Divergent effects of RIP1 or RIP3 blockade in murine models of acute liver injury.

Necroptosis is a recently described Caspase 8-independent method of cell death that denotes organized cellular necrosis. The roles of RIP1 and RIP3 in mediating hepatocyte death from acute liver injury are incompletely defined. Effects of necroptosis blockade were studied by separately targeting RIP1 and RIP3 in diverse murine models of acute liver injury. Blockade of necroptosis had disparate effects on disease outcome depending on the precise etiology of liver injury and component of the necrosome targeted. In ConA-induced autoimmune hepatitis, RIP3 deletion was protective, whereas RIP1 inhibition exacerbated disease, accelerated animal death, and was associated with increased hepatocyte apoptosis. Conversely, in acetaminophen-mediated liver injury, blockade of either RIP1 or RIP3 was protective and was associated with lower NLRP3 inflammasome activation. Our work highlights the fact that diverse modes of acute liver injury have differing requirements for RIP1 and RIP3; moreover, within a single injury model, RIP1 and RIP3 blockade can have diametrically opposite effects on tissue damage, suggesting that interference with distinct components of the necrosome must be considered separately.

False-positive rate of positron emission tomography/computed tomography for presumed solitary metastatic adrenal disease in patients with known malignancy.

PURPOSE: The aim of this study was to determine the diagnostic accuracy of positron emission tomography (PET) in cancer patients undergoing adrenalectomy for presumed metastatic disease, utilizing the gold standard of histopathology. METHODS: We retrospectively reviewed all adrenalectomies for metastatic disease performed at our institution over the last 12 years. Preoperative PET scans were compared with final pathology reports. Statistical analyses were performed with Fisher's exact test for categorical variables and Student's t test for continuous variables. RESULTS: Forty-nine adrenalectomies were performed for metastatic disease. Thirty had preoperative PET imaging and were included in this analysis. Mean age was 65.5 ± 13.6 years (29-91) and 54 % were male. Mean size was 3.8 cm (0.4-7.1). Primary tumor distribution was 61 % (n = 17) pulmonary; 11 % (n = 3) breast; 7 % (n = 2) gastric; 7 % (n = 2) renal; and 4 % (n = 1) each of brain, lymphoma, melanoma, and uterine. Mean standardized uptake value (SUV) was 11 ± 7.3 (3.2-30.0). Final pathology revealed that 80 % (25/30) were positive for metastatic disease and 20 % (5/30) were negative. The positive predictive value of PET in correctly identifying adrenal metastatic disease was 83 % (24 true-positive cases and 5 false-positive cases); there was one false-negative PET. False-positive PET results were not correlated with sex (p = 0.35), age (p = 0.24), or maximum SUV units (p = 0.26). CONCLUSIONS: The 20 % false-positive rate for PET-positive adrenalectomies performed for metastatic disease should warrant its inclusion in preoperative counseling to the patient and interaction with the treating oncologist.

Can the location of the CT whirl sign assist in differentiating sigmoid from caecal volvulus?

AIM: To determine whether the location of the computed tomography (CT) whirl sign can be used to help differentiate caecal from sigmoid volvulus. MATERIALS AND METHODS: Thirty-one patients (mean age 64.6 years) underwent multidetector CT and had confirmed colonic volvulus. There were 15 patients with caecal volvulus and 16 with sigmoid volvulus. Axial and coronal images were retrospectively evaluated on the picture archiving and communication system (PACS) by two reviewers in consensus without knowledge of the final diagnosis to determine whether a CT whirl sign was present and, if so, was the location to the right of midline or in the midline/left. The location of the twisting at imaging was correlated with whether the patient had caecal or sigmoid volvulus. Fisher's exact test was used to determine whether there was an association between the location of the twist (right versus mid-left) and the location of the colonic volvulus (caecal versus sigmoid). The non contrast CT (NCCT) examinations of 30 additional patients without colonic volvulus were evaluated for the presence or absence of a CT whirl sign. RESULTS: All 31 patients with colonic volvulus had a CT whirl sign. No patient who underwent NCCT for kidney stones demonstrated a CT whirl sign. According to Fisher's exact test, there was a highly significant association (p<0.0001) between the location of the twist (right versus mid-left) and the location of the colonic volvulus (caecal versus sigmoid). Using the location of the twist as a predictor of whether the volvulus was caecal or sigmoid provided a correct diagnosis for 93.3% (14/15) of the patients with caecal volvulus and 100% (16/16) of those with sigmoid volvulus, yielding an overall diagnostic accuracy of 96.8% (30/31). CONCLUSION: The location of the mesenteric twist (CT whirl sign) is a highly accurate finding in discriminating caecal from sigmoid volvulus.

