Using MRI appendicitis scale and DWI for the diagnosis of acute appendicitis in pregnant women.

OBJECTIVES: To assess the performance of MRI scale for the diagnosis of acute appendicitis in pregnant women and to determine the added diagnostic value of diffusion-weighted imaging (DWI). METHODS: From January 2018 to December 2020, 80 patients were included. All MRI were performed with a 1.5-Tesla scanner with anterior array body coil. This analysis included (1) T2-weighted imaging (T2WI), (2) fat-saturated T2WI, and (3) DWI. Two radiologists blinded to the diagnosis recorded their assessment of four findings: appendiceal diameter, appendiceal wall thickness, luminal mucus, and periappendiceal inflammation. The MRI scale of acute appendicitis which ranged from 0 to 4 was determined from these factors. An additional one point was added to the MRI appendicitis scale in those patients with evidence of appendiceal restricted diffusion on DWI. The diagnostic values and predictive factors were computed. RESULTS: Multivariate analysis demonstrated that the calculated MRI appendicitis scale was a significant independent predictor of acute appendicitis with a sensitivity of 96.6%, specificity of 90.2%, and PPV of 84.8%. The odds ratio of appendicitis is increased by 22.3 times for every increase in one point on the MRI appendicitis scale. Therefore, the addition of one point for restricted diffusion in the appendix on DWI imaging can add substantial value, both positive and negative predictive value, towards making an accurate diagnosis of acute appendicitis. CONCLUSIONS: MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. Incorporation of diffusion weighted imaging to MRI can improve diagnosis of acute appendicitis. CLINICAL RELEVANCE STATEMENT: MRI appendicitis scale is an objective and significant independent predictor of acute appendicitis in pregnant women. Incorporation of DWI/ADC map to MRI examinations can improve diagnosis of acute appendicitis in pregnant women. KEY POINTS: • MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. • The odds ratio of appendicitis can be increased by 22.3 times for every increase of one unit in MRI scale. • Incorporation of diffusion-weighted imaging to MRI examinations can add value to the scale (4.2 ± 0.7 vs. 0.7 ± 1.1; p < 0.001) among pregnant women with appendicitis versus pregnant women without appendicitis.

Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS.

BACKGROUND: This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE). METHODS: We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE. RESULTS: In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate. CONCLUSIONS: Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.

Comparison of outcomes of proximal versus distal and combined splenic artery embolization in the management of blunt splenic injury: a report of 202 cases from a single trauma center.

BACKGROUND: To compare the outcomes of blunt splenic injuries (BSI) managed with proximal (P) versus distal (D) versus combined (C) splenic artery embolization (SAE). METHODS: This retrospective study included patients with BSI who demonstrated vascular injuries on angiograms and were managed with SAE between 2001 and 2015. The success rate and major complications (Clavien-Dindo classification ≥ III) were compared between the P, D, and C embolizations. RESULTS: In total, 202 patients were enrolled (P, n = 64, 31.7%; D, n = 84, 41.6%; C, n = 54, 26.7%). The median injury severity score was 25. The median times from injury to SAE were 8.3, 7.0, and 6.6 h for the P, D, and C embolization, respectively. The overall haemostasis success rates were 92.6%, 93.8%, 88.1%, and 98.1% in the P, D, and C embolizations, respectively, with no significant difference (p = 0.079). Additionally, the outcomes were not significantly different between the different types of vascular injuries on angiograms or the materials used in the location of embolization. Splenic abscess occurred in six patients (P, n = 0; D, n = 5; C, n = 1), although it occurred more commonly in those who underwent D embolization with no significant difference (p = 0.092). CONCLUSIONS: The success rate and major complications of SAE were not significantly different regardless of the location of embolization. The different types of vascular injuries on angiograms and agents used in different embolization locations also did not affect the outcomes.

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures.

BACKGROUND: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. METHOD: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. RESULTS: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. CONCLUSION: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

Laparoscopic repair of perforated peptic ulcer: simple closure versus omentopexy.

