of bile duct injury is good, it is associated with a significant decrease in QoL, loss of productivity in both paid and unpaid work and high rates of disability benefits use.

Parecoxib's effects on anastomotic and abdominal wound healing: a randomized Controlled trial.

BACKGROUND: Current evidence regarding the effects of selective cyclooxygenase inhibitors on gastrointestinal anastomoses is controversial. An experimental randomized control study was conducted in our institution to histopathologically evaluate the consequences of parecoxib, on intestinal and abdominal wound healing. METHODS: Twenty-four adult Wistar rats underwent laparotomy, ascending colon transection, and hand-sewn anastomosis. They were randomized to receive either parecoxib (0.5 mg/kg twice daily) or 0.9% normal saline by intraperitoneal injection postoperatively. Animals were euthanatized either on the third or the seventh postoperative day. Semiquantitative methods were used to evaluate both intestinal and abdominal wounds for inflammatory cell composition, angiogenesis, fibroblasts, granular tissue, collagen deposition, epithelization, and presence of necrosis, exudate, and abscess formation. Results are presented as (parecoxib: median [IQR] versus control: median [IQR], P-value). RESULTS: No macroscopic anastomotic leakage or wound dehiscence was observed. Intestinal anastomoses in the parecoxib group, showed significantly decreased epithelization (2 [1] versus 3 [1], [P = 0.004]) and collagen deposition (2 [0] versus 3 [1], [P = 0.041]). No difference was observed in angiogenesis (3 [1] versus 2.5 [1], [P = 0.158]). Abdominal wall specimens appeared to demonstrate decreased epithelization (2 [2] versus 4 [0.5], [P = 0.0004]) in the treatment group. No difference between the two groups was identified regarding collagen deposition (2.5 [1] versus 2 [0.5], [P = 0.280]) and angiogenesis (2.5 [1] versus 2 [1], [P = 0.633]). Necrosis was significantly more present in the parecoxib group in both specimen types, (3.5 [1] versus 2.5 [1], [P = 0.017]) and (3 [1] versus 1 [0.5], [P < 0.0001]). CONCLUSIONS: The present study shows that despite the absence of clinical adverse effects, parecoxib can impair anastomotic and abdominal wound healing on a histopathological level.

REBOA by a non-surgeon as an adjunct during MASCAL.

Use of Resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of non-compressible hemorrhage is a re-emerging technology that historically is employed by surgeons. We present a case in which REBOA was successfully placed by an emergency physician in a critical mass casualty patient awaiting transfer to the operating table. This case is an example in which emergency physicians, in collaboration with the surgeon, can utilize REBOA to temporize non-compressible hemorrhage when a surgeon is not immediately available.

Liver trauma: What current management?

BACKGROUND: The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years. METHODS: The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed. RESULTS: The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group. CONCLUSIONS: Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

Damage control surgery: current state and future directions.

PURPOSE OF REVIEW: Damage control surgery (DCS) represents a staged surgical approach to the treatment of critically injured trauma patients. Originally described in the context of hepatic trauma and postinjury-induced coagulopathy, the indications for DCS have expanded to the management of extra abdominal trauma and to the management of nontraumatic acute abdominal emergencies. Despite being an accepted treatment algorithm, DCS is based on a limited evidence with current concerns of the variability in practice indications, rates and adverse outcomes in poorly selected patient cohorts. RECENT FINDINGS: Recent efforts have attempted to synthesize evidence-based indication to guide clinical practice. Significant progress in trauma-based resuscitation techniques has led to improved outcomes in injured patients and a reduction in the requirement of DCS techniques. SUMMARY: DCS remains an important treatment strategy in the management of specific patient cohorts. Continued developments in early trauma care will likely result in a further decline in the required use of DCS in severely injured patients.

Spleen and liver injuries: when to operate?

PURPOSE OF REVIEW: Although nonoperative management (NOM) is the safest option in most patients with liver and splenic injuries or splenic injuries, some cases still need operative intervention. The aim of this review is to address the most recent literature and the evidence it provides for indications and timing of operative treatment for liver and spleen injuries. RECENT FINDINGS: There seems to be a decrease in publication rate on these topics over the last years, parallel to the acceptance of NOM as the 'gold standard', with little added to the existing body of evidence over the last 12-24 months. Most published studies are retrospective descriptions or comparisons with historical controls, some observational studies, but no randomized control trials (RCTs).There is a striking lack of high-level evidence for the optimal treatment of solid organ injuries. The role of angiographic embolization as an adjunct to the treatment of liver and spleen injuries is still a matter of discussion. SUMMARY: Unstable patients with suspected ongoing bleeding from liver and spleen injuries or spleen injuries with inadequate effect of resuscitation should undergo immediate explorative laparotomy.More RCTs are needed to further determine the role of angiographic embolization and who can be safely be treated nonoperatively and who needs surgical intervention.

