CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma.

OBJECTIVES: To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma. METHODS: This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort. RESULTS: CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI. CONCLUSIONS: An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination. KEY POINTS: • A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.

Factors associated with enteral nutrition tolerance after trauma laparotomy of the small bowel and mesenteric injuries by blunt trauma.

BACKGROUND: In patients with blunt injury due to abdominal trauma, the common cause for laparotomy is damage to the small bowel and mesentery. Recently, postoperative early enteral nutrition (EEN) has been recommended for abdominal surgery. However, EEN in patients with blunt bowel and/or mesenteric injury (BBMI) has not been established. Therefore, this study aimed to identify the factors that affect early postoperative small bowel obstruction (EPSBO) and the date of tolerance to solid food and defecation (SF + D) after surgery in patients with BBMI. METHODS: We retrospectively reviewed patients who underwent laparotomy for BBMI at a single regional trauma center between January 2013 and July 2021. A total of 257 patients were included to analyze the factors associated with enteral nutrition tolerance in patients with EPSBO and the postoperative day of tolerance to SF + D. RESULTS: The incidence of EPSBO in patients with BBMI was affected by male sex, small bowel organ injury scale (OIS) score, mesentery OIS score, amount of crystalloid, blood transfusion, and postoperative drain removal date. The higher the mesentery OIS score, the higher was the EPSBO incidence, whereas the small bowel OIS did not increase the incidence of EPSBO. The amount of crystalloid infused within 24 h; the amount of packed red blood cells, fresh frozen plasma, and platelet concentrate transfused; the time of drain removal; Injury Severity Score; and extremity abbreviated injury scale (AIS) score were correlated with the day of tolerance to SF + D. Multivariate analysis between the EPSBO and non-EPSBO groups identified mesentery and small bowel OIS scores as the factors related to EPSBO. CONCLUSION: Mesenteric injury has a greater impact on EPSBO than small bowel injury. Further research is needed to determine whether the mesentery OIS score should be considered during EEN in patients with BBMI. The amount of crystalloid infused and transfused blood components within 24 h, time of drain removal, injury severity score, and extremity AIS score are related to the postoperative day on which patients can tolerate SF + D.

Segmental Bowel Hypoenhancement on CT Predicts Ischemic Mesenteric Laceration After Blunt Trauma.

OBJECTIVE. The objectives of this study were to examine the performance of CT in the diagnosis of ischemic mesenteric laceration after blunt trauma and to assess the predictive value of various CT signs for this injury. MATERIALS AND METHODS. In this retrospective study, consecutive patients with bowel and mesenteric injury diagnosed by CT or surgery from January 2011 through December 2016 were analyzed. Two radiologists evaluated CT images for nine signs of bowel injury. The outcome evaluated was ischemic mesenteric laceration. Univariable analysis followed by logistic regression was performed. RESULTS. The study included 147 patients (96 men and 51 women; median age, 35 years; age range, 23-52 years). Thirty-three patients had surgically confirmed ischemic mesenteric lacerations. CT signs that correlated with ischemic mesenteric laceration were abdominal wall injury, mesenteric contusion, free fluid, segmental bowel hypoenhancement, and bowel hyperenhancement adjacent to a hypoenhancing segment. The regression model developed after inclusion of clinical variables identified two predictors: segmental bowel hypoenhancement (adjusted odds ratio, 22.9 [95% CI, 7.9-66.2; p < .001] for reviewer 1 and 20.7 [95% CI, 7.2-59.0; p < .001] for reviewer 2) and abdominal wall injury (adjusted odds ratio, 5.26 [95% CI, 1.7-15.9; p = .003] for reviewer 1 and 5.3 [95% CI, 1.9-15.0; p = .002] for reviewer 2), which yielded an AUC of 0.87 for predicting injury. For reviewer 1 and reviewer 2, the sensitivities of CT in detecting the injury were 72.3% (95% CI, 54.5-86.7%) and 78.8% (95% CI, 61.0-91.0%), respectively, whereas the specificities were 94.7% (95% CI, 88.9-98.0%), and 92.1% (95% CI, 85.5-96.3%), respectively. CONCLUSION. CT has limited sensitivity but good specificity for detecting ischemic mesenteric laceration, with segmental bowel hypoenhancement considered the most predictive imaging sign.