BACKGROUND: This report presents our experience with laparoscopic repair performed in 118 consecutive patients diagnosed with a perforated peptic ulcer (PPU). We compared the surgical outcome of simple closure with modified Cellan-Jones omentopexy and report the safety and benefit of simple closure. METHODS: From January 2010 to December 2014, 118 patients with PPU underwent laparoscopic repair with simple closure (n = 27) or omentopexy (n = 91). Charts were retrospectively reviewed for demographic characteristics and outcome. The data were compared by Fisher's exact test, Mann-Whitney U test, Pearson's chi-square test, and the Kruskal-Wallis test. The results were considered statistically significant if P < 0.05. RESULTS: No patients died, whereas three incurred leakage. After matching, the simple closure and omentopexy groups had similarity in sex, systolic blood pressure, pulse rate, respiratory rate, Boey score, Charlson comorbidity index, Mannheim peritonitis index, and leakage. There were statistically significant differences in age, length of hospital stay, perforated size, and operating time. Comparison of the operating time in the ≤4.0 mm and 5.0-12 mm groups revealed that the simple closure took less time than omentopexy in both groups (≤4.0 mm, 76 versus 133 minutes, P < 0.0001; 5.0-12 mm, 97 versus 139.5 minutes; P = 0.006). CONCLUSIONS: Compared to the omentopexy, laparoscopic simple closure is a safe procedure and shortens the operating time.

Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification.

BACKGROUND: To evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD). METHODS: Between August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome. RESULTS: Of the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%. CONCLUSION: Based on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries.

Computed tomography angiography provides limited benefit in the evaluation of patients with pelvic fractures.

INTRODUCTION: Computed tomography angiography (CTA) has been applied in imaging studies for the assessment of most abdominal and pelvic injuries in some trauma centers. However, in most institutions, CTA is not routinely performed as part of the computed tomography scan protocol. In this study, we aimed to assess the efficiency of CTA in the evaluation of patients with pelvic fractures. MATERIALS AND METHODS: During the study period, patients with pelvic fracture were retrospectively analyzed. In addition to conventional computed tomography scanning that includes only the single venous phase, CTA with an additional arterial phase was used to obtain more information regarding vascular injuries. Further angiographic examination was performed in the patients with positive results in either the arterial or venous phase. The sensitivity and specificity of the multiphasic CTA images in the evaluation of active arterial hemorrhage were investigated. Furthermore, the results obtained for the arterial and venous phases were also combined to evaluate associated active arterial hemorrhage. RESULTS: A total of 144 patients with pelvic fractures who underwent CTA were enrolled in this study. Of these patients, 49 (34.0%) had active arterial hemorrhage. The sensitivities of the venous and arterial phase CTA images in the evaluation of active arterial hemorrhage were 100% (49/49) and 89.8% (44/49), respectively. Furthermore, all of the patients with positive results based on the arterial phase images were included in the group of patients with positive results based on the venous phase images. Although there were 4 patients without active arterial hemorrhage based on the angiographic examination, they still underwent embolization. CONCLUSIONS: In the management of patients with pelvic fractures, CTA provides limited benefits in the evaluation of the active arterial hemorrhage. The additional arterial phase may be helpful for distinguishing between arterial and venous hemorrhage. However, this study showed that subsequent treatment was not changed.

The diminishing role of pelvic x-rays in the management of patients with major torso injuries.

INTRODUCTION: A pelvic x-ray (PXR) can be used as an effective screening tool to evaluate pelvic fractures and stability. However, associated intra-abdominal/retroperitoneal organ injuries and hemorrhage should also be considered and evaluated in patients with major torso injuries. An abdominal/pelvic computed tomographic (CT) scan may provide higher resolution and more information than a PXR. The role of conventional PXRs was delineated in the current study in the context of the development of the CT scan. MATERIALS AND METHODS: We retrospectively reviewed patients with major torso injuries in our institution. The characteristics of the patients who received different diagnostic modalities (PXR only, CT scan only, or both) were investigated and compared. The characteristics of patients who underwent transcatheter arterial embolization (TAE) for the hemostasis of pelvic fracture-related retroperitoneal hemorrhage were also analyzed. RESULT: There were 726 patients enrolled in current stud. Only 72.0% (523/726) of the patients who had major torso injuries were examined using PXRs, and 69.6% (505/726) of the patients underwent an abdominal/pelvic CT scan. For the patients who were examined using PXRs, there was no significant difference in the usage rate of an additional CT scan between the patients with positive (52.7%, 108/205) and negative (61.0%, 194/318) PXR examinations (P = .070). Four patients underwent TAE immediately following PXR examinations only, without a CT scan. These four patients had unstable pelvic fractures on the PXR examination and significantly a lower systolic blood pressure (61.0 ± 13.0 mmHg), a lower revised trauma score (3.560 ± 2.427), a greater requirement for blood transfusions (1750 ± 957.2 ml) than the patients who underwent TAE after a CT scan. CONCLUSION: For the management of patients with major torso injuries, the role of PXR is diminishing due to the development of the CT scan. However, the PXR is still valuable for patients who are in critical condition and have an obviously high probability of retroperitoneal hemorrhaging.