Pelvic Free Fluid in Asymptomatic Pediatric Blunt Abdominal Trauma Patients: A Case Series and Review of the Literature.

BACKGROUND: With focused assessment with sonography in trauma (FAST) examinations being performed more commonly on pediatric trauma patients, emergency providers will encounter a positive FAST examination in patients with benign abdominal examinations. This poses a diagnostic dilemma for the provider when deciding whether to obtain a computed tomography (CT) scan of the abdomen/pelvis, observe the patient, or admit the patient. CASE REPORT: We report a series of pediatric patients involved in blunt abdominal trauma who had small pelvic free fluid on FAST but a benign abdominal examination. Three patients were managed without CT scan and 2 with CT scan. All patients did well and were discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Free intra-abdominal fluid may be physiologic in both male and female pediatric patients. Clinical examination and hemodynamic stability should be taken into account when deciding to order a CT scan. We review the literature and highlight new protocols that may decrease CT utilization and ionizing radiation exposure, though further studies in this specific population are needed.

[PECULIARITIES OF COURSE OF TRAUMATIC DISEASE IN THE INJURED PERSONS IN COMBINED CRANIOABDOMINAL TRAUMA].

Prospective investigation of the traumatic disease course was conducted in 71 injured persons, suffering a combined cranioabdominal trauma with the objective to determine the main functional systems and dynamics of their state severity. The occurrence rate and the severity degree of cardiovascular insufficiency were determined--in accordance to indices of the integrative body rheography and integrative dual frequency impedansometry, respiratory insufficiency (PaO2/FiO2 ratio), the organ insufficiency severity (in accordance to SOFA scale). There was established, that changes in respiratory and cardiovascular systems are corresponding to the staged pathogenetic characteristics of the traumatic disease periods. So on, it is expedient to perform the urgent and postponed operative interventions in a period of their relative stabilization. The presence of severe craniocerebral trauma, as a part of a combined cranioabdominal trauma causes significant and durable impairment of the functional systems activity.

Management of severe blunt liver injuries by applying the damage control strategies with packing-oriented surgery: experiences at a single institution in Korea.

BACKGROUND/AIMS: This study was conducted to investigate effective management strategies for patients with severe blunt liver injuries. METHODOLOGY: Treatment methods and outcomes of 77 patients with grade IV-V damage among patients with liver injury managed between 2009 and 2013 were investigated. RESULTS: Of the 77 patients, 32 were managed surgically. Packing was performed in 29 of these patients, while 26 also underwent liver surgery to maximize the hemostatic effect of packing. All 32 underwent temporary abdominal closure, and the mean amount of blood products used in the first 24 hours after admission included packed red blood cell, 13.3 units; fresh frozen plasma, 12.4 units; and platelets, 12.2 units, very close to 1:1:1. A total of 9 of 77 (11.7%) patients and 8 of 32 who underwent the operation died (operative mortality rate, 25%). Liver-related uncontrolled hemorrhage contributing to death occurred in four patients (12.5%). CONCLUSIONS: Although nonoperative management can first be pursued if the patient's condition allows for it, hemodynamic instability and evidence of peritonitis requires surgical management. Surgical management should abide by the damage control surgery principles that focus on packing to minimize surgical time, followed by aggressive critical care according to damage control resuscitation.

[Spleen trauma in children].

UNLABELLED: The aim was to determine blood loss degree in case of spleen trauma in children and to justify safety of victims treatment without surgery. MATERIALS AND METHODS: It was performed retrospective cohort study of 105 autopsies of children who died of combined trauma. 33 of them had spleen injury. Prospective cohort study was performed in 75 children with spleen injury, 69 (92%) from whom were treated without surgery. RESULTS: It was established that thanatogenetic feature of spleen injury in children is moderate blood loss (89.6% of victims), incidence of large and massive blood loss was 6.8% and 3.4% respectively. In unoperated children blood loss did not exceed 15% of blood volume. In group of operated children (n=6; 8%) incidence of large blood loss was 4% (n=3) and did not exceed 28% of blood volume. Prevalence of moderate blood loss in case of spleen trauma due to anatomic and physiological features and mechanisms of spleen injury is theoretically justified.

Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures.