Vascular bowel and mesenteric injury in blunt abdominal trauma: a single centre experience.

AIM: To establish common patterns of injury in vascular bowel and mesenteric injury (VBMI) and to identify any factors that may lead to delayed treatment. METHODS AND MATERIALS: Forty-one patients with blunt VBMI presented to the level 1 trauma centre of the The Royal London Hospital over 5 years. Computed tomography (CT) images were reviewed to identify the specific location of injury and additional features such as seatbelt bruising and lumbar hernias. Surgical reports were reviewed to record any pertinent surgical findings at laparotomy. RESULTS: The commonest mechanism of injury was a restrained car occupant involved in a road traffic collision (49%, n=20). The ileocaecal mesenteric vasculature was most frequently injured (41.5%, n=17), followed by the mid ileum (17.1%, n=7). Seatbelt bruising was identified in 80% of restrained car occupants and lumbar hernias in 22% of all patients with VBMI. CONCLUSION: Restrained car occupants involved in road traffic collisions are at increased risk of VBMI with particular susceptibility of the ileocaecal mesentery. This has implications for the reporting radiologist and trauma surgeon in deciding which patients require careful monitoring for the development of delayed bowel ischaemia.

Radiographic and CT features of colonic entrapment due to an omental rent in a dog.

A 2-year-old female spayed Great Dane presented for inappetence and lethargy. Abdominal radiographs revealed a severely gas-distended segment of colon. Computed tomography was performed and characterized a 180° anticlockwise colonic torsion with entrapment in a mesenteric/omental rent without vascular compromise. Exploratory laparotomy confirmed entrapment, but not colonic torsion. Computed tomography provided important information to assist clinical management decisions for this dog with colonic entrapment.

Absorbable suture can be effectively and safely used to close the mesenteric defect in a gastric bypass Sprague-Dawley rat model.

BACKGROUND: To observe if closing the mesenteric defect with absorbable sutures creates a safe adhesion compared to non-absorbable suture after Roux-en-Y gastric bypass. METHODS: Rats were randomly assigned to 5 experimental groups according to the different suture materials used in closing the mesenteric defects (Peterson's space) after Roux-en-Y gastric bypass. Group A (control group), Group B (non-absorbable suture, Prolene suture), Group C (biological glue), Group D (non-absorbable suture, polyester suture) and Group E (absorbable suture). All rats were followed up for 8 weeks postoperatively and underwent laparotomy to observe the degree of adhesion and closure of the mesenteric defect. RESULTS: No significant difference was found in the decrease in food intake and body weight among all groups. No internal hernia (IH) occurred in any group. The mesenteric defects of Group A remained completely visible without any closure or adhesion. Multiple gaps were found between the Prolene suture and the mesentery along the suture line in Group B. The mesenteric defects of Group C were complete closed with multiple adhesions of the small intestine and the greater omentum. The mesenteric defects in both Group D and Group E closed completely. The average adhesion scores in Group A and Group B were 0 and 0.33 ± 0.52 respectively. The average adhesion score in group C (3.83 ± 0.41) was higher than the other groups (p<0.05). The average adhesion scores in Group D and E were similar (3.17 ± 0.41 and 3.00 ± 0.00 respectively). CONCLUSION: Absorbable suture created a safe adhesion score between the mesentery which was not inferior to non-absorbable sutures.

Evaluation of Bowel and Mesentery in Abdominal Trauma.

Since the advent of multidetecter computed tomography (CT), radiologist sensitivity in detection of traumatic bowel and mesenteric abnormalities has significantly improved. Although several CT signs have been described to identify intestinal injury, accurate interpretation of these findings can remain challenging. Early detection of bowel and mesenteric injury is important as it alters patient management, disposition, and follow-up. This article reviews the common imaging findings of traumatic small bowel and mesenteric injury.

Accuracy of Preoperative MDCT in Patients With Penetrating Abdominal and Pelvic Trauma.