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.

Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers.

INTRODUCTION: Patients with pelvic fracture usually require transfers to trauma centers for additional advanced treatment. Patient safety during the transfer should always be a priority. The noninvasive pelvic circumferential compression device (PCCD) can reportedly provide a tamponade effect, which reduces hemorrhage. In the present study, we evaluated the feasibility and efficiency of PCCD in patients with pelvic fracture who required transfer to trauma centers. MATERIALS AND METHODS: In the present study, we aimed to evaluate patients with pelvic fractures who were transferred from other hospitals. We investigated and compared the characteristics of these types of patients with and without pretransfer PCCD. We compared 2 groups (with and without pretransfer PCCD) of patients under different situations (unstable pelvic fracture, stable pelvic fracture, or indicated for transcatheter arterial embolization). We also analyzed the characteristics of patients with unstable pelvic fracture who were initially evaluated as having stable pelvic fracture primarily before being transferred. RESULTS: During the 53-month period, we enrolled 585 patients in the study. The patients with unstable pelvic fractures who received pretransfer PCCDs required significantly fewer blood transfusions (398.4 ± 417.6 mL vs 1954.5 ± 249.0 mL, P < .001), shorter intensive care unit length of stay (LOS; 6.6 ± 5.2 days vs 11.8 ± 7.7 days, P = .024), and shorter hospital LOS (9.4 ± 7.0 days vs 19.5 ± 13.7 days, P = .006) compared with patients who did not receive the pretransfer PCCD. The stable patients who received pretransfer PCCDs required significantly fewer blood transfusions (120.2 ± 178.5 mL vs 231.8 ± 206.2 mL, P = .018) and had shorter intensive care unit LOS (1.7 ± 3.3 days vs 3.4 ± 2.9 days, P = .029) and shorter hospital LOS (6.8 ± 5.1 days vs 10.4 ± 7.6 days, P = .018) compared with patients who did not receive the pretransfer PCCD. CONCLUSION: Pelvic circumferential compression devices benefit patients with pelvic fracture who need to be transferred to trauma centers. Pretransfer PCCDs appeared to be a feasible and safe procedure during the transfer. In discussions between the referring physicians and the receiving physicians, we recommend using pretransfer PCCDs.

Intra-Arterial Urokinase for Acute Superior Mesenteric Artery Occlusion: A Retrospective 12-Year Report of 13 Cases.

This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted.

Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience.

INTRODUCTION: We aimed to compare outcomes of pancreatic resection with that of peripancreatic drainage for American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) grade IV blunt pancreatic injury in order to determine the optimal treatment method. MATERIALS AND METHODS: Nineteen surgical patients with AAST-OIS grade IV blunt pancreatic injury between 1994 and 2016 were retrospectively studied. RESULTS: Among the 19 patients, 14 were men and 5 were women (median age: 33 years). Twelve patients underwent pancreatic resection (spleen-sacrificing distal pancreatectomy, n = 6; spleen-preserving distal pancreatectomy, n = 3; and central pancreatectomy with Roux-en-Y anastomosis, n = 3), and seven underwent peripancreatic drainage. After comparing these two groups, no significant differences were found in terms of gender, shock at triage, laboratory data, injury severity score, associated injury, length of hospital stay, and complication. The only significant difference was that in the drainage group, the duration from injury to surgery was longer than that from injury to resection (median, 48 hours vs. 24 hours; P = 0.036). In the drainage group, three patients required reoperation, and another three required further pancreatic duct stent therapy. CONCLUSIONS: In the surgery of the grade IV blunt pancreatic injury, pancreatic resection is warranted in early, conclusive MPD injury; if surgery is delayed or MPD injury has not been clearly assessed, peripancreatic drainage is an alternative method. However, peripancreatic drainage alone is not adequate and further pancreatic duct stent or reoperation is required. Further studies should be conducted to confirm our conclusions.