CT of jejunal diverticulitis: imaging findings, differential diagnosis, and clinical management.

AIM: To describe the imaging findings of jejunal diverticulitis as depicted at contrast-enhanced computed tomography (CT) and review the differential diagnosis and clinical management. MATERIALS AND METHODS: CT and pathology databases were searched for the diagnosis of jejunal diverticulitis. Three cases were identified and the imaging and clinical findings correlated. RESULTS: Jejunal diverticulitis presents as a focal inflammatory mass involving the proximal small bowel. A trial of medical management with antibiotics may be attempted. Surgical resection may be required if medical management is unsuccessful. CONCLUSION: The imaging findings at MDCT may allow a specific diagnosis of jejunal diverticulitis to be considered and may affect the clinical management of the patient.

Multiinstitutional experience with the management of superior mesenteric artery injuries.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN: We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS: There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. CONCLUSION: SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Topical hepatic hypothermia attenuates pulmonary injury after hepatic ischemia and reperfusion.

BACKGROUND: Prolonged periods of hepatic ischemia are associated with hepatocellular injury and distant organ dysfunction in experimental models. Neutrophils (PMN) and tumor necrosis factor (TNF)-alpha have been implicated, mostly because of their local deleterious effects on the hepatocyte after hepatic ischemia and reperfusion (I/R) injury. We hypothesize that topical hepatic hypothermia (THH) reduces ischemia and reperfusion-induced hepatic necrosis, PMN infiltration, TNF-alpha release, and consequent acute pulmonary injury. STUDY DESIGN: Sprague-Dawley rats (250 to 300g) were evenly divided into three groups: 90 minutes of normothermic (37 degrees C) partial hepatic ischemia (normothermic I/R), 90 minutes of hypothermic (25 degrees C) partial hepatic ischemia (hypothermic I/R), and sham laparotomy (without ischemia). There were six animals in each experimental group per time point unless otherwise specified. Hepatic necrosis and PMN infiltration were evaluated and scored on hematoxylin and eosin-stained liver specimens 12 hours after reperfusion. Serum TNF-alpha levels were determined by ELISA at 0 minutes, 15 minutes, 30 minutes, 1 hour, and 12 hours postreperfusion. Pulmonary PMN infiltration and vascular permeability were measured by myeloperoxidase activity and Evans blue dye extravasation, respectively, to quantitate pulmonary injury 12 hours after reperfusion. RESULTS: Normothermic I/R results in a significant increase in TNF-alpha at 15 and 30 minutes (p < 0.005), PMN infiltration (p < 0.001), and hepatic necrosis (p < 0.001), compared with sham. Institution of THH reduced peak serum TNF-alpha levels by 54% at 15 minutes (p < 0.005) and by 73% at 30 minutes (p < 0.001) postreperfusion compared with normothermic I/R. Similarly, hepatic PMN infiltration and necrosis at 12 hours were reduced by 60% (p < 0.05) and 47% (p < 0.05), respectively. Myeloperoxidase activity and Evans blue extravasation (measures of acute lung injury) were reduced by 42% and 39%, respectively, with institution of THH compared with animals undergoing normothermic I/R (p < 0.001). CONCLUSIONS: These results demonstrate that THH protects the liver from ischemia and reperfusion-induced necrosis and PMN infiltration. In addition, THH reduces the serum levels of TNF-alpha and associated pulmonary injury. These data suggest that the ischemic liver is a potential source of inflammatory mediators associated with hepatic ischemia and reperfusion-induced pulmonary injury.

The current status of splenic preservation.

The recognition of the fundamental role of the spleen in the immune response has led to greater efforts to preserve the spleen after injury. Whenever possible, splenic preservation is the preferred treatment modality for both blunt and penetrating injuries. The past 2 decades have seen an evolution in the way this goal is accomplished. Operative splenic preservation achieved by splenorrhaphy as the most prevalent method for the management of splenic trauma has progressed to the nonoperative management of these injuries. The factor most responsible for bringing about this change has been the development of more sophisticated and accurate imaging techniques in the evaluation of these patients. Splenectomy should be avoided whenever possible, as the procedure continues to be associated with excessive transfusion requirements and increased postoperative sepsis rates.

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis.

BACKGROUND: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. OBJECTIVE: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. METHODS: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome. RESULTS: A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051). CONCLUSION: Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury.

Decreasing length of stay after pancreatoduodenectomy.