PURPOSE: This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI). METHOD AND MATERIALS: We used our hospitals' trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted. RESULTS: Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system (F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge. CONCLUSION: The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.

Lethal mesenteric perforation by osteophytes after blunt abdominal trauma.

A 50 year-old homeless man was found dead the day after he had sustained blunt abdominal trauma during a physical assault. Autopsy revealed no apparent injury to the abdominal wall, but showed a massive hemoperitoneum resulting from a large (8 cm) tear of the mesenteric root. It also revealed prominent and diffuse spinal osteophytes predominating in the lumbar region, where they were fused and formed a large anterior ossified excrescence. The diagnosis of diffuse idiopathic skeletal hyperostosis was established in the presence of continuous ossification along the anterior aspect of five contiguous vertebral bodies, without any additional features of degenerative disease on imaging. Death was attributed to intra-abdominal hemorrhage due to mesenteric perforation caused by blunt abdominal trauma in the context of diffuse idiopathic skeletal hyperostosis. This pre-existing condition was considered an aggravating factor, as anterior lumbar osteophytosis had made the mesentery more vulnerable to blunt trauma by reducing both the space separating the abdominal wall from the spine and the surface of interaction between the spine and the mesentery. Only a few cases of osteophyte-related visceral injury have been described in the literature. To our knowledge, this is the first reported case of lethal abdominal injury caused by osteophytes after blunt trauma.

Value of early repeated abdominal CT in selective non-operative management for blunt bowel and mesenteric injury.

OBJECTIVES: To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI). METHODS: This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test). RESULTS: Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94). CONCLUSION: In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment. KEY POINTS: • Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. • An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.

The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma.

BACKGROUND: Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma. METHODS: We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury. RESULTS: There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88). CONCLUSIONS: Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

Is mesenteric defect closure needed in urologic surgery using ileum?

INTRODUCTION: Classic surgical teaching advocates for closure of the mesenteric defect (MD) after bowel anastomosis but the necessity is controversial. We sought to evaluate the necessity of MD closure at the time of harvest of ileum for genitourinary reconstructive surgery (GURS) by analyzing the incidence of early and late gastrointestinal adverse events (GIAE) in patients with and without MD closure. MATERIALS AND METHODS: A retrospective review was conducted on patients undergoing urologic reconstruction with ileum to identify incidence of ileus, small bowel obstruction (SBO), gastrointestinal (GI) fistula and stoma complications. Patient and procedure variables were analyzed to identify risk factors for GIAE. RESULTS: A total of 288 patients met inclusion criteria and 93% of GURS was for urinary diversion following cystectomy. MD was closed in 194 cases (67%). Median follow up was 19 months. Early (< 30 day) GIAE rates were 16.5% (n = 32) and 21.3% (n = 20) in the closure and non-closure groups, respectively (p = 0.22). The rate of early ileus/SBO requiring nasogastric tube decompression or laparotomy were similar after closure (15.0%) and non-closure (21.3%) (p = .18). The late GIAE rates were 5.7% (n = 11) and 6.4% (n = 6) in the closure and non-closure cohorts, respectively (p = 0.56). The rate of late SBO were similar and no cases of early or late SBO in either cohort were due to internal herniation. On multivariate analysis, increasing BMI was associated with both early and late GIAE. CONCLUSIONS: After harvesting ileum for urologic reconstruction, the MD can safely be left open as we found no association between non-closure and early or late GIAE..

Blunt bowel and mesenteric trauma: role of clinical signs along with CT findings in patients' management.