Angioembolization and laparotomy for patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma.

BACKGROUND: Treatment of patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma (BAT) is challenging. Controversies remain over the diagnostic approach and the priority of available treatment resources. METHODS: Between 1999 and 2008, 545 patients were admitted due to concomitant BAT and pelvic fracture. Seventy-six patients receiving both angiography and laparotomy were studied. Focused abdominal sonography for trauma (FAST) was used as the primary triage tool in the early 5 years and multi-detector computed tomography (MDCT) in the later 5 years. The clinical courses and results were retrospectively analyzed to determine if the evolution of the clinical pathways for managing these patients resulted in improved outcomes. RESULTS: Performing laparotomy solely based on FAST during the early 5 years resulted in a high nontherapeutic laparotomy rate (36%). Contrast enhanced MDCT, as the primary triage tool, accurately disclosed active intra-abdominal and pelvic injuries and was helpful in promptly tailoring the subsequent treatment. Additional surgical trauma was avoided in some patients and nontherapeutic laparotomy rate decreased to 16%. Multiple bleeders were found in 70% of positive angiograms; bilateral internal iliac artery embolization for the purpose of damage control showed a lower repeat angioembolization rate for these severely injured patients. CONCLUSION: The revised clinical algorithm served well for guiding the treatment pathway. Priority of laparotomy or angiography should be individualized and customized according to the clinical evaluation and CT findings. Angiography can be both diagnostic and therapeutic and simultaneously treat multiple bleeders; thus, it has a higher priority than laparotomy. The primary benefits of our later clinical pathway were in reducing nontherapeutic laparotomy and repeat angioembolization rates.

Contrast-enhanced multiphasic computed tomography for identifying life-threatening mesenteric hemorrhage and transmural bowel injuries.

BACKGROUND: Active mesenteric hemorrhage and bowel perforation after blunt abdominal trauma warrant immediate surgical intervention. We investigate whether findings on multiphasic computed tomography (CT) can identify life-threatening mesenteric hemorrhage and bowel injuries. METHODS: Within 1-year period, 106 patients underwent multiphasic CT for evaluation of blunt abdominal injuries. Images obtained at arterial phase, portal phase, and equilibrium phase were retrospectively reviewed with special focus on mesentery and bowel injuries. We compared the recorded findings with surgically proven active mesenteric hemorrhage and transmural bowel injuries. The diagnostic values and positive likelihood ratios of individual CT signs were calculated. RESULTS: Mesenteric contrast extravasation had 73.5 positive likelihood ratio and 75% sensitivity for active mesenteric hemorrhage. Hemorrhage first appeared at arterial phase and portal phase was active and life threatening, different from a contained hemorrhage appeared only at equilibrium phase. For transmural bowel injuries, positive likelihood ratio of full-thickness bowel wall abnormality and extraluminal air was large at 32.5 and 26.9, respectively. However, increased mesenteric fat density and peritoneal fluid had high negative predictive value at 98.9 and 97.8. Mean radiodensity of peritoneal fluid in transmural bowel injuries was significantly lower (30 vs. 44 Hounsfield unit, p = 0.008). CONCLUSIONS: Multiphasic CT is accurate in identifying life-threatening mesenteric hemorrhage and transmural bowel injuries.

Acute liver abscess after non-operative management of blunt liver injury: A rare case managed with laparoscopic drainage.