HYPOTHESIS: Decreased length of stay (LOS) after pancreatoduodenectomy is due to multiple factors, including a lower complication rate and more efficient perioperative care for all patients, with and without complications. DESIGN: A retrospective review, validation cohort. SETTING: A single university hospital referral center. PATIENTS: A consecutive sample of patients undergoing pancreatoduodenectomy from January 9, 1986, to December 21, 1992 (group 1 [n = 104]) and from February 16, 1993, to November 9, 1998 (group 2 [n = 111]). INTERVENTION: Mann-Whitney test and linear [correction of logistic] regression analysis applied to clinical variables and LOS. MAIN OUTCOME MEASURES: Difference in median LOS between early and late groups and identification of factors predictive of decreased LOS. RESULTS: Total LOS decreased between the 2 groups (26 days [range, 13-117 days] vs 15 days [range, 5-61 days]; P<.001), with a decrease in preoperative (4 days [range, 0-28 days] vs 2 days [range, 0-36 days]; P<.001) and postoperative (19 days [range, 11-95 days] vs 12 days [range, 4-58 days]; P<.001) LOS (data given for group 1 vs group 2). Major complications decreased from 49% in group 1 to 25% in group 2 (P<.001). Postoperative LOS decreased for patients with (25 days [range, 15-95 days] vs 20 days [range, 8-58 days]; P = .05) and without (15 days [range, 11-47 days] vs 11 days [range, 4-55 days]; P<.001) major complications (data given for group 1 vs group 2). Multivariate analysis identified age (P = .01), pancreatic fistula (P<.001), delayed gastric emptying (P<.001), biliary complications (P<.001), operative time (P<.005), extra-abdominal infection (P<.005), use of a percutaneous stent (P = .04), and year of operation (P<.001) as independent predictors of total LOS. CONCLUSION: A reduction in complications in combination with factors leading to a streamlining of perioperative care has contributed to the decreased LOS after pancreatoduodenectomy.

Complete biliary avulsion from blunt compression injury.

The liver is the solid organ most commonly injured as a result of blunt abdominal trauma. Complete avulsion of the common hepatic duct is a rare and devastating type of hepatobiliary trauma. Here the authors report the case of a 7-year-old child who had complete biliary disruption as a result of an abdominal crush injury that was not diagnosed correctly preoperatively. The intraoperative diagnosis and treatment of this injury is discussed.

Changing patterns in the management of splenic trauma: the impact of nonoperative management.

OBJECTIVE: The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed. METHODS: Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. RESULTS: Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management. CONCLUSIONS: Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.

Endoscopic biliary drainage before pancreaticoduodenectomy for periampullary malignancies.

Despite decreased operative mortality, pancreaticoduodenectomy (PD) remains a formidable operation with substantial morbidity. We have evaluated the influence of preoperative endoscopic biliary drainage (EBD) on morbidity after PD for malignant biliary obstruction by retrospectively reviewing the medical records of 182 patients undergoing PD between April 1985 and August 1996. Of 52 study patients with malignant obstructive jaundice, 22 underwent preoperative EBD, and 30 were not drained. Eighty-three patients were excluded for bilirubin levels less than 5 mg/dl, 43 had other biliary drainage, and 4 had jaundice with benign pathology. Preoperative, intraoperative, and postoperative factors were compared. The two groups were well matched for clinical presentation and operative characteristics except for lower preoperative values of liver chemistries in patients undergoing EBD. Length of postoperative hospitalization for patients undergoing EBD was 13.5 days, compared with 19 days for patients who were not drained (p = 0.02). Patients who were not drained tended to have more overall complications (p = 0.054). Multivariate analysis revealed time to regular diet (p < 0.0001) and no preoperative drainage (p = 0.04) to be independent factors significantly increasing the length of hospitalization. Endoscopic biliary drainage before PD significantly reduced the length of postoperative hospitalization and was associated with less postoperative morbidity. Further studies, including cost analysis, are warranted.

Laparoscopy for penetrating thoracoabdominal trauma: pitfalls and promises.

BACKGROUND: How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention. DESIGN: Prospective case series. MATERIALS AND METHODS: Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken. RESULTS: Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma victims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy. CONCLUSIONS: Laparoscopy has become a useful and accurate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontherapeutic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the primary technique to evaluate penetrating lower thoracic trauma.

Rupture of the pathologic spleen: is there a role for nonoperative therapy?