BACKGROUND: Bowel and/or mesentery injuries represent the third most common injury among patients with blunt abdominal trauma. Delayed diagnosis increases morbidity and mortality. The aim of our study was to evaluate the role of clinical signs along with CT findings as predictors of early surgical repair. MATERIAL AND METHODS: Between March 2014 and February 2017, charts and CT scans of consecutive patients treated for blunt abdominal trauma in two different trauma centers were reread by two experienced radiologists. We included all adult patients who underwent contrast-enhanced CT of the abdomen and pelvis with CT findings of blunt bowel and/or mesenteric injury (BBMI). We divided CT findings into two groups: the first included three highly specific CT signs and the second included six less specific CT signs indicated as "minor CT findings." The presence of abdominal guarding and/or abdominal pain was considered as "clinical signs." Reference standards included surgically proven BBMI and clinical follow-up. Association was evaluated by the chi-square test. A logistic regression model was used to estimate odds ratio (OR) and confidence intervals (CI). RESULTS: Thirty-four (4.1%) out of 831 patients who sustained blunt abdominal trauma had BBMI at CT. Twenty-one out of thirty-four patients (61.8%) underwent surgical repair; the remaining 13 were treated conservatively. Free fluid had a significant statistical association with surgery (p = 0.0044). The presence of three or more minor CT findings was statistically associated with surgery (OR = 8.1; 95% CI, 1.2-53.7). Abdominal guarding along with bowel wall discontinuity and extraluminal air had the highest positive predictive value (100 and 83.3%, respectively). CONCLUSION: In patients without solid organ injury (SOI), the presence of free fluid along with abdominal guarding and three or more "minor CT findings" is a significant predictor of early surgical repair. The association of bowel wall discontinuity with extraluminal air warrants exploratory laparotomy.

Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries.

PURPOSE: To determine the accuracy of MDCT in the evaluation of blunt surgically relevant bowel and/or mesenteric injuries (BMIs) using single specific CT signs together with specific pairs of nonspecific signs. METHODS: Fifty-four patients examined with MDCT were divided into two groups: a 'surgical' group of 20 patients-which underwent surgery for blunt BMIs-and a control group of 34 'nonsurgical' trauma patients. Two radiologists with different experience performed a double-blind retrospective evaluation of the images, classifying the patients in the two groups by using only single specific signs; then, the images were reviewed in consensus with a third radiologist and sensitivity and specificity were calculated. Subsequently, the frequency of every single sign and of every possible combination of nonspecific signs in the two groups was registered, to find combinations present only in the surgical group; sensitivity and specificity were calculated by using even those specific combinations. RESULTS: At the first consensual evaluation, sensitivity and specificity were 75 and 100%, respectively. Two combinations of nonspecific signs (focal wall thickening + extraluminal air; focal wall thickening + seat belt sign) were found only in surgical patients that did not present any single specific sign: Sensitivity calculated adding those two combinations was 95%, without a decrease in specificity. CONCLUSIONS: MDCT is an accurate technique in the evaluation of blunt surgically relevant BMIs. The single specific CT signs were sufficient for the diagnosis in only 75% of the cases; adding the two specific combinations allowed an increase in sensitivity of 20%.

Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial.

BACKGROUND: Small bowel obstruction due to internal hernia is a common and potentially serious complication after laparoscopic gastric bypass surgery. Whether closure of surgically created mesenteric defects might reduce the incidence is unknown, so we did a large randomised trial to investigate. METHOD: This study was a multicentre, randomised trial with a two-arm, parallel design done at 12 centres for bariatric surgery in Sweden. Patients planned for laparoscopic gastric bypass surgery at any of the participating centres were offered inclusion. During the operation, a concealed envelope was opened and the patient was randomly assigned to either closure of mesenteric defects beneath the jejunojejunostomy and at Petersen's space or non-closure. After surgery, assignment was open label. The main outcomes were reoperation for small bowel obstruction and severe postoperative complications. Outcome data and safety were analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01137201. FINDINGS: Between May 1, 2010, and Nov 14, 2011, 2507 patients were recruited to the study and randomly assigned to closure of the mesenteric defects (n=1259) or non-closure (n=1248). 2503 (99·8%) patients had follow-up for severe postoperative complications at day 30 and 2482 (99·0%) patients had follow-up for reoperation due to small bowel obstruction at 25 months. At 3 years after surgery, the cumulative incidence of reoperation because of small bowel obstruction was significantly reduced in the closure group (cumulative probability 0·055 for closure vs 0·102 for non-closure, hazard ratio 0·56, 95% CI 0·41-0·76, p=0·0002). Closure of mesenteric defects increased the risk for severe postoperative complications (54 [4·3%] for closure vs 35 [2·8%] for non-closure, odds ratio 1·55, 95% CI 1·01-2·39, p=0·044), mainly because of kinking of the jejunojejunostomy. INTERPRETATION: The results of our study support the routine closure of the mesenteric defects in laparoscopic gastric bypass surgery. However, closure of the mesenteric defects might be associated with increased risk of early small bowel obstruction caused by kinking of the jejunojejunostomy. FUNDING: Örebro County Council, Stockholm City Council, and the Erling-Persson Family Foundation.