INTRODUCTION: Transcatheter arterial embolization (TAE) is usually necessary in the management of hemodynamically unstable patients with concomitant pelvic fractures. Given the critical conditions of such patients, TAE is at times performed only according to the results of a primary evaluation without computed tomographic (CT) imaging. Therefore, the evaluation of associated intra-abdominal injuries (IAIs) might be insufficient. Clinically, some patients have required post-TAE laparotomy due to further deterioration. In this study, we attempted to determine a feasible protocol for post-TAE observation. MATERIALS AND METHODS: This study focused on patients who received TAE to achieve hemostasis of retroperitoneal hemorrhage and who did not undergo CT imaging due to their unstable hemodynamics. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. We also analyzed the effects of the timing of post-TAE CT imaging on patients with IAIs requiring surgery. RESULTS: A total of 41 patients were enrolled in the study. Of these patients, all of whom underwent primary TAE without preprocedure CT imaging; 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Comparisons between the 2 patient groups revealed no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P=.480), loss of consciousness (66.7% vs 73.1%, P=.730), or abdominal symptoms (20.0% vs 23.1%, P=1.000). CONCLUSION: In the management of hemodynamically unstable patients with concomitant pelvic fractures, greater attention should be paid to associated IAIs. Early CT imaging is encouraged after the patient's hemodynamic status is stabilized with TAE.

Angiographic embolization in the treatment of intrahepatic arterial bleeding in patients with blunt abdominal trauma.

BACKGROUND: Angiographic embolization (AE) as an adjunct non-operative treatment of intrahepatic arterial bleeding has been widely used. The present study aimed to evaluate the efficacy of selective AE in patients with hepatic trauma. METHODS: Seventy patients with intrahepatic arterial bleeding after blunt abdominal trauma who had undergone selective AE in 10 years at this institution were retrospectively reviewed. The criteria for selective AE included active extravasation on contrast-enhanced CT, an episode of hypotension or a decrease in hemoglobin level during the non-operative treatment. The data of the patients included demographics, grade of liver injuries, mechanism of blunt abdominal trauma, associated intra-abdominal injuries, indications for AE, angiographic findings, type of AE, and AE-related hepatobiliary complications. RESULTS: In the 70 patients, 32 (45.71%) had high-grade liver injuries. Extravazation during the early arterial phase mainly involved the right hepatic segments. Thirteen (18.57%) patients underwent embolization of intrahepatic branches and the extrahepatic trunk and these patients all developed AE-related hepatobiliary complications. In 19 patients with AE-related complications, 14 received minimally invasive treatment and recovered without severe sequelae. CONCLUSIONS: AE is an adjunct treatment for liver injuries. Selective and/or super-selective AE should be advocated to decrease the incidence and severity of AE-related hepatobiliary complications.

[The criteria for choose of treatment method of children with spleen injuries].

It was performed cohort prospective study of treatment results of 69 children with through-capsule spleen injuries for the period from 2002 to 2013. Patients were divided into 2 groups. The first group included 63 patients after non-surgical treatment. The second group included 6 children who underwent surgery. In the first group 95.3% of patients had stable hemodynamics at admission. In the second group only 2 patients had the signs of deferred bleeding. Continuing abdominal bleeding was the indication for surgery in 4 patients although stable hemodynamics. Hemoperitoneum in case of spleen injury is not significant prognostic factor defining the tactics of treatment. The physiological response on bleeding but not the amount of blood in abdominal cavity determines tactics of treatment. Hemodynamic status is single statistically significant criterion for choose of surgical treatment of children with spleen injuries. Unstable hemodynamics increases the risk of surgical treatment in 20 times (p<0.007).

[Features of diagnostics and surgical strategy of diaphragmatic rupture in patients with closed chest and abdominal polytrauma].

The article presents results of diagnostics and surgical treatment of diaphragmatic rupture in 32 victims with an estimation of diagnostic value of different instrumental methods of investigation and the efficacy of surgical approach. The correct interpretation of typical clinical and instrumental signs in consideration with trauma mechanogenesis allowed diagnostics of diaphragmatic rupture before the operation in 17 (53.1%) cases. It was observed that an undiagnosed rupture of the left hemidiaphragm caused a formation of posttraumatic diaphragmatic hernia in 2 (6.2%) patients. The laparotomy was applied in 28 patients as a surgical approach and thoracotomy--in 2patients. The laparotomy and after that thoracotomy were performed on one patient. The thoracotomy and laparotomy were carried out on the second patient in turn. The authors consider the laparotomy as optimal variant of surgical approach in acute period of trauma. The postoperative lethality was 15.6%.

[Diagnostics and treatment of renal injury after closed abdominal trauma].

The 10-year experience of treatment of closed isolated and combined abdominal trauma and renal injury included data of 117 cases. The diagnose was made basing on the clinical analysis, ultrasound investigation and computed tomography. 61 patients were operated on, though only 6 of them on the reason of the renal injury. The rest 55 were operated on the reason of accompanying spleen injury, urinary bladder of diaphragm rupture. 56 patients with renal injury were treated conservatively, of them 55 - successfully. The study showed, that the computed tomography provided the complete information about the severity of the renal trauma and bleeding, defining the indication to surgery. Authors worked out the indications for the visual intraoperative kidney revision, if the severity of the injury had been not assessed before. Nevertheless, the conservative therapy proved to be effective in 98.2% of patients with kidney trauma stage I-IV.