INTRODUCTION: While nonoperative management of blunt splenic injury in the stable patient has become the standard of care, splenectomy is still advocated as the safest management for rupture of the diseased spleen. The combination of splenectomy and underlying immunosuppression may render these patients particularly susceptible to postsplenectomy infection, and thus we undertook a prospective trial of nonoperative management of the ruptured pathologic spleen. METHODS: Hemodynamically stable patients with preexisting pathologic splenomegaly and isolated splenic disruptions diagnosed by computed tomographic (CT) scan (American Association for the Surgery of Trauma (AAST) grades 1-4) requiring 2 or less units blood transfusion were prospectively studied. Patients were monitored in a critical care setting, and resolution of splenic disruption was followed by serial CT examinations. RESULTS: Nonoperative management was successful in all 11 patients (eight, HIV/AIDS; one each, acute leukemia, infectious mononucleosis, sickle cell anemia). The mean transfusion requirement was 0.7 units; the mean length of stay was 16 days. CONCLUSIONS: The pathologic spleen can heal after parenchymal disruption. While not appropriate for all patients, a subset of hemodynamically stable patients can be successfully managed nonoperatively using CT diagnosis, close clinical monitoring, and minimal transfusions.

Complex hepatic injuries.

The most significant contribution to the management of hepatic injuries over the past 5 years has been the nonoperative management of blunt injuries in the adult patient. Recent data suggest that as many as 80% of all blunt hepatic injuries may be treated in this fashion, with a success rate exceeding 95%. The fear of missing hollow viscus injuries, as well as the risk of sudden hemorrhage in the observational period, leading to an increase in hepatic-related deaths, seems exaggerated. The intraoperative management of complex hepatic injuries revolves around strict adherence to resuscitation prior to addressing the lesion itself. At times, "damage control" with termination of surgery and "packing" the patient with planned re-exploration are critical, as these maneuvers are often lifesaving. The Pringle maneuver and intrahepatic hemostasis for grades III to IV injuries have resulted in a mortality rate under 10%. Juxtahepatic venous injuries continue to carry an inordinately high mortality rate. Intracaval shunts, when used, should be inserted early in the course of the operation before excess transfusions are given and acidosis and hypothermia develop.

Human immunodeficiency virus and the trauma patient: factors influencing postoperative infectious complications.

OBJECTIVE: While immunosuppression 2 degrees to human immunodeficiency virus (HIV) infection should logically render HIV+ trauma victims more prone to infection after injury, little data is available regarding trauma outcome in this group of patients. Since the helper CD4+ lymphocyte count is a marker for progression of HIV-associated diseases, we examined the relationship between CD4+ counts, Injury Severity Score (ISS), and bacterial infectious complications in HIV+ trauma patients. METHOD: Retrospective review of 56 consecutive HIV+ trauma patients treated at a Level I trauma center. RESULTS: Nine patients (15%) developed significant infectious complications (four pneumonias, three soft-tissue infections, one urinary tract infection, one wound infection) with no pattern to the causative agents. Evaluation of CD4+ counts, white blood cell counts, serum albumin levels, blood transfusion requirements, and ISS revealed that only the ISS was associated with infectious complications. CONCLUSION: Despite the profound immunosuppression in this group of patients, the incidence of bacterial infectious complications was independent of the CD4+ count (p = 0.958), but was associated with increases in the ISS (p = 0.003).

Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients.

INTRODUCTION: Nonoperative management is presently considered the treatment modality of choice in over 50% of adult patients sustaining blunt hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma centers could validate the currently reported high success rate, low morbidity, and virtually nonexistent mortality associated with this approach. Thirteen level I trauma centers accrued 404 adult patients sustaining blunt hepatic injuries managed nonoperatively over the last 5 years. Seventy-two percent of the injuries resulted from motor vehicle crashes. The mean injury severity score for the entire group was 20.2 (range, 4-75), and the American Association for the Surgery of Trauma-computerized axial tomography scan grading was as follows: grade I, 19% (n = 76); grade II, 31% (n = 124); grade III, 36% (n = 146); grade IV, 10% (n = 42); and grade V, 4% (n = 16). There were 27 deaths (7%) in the series, with 59% directly related to head trauma. Only two deaths (0.4%) could be attributed to hepatic injury. Twenty-one (5%) complications were documented, with the most common being hemorrhage, occurring in 14 (3.5%). Only 3 (0.7%) of these 14 patients required surgical intervention, 6 were treated by transfusions alone (0.5 to 5 U), 4 underwent angio-embolization, and 1 was further observed. Other complications included 2 bilomas and 3 perihepatic abscesses (all drained percutaneously). Two small bowel injuries were initially missed (0.5%), and diagnosed 2 and 3 days after admission. Overall, 6 patients required operative intervention: 3 for hemorrhage, 2 for missed enteric injuries, and 1 for persistent sepsis after unsuccessful percutaneous drainage. Average length of stay was 13 days. Nonoperative management of blunt hepatic injuries is clearly the treatment modality of choice in hemodynamically stable patients, irrespective of grade of injury or degree of hemoperitoneum. Current data would suggest that 50 to 80% (47% in this series) of all adult patients with blunt hepatic injuries are candidates for this form of therapy. Exactly 98.5% of patients analyzed in this study successfully avoided operative intervention. Bleeding complications are infrequently encountered (3.5%) and can often be managed nonoperatively. Although grades IV and V injuries composed 14% of the series, they represented 66.6% of the patients requiring operative intervention and thus merit constant re-evaluation and close observation in critical care units. The optimal time for follow-up computerized axial tomography scanning seems to be within 7 to 10 days after injury.