INTRODUCTION: Liver abscess may develop as a rare complication of the non-operative management (NOM) of blunt liver injury. PRESENTATION: A 36-year-old male was injured in a motorcycle accident on November 28, 2017. First aid was performed at the local hospital, then he was transferred to our trauma center for further management. The abdominal computed tomography (CT) revealed a segment 7/8 liver laceration, and the liver injury was of grade III according to the American Association for the Surgery of Trauma-Organ Injury Scale for liver injury. Intermittent high fever was observed for the first 3 days after NOM, and repeat abdominal CT showed an abscess with rupture at the previously injured liver parenchyma. He underwent laparoscopic drainage of the liver abscess, and culture revealed the presence of Salmonella enterica, serogroup D. After laparoscopic drainage, the patient recovered well, with a 21-day hospital stay. DISCUSSION: Liver abscess as a complication after NOM of blunt liver injury is a rare entity, with an incidence rate of 1.5%. It is usually seen in major liver injuries (grade III and above) and the abscesses take a median of 6 days (range, 1-12 days) to form and be diagnosed. The management of liver abscess may be by surgical drainage (laparotomy or laparoscopy) or percutaneous drainage. CONCLUSION: This report reminds us the liver abscess complication after NOM of blunt liver injury, although it is a rare entity. Results of this patient support drainage of the liver abscess can be safely and effectively performed by laparoscopy.

Differences of liver CT perfusion of blunt trauma treated with therapeutic embolization and observation management.

Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.

Repeat transcatheter arterial embolization for the management of pelvic arterial hemorrhage.

BACKGROUND: Most arterial hemorrhage associated with pelvic fracture can be adequately controlled by a single transcatheter arterial embolization (TAE). However, there is a small group of patients who remain hemodynamically unstable after TAE, have no other identifiable source of bleeding, and who benefit from repeat TAE of the pelvis. METHODS: We conducted a retrospective study of patients with hemorrhage from pelvic fractures between January 2001 and June 2006. Clinical parameters and results were compared between patients requiring more than one pelvic TAE and those undergoing a single TAE. Risk factors for repeat TAE were identified by univariate and stepwise logistic regression analyses. RESULTS: During the study period, 174 of 964 patients with pelvic fracture received pelvic angiography for suspected arterial hemorrhage. One hundred forty TAEs were performed. Thirty-four (24.3%) patients underwent more than one angiography for suspected recurrent arterial hemorrhage, and 26 (18.6%) underwent repeat TAE. Repeat angiography was performed 3 to 58 hours (mean, 21 hours) after initial TAE. Patients with repeat TAE had significantly more blood transfusions, higher mortality rate, and longer intensive care unit stay. Independent predictors for repeat TAE included initial hemoglobin level lower than 7.5 g/dL (OR, 6.22), superselective arterial embolization in initial TAE (OR, 3.22), and more than 6 units of blood transfusion after initial TAE (OR, 3.22). CONCLUSION: Careful monitoring and prompt recognition of patients requiring repeat TAE is paramount. The arterial access sheath should remain in place for up to 72 hours after angiography. Initial hemoglobin level lower than 7.5 g/dL and more than 6 units of blood transfusion after initial angiography are predictors for repeat TAE. Superselective TAE is associated with a significantly higher risk of recurrent hemorrhage, and its use should be limited.

Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre.