Portal triad injuries.

OBJECTIVE: Injuries to the portal triad are a rare and complex challenge in trauma surgery. The purpose of this review is to better characterize the incidence, lethality, and successful management schemes used to treat these injuries. DESIGN: A retrospective review of the experience of eight academic level I trauma centers over a combined 62 years. RESULTS: A retrospective review of the experience of eight anatomical structures of the portal hepatis: 118 injuries to the anatomical structures of the portal hepatis: 55 extrahepatic portal vein injuries, 28 extrahepatic arterial injuries, and 35 injuries to the extrahepatic biliary tree. Sixty-nine percent of the injuries were by penetrating mechanism and 31% were by blunt mechanism. All patients had associated injuries with a mean Injury Severity Score of 34 in blunt trauma patients. Overall mortality was 51%, rising to 80% in patients with combination injuries. Sixty-six percent of deaths occurred in the operating room, primarily from exsanguination; 18% of deaths occurred within 48 hours of injury from refractory shock, coagulopathy, or cardiac arrest; 16% occurred late. Ten percent of patients undergoing portal vein ligation survived, compared to 58% managed by primary repair. Survival after hepatic artery ligation was 42%, compared to 14% after primary repair. Survival after biliary-enteric anastomosis as treatment of extrahepatic bile duct injury was 89%, compared to 50% after primary repair and 100% after ligation of lobar bile duct injuries. Missed bile duct injuries had a high (75%) severe complication rate. CONCLUSIONS: Injuries to the anatomical structures of the portal triad are rare and often lethal. Intraoperative exsanguination is the primary cause of death, and hemorrhage control should be the first priority. Bile duct injuries should be identified by intraoperative cholangiography and repaired primarily or by enteric anastomosis; lobar bile ducts can be managed by ligation.

Pitfalls in the diagnosis of blunt diaphragmatic injury.

BACKGROUND: Severe blunt trauma to the torso can result in diaphragmatic disruption. Prompt recognition of this potentially life-threatening injury is difficult when the initial chest roentgenogram is unrevealing and immediate thoracotomy or celiotomy is not performed. This retrospective study was undertaken to: (1) determine the incidence of missed diaphragmatic injuries on initial evaluation; (2) identify factors contributing to diagnostic delays; and (3) formulate a diagnostic approach that reliably detects diaphragmatic rupture following blunt trauma. METHODS: Retrospective review of hospital records and radiographs from our 18-year experience with blunt diaphragmatic injuries. RESULTS: Seven of 57 (12%) blunt diaphragmatic injuries were missed on initial evaluation. Recognition followed 2 days to 3 months later. Two (4%) isolated left-sided injuries initially presented with normal chest roentgenograms. Five patients (9%) (4 with right-sided ruptures) had abnormalities on chest roentgenogram or computed tomography (CT) initially attributed to chest trauma. They were diagnosed by radionuclide, ultrasound, or CT investigations of hemothorax, pulmonary sepsis, and right upper quadrant pain; and, in 1 case, at thoracotomy for a persistent right hemothorax. In the remaining 50 patients (88%), the diagnosis was established within 24 hours. In 21 (42%) of these, the problem was initially recognized at the time of celiotomy for accompanying injuries. CONCLUSIONS: Blunt diaphragmatic injuries are easily missed in the absence of other indications for immediate surgery, since radiologic abnormalities of the diaphragm--particularly those involving the right hemidiaphragm--are often interpreted as thoracic trauma. In this setting, a high index of suspicion coupled with selective use of radionuclide scanning, ultrasound, and CT or magnetic resonance imaging is necessary for early detection of this uncommon injury.