INTRODUCTION: The aim of this study was to present our surgical experience of isolated blunt major pancreatic injury (IBMPI), and to compare its characteristic outcomes with that of multi-organ injury. MATERIALS AND METHODS: From 1994-2015, 31 patients with IBMPI and 54 patients with multi-organ injury, who underwent surgery, were retrospectively studied. RESULTS: Of the 31 patients with IBMPI, 22 were male and 9 were female. The median age was 30 years (interquartile range, 20-38). Twenty-one patients were classified as the American Association for the Surgery of Trauma-Organ Injury Scale Grade III, and 10 patients as Grade IV. Patients with IBMPI had significantly lower shock-at-triage rates, lower injury severity scores, longer injury-to-surgery time, and shorter length of hospital stay than those with multi-organ injury. There were no statistically significant differences in sex, age, trauma mechanism, laboratory data, surgical procedures, and complications between the two groups. Eight patients with IBMPI underwent endoscopic retrograde pancreatography, and 5 patients with complete major pancreatic duct (MPD) disruption underwent pancreatectomy eventually. The remaining 3 patients had partial MPD injury and two of them received a pancreatic duct stent for the treatment of existing postoperative pancreatic fistula. Spleen-sacrificing distal pancreatectomy (SSDP) was performed in 13 patient with IBMPI, followed by spleen-preserving distal pancreatectomy (n = 12), peripancreatic drainage (n = 4), and central pancreatectomy with Roux-en-Y reconstruction (n = 2). The overall complication rates, related to the SSDP, SPDP, peripancreatic drainage, and central pancreatectomy, were 10/13 (77%), 4/12 (33%), 3/4 (75%), and 2/2 (100%), respectively. Three patients died resulting in a 10% mortality rate, and the other 16 patients developed intra-abdominal complications resulting in a 52% morbidity rate. In the subgroup analysis of the 25 patients who underwent distal pancreatectomy, SPDP was associated with a shorter injury-to-surgery time than SSDP. CONCLUSIONS: Patients with IBMPI have longer injury-to-surgery times, compared to those with multi-organ injury. Of the distal pancreatectomy patients, the time interval from injury to surgery was a significant associated factor in preserving or sacrificing the spleen.

Multidetector-row computed tomography (CT) of blunt pancreatic injuries: can contrast-enhanced multiphasic CT detect pancreatic duct injuries?

BACKGROUND: We examined patients of blunt trauma with contrast-enhanced multiphasic computed tomography (CT) and determined if it could detect pancreatic duct injuries. METHODS: During a 17-month period, 95 patients of blunt abdominal trauma underwent multiphasic CT examinations. The CT grading scales of pancreatic injuries at parenchymal phase, portal venous phase, and equilibrium phase were recorded and compared with surgery, endoscopic retrograde cholangiopancreatography, or discharged diagnosis. The diagnostic values of multiphasic CT and interobserver agreements at different phases were computed. RESULTS: Of the 95 patients, nine (9.5%) had pancreatic injuries (six with main duct injuries, three without main duct injuries). The interobserver agreement presented in kappa values between two radiologists regarding the integrity or disruption of the main duct were good at parenchymal phase (K = 0.73), portal venous phase (K = 0.64), and equilibrium phase (K = 0.68). The overall accuracies of multiphasic CT in detecting main duct injuries were 97.9% (parenchymal phase), 100.0% (portal venous phase), and 96.8% (equilibrium phase), respectively. The sensitivity (50.0%) and negative predictive value (96.7%) of equilibrium phase CT were the lowest among the three phases of CT scans. CONCLUSION: The portal venous phase CT was the most accurate scan to detect pancreatic duct injuries. However, equilibrium phase CT might underestimate major pancreatic injuries. Multiphasic CT shows early promise in this clinical application and further multi-institutional studies to verify its accuracy and reveal the optimal CT methodology are needed.

Detection and characterization of traumatic bile leaks using Gd-EOB-DTPA enhanced magnetic resonance cholangiography.

Expanding bile leaks after blunt liver trauma require more aggressive treatment than contained bile leaks. In this retrospective study approved by institution review board, we analyzed if non-invasive contrast-enhanced magnetic resonance cholangiography (CEMRC) using hepatocyte-specific contrast agent (gadoxetic acid disodium) could detect and characterize traumatic bile leaks. Between March 2012 and December 2014, written informed consents from 22 included patients (17 men, 5 women) with a median age of 24.5 years (IQR 21.8, 36.0 years) were obtained. Biliary tree visualization and bile leak detection on CEMRC acquired at 10, 20, 30, 90 minutes time points were independently graded by three radiologists on a 5-point Likert scale. Intraclass Correlation (ICC) was computed as estimates of interrater reliability. Accuracy was measured by area under receiver operating characteristic curves (AUROC). Biliary tree visualization was the best on CEMRC at 90 minutes (score 4.30) with excellent inter-rater reliability (ICC = 0.930). Of 22 CEMRC, 15 had bile leak (8 expanding, 7 contained). The largest AUROC of bile leak detection by three radiologists were 0.824, 0.914, 0.929 respectively on CEMRC at 90 minutes with ICC of 0.816. In conclusion, bile leaks of blunt liver trauma can be accurately detected and characterized on CEMRC.