CT Findings of Traumatic Bucket-Handle Mesenteric Injuries.

OBJECTIVE: The purpose of this study is to describe a specific type of blunt traumatic mesenteric injury called a bucket-handle tear, review its varied CT appearances, and discuss the role of CT in its detection. CONCLUSION: A bucket-handle mesenteric injury is a rare but life-threatening blunt traumatic injury that can be difficult to detect prospectively on CT and for which delays in diagnosis and definitive surgical management can result in poor outcomes.

Multidetector CT of Surgically Proven Blunt Bowel and Mesenteric Injury.

Blunt traumatic injury is one of the leading causes of morbidity and mortality in the United States. Unintentional injury represents the leading cause of death in the United States for all persons between the ages of 1 and 44 years. In the setting of blunt abdominal trauma, the reported rate of occurrence of bowel and mesenteric injuries ranges from 1% to 5%. Despite the relatively low rate of blunt bowel and mesenteric injury in patients with abdominal and pelvic trauma, delays in diagnosis are associated with increased rates of sepsis, a prolonged course in the intensive care unit, and increased mortality. During the past 2 decades, as multidetector computed tomography (CT) has emerged as an essential tool in emergency radiology, several direct and indirect imaging features have been identified that are associated with blunt bowel and mesenteric injury. The imaging findings in cases of blunt bowel and mesenteric injury can be subtle and may be seen in the setting of multiple complex injuries, such as multiple solid-organ injuries and spinal fractures. Familiarity with the various imaging features of blunt bowel and mesenteric injury, as well as an understanding of their clinical importance with regard to the care of the patient, is essential to making a timely diagnosis. Once radiologists are familiar with the spectrum of findings of blunt bowel and mesenteric injury, they will be able to make timely diagnoses that will lead to improved patient outcomes. ©RSNA, 2017.

Duodenojejunal mesenteric rents: Survival and complications after surgical correction in 38 broodmares (2006-2014).

OBJECTIVES: To describe short-term and long-term survival of horses with duodenojejunal mesenteric rents, and to examine the association of selected preoperative, intraoperative, and postoperative factors with survival or colic after discharge, in horses with duodenojejunal mesenteric rents. STUDY DESIGN: Retrospective case series. ANIMALS: Horses undergoing surgery for correction of small intestinal lesions secondary to duodenojejunal mesenteric rents (n = 38). METHODS: Medical records (2006-2014) of horses admitted to a referral hospital in Kentucky were reviewed. Data for preoperative and intraoperative findings, postoperative complications, and short-term survival to discharge were recorded Long-term (>12 months) survival was determined by follow-up telephone query. Association of factors with survival and colic after discharge was determined using logistic regression. RESULTS: All 38 horses were Thoroughbred broodmares. Short-term survival was 76% overall and 88% among horses that recovered from general anesthesia. Long-term survival was 74% overall and 97% for mares that survived to discharge. All long-term survivors and 85% of mares that recovered from general anesthesia returned to use for breeding. The odds of survival were significantly higher for horses ≤10 years of age (OR = 6.2; 95% CI, 1.1-34.4). Failure to close the rent was associated with increased odds of colic after discharge, but had no effect on survival. CONCLUSION: Short-term and long-term survival was high relative to prior reports and mares surviving to discharge following mesenteric rent surgery had an excellent prognosis for long-term survival. Based on our data, closure of rents is recommended to prevent recurrence of colic, but may be unnecessary for survival.

Educational Review of Predictive Value and Findings of Computed Tomography Scan in Diagnosing Bowel and Mesenteric Injuries After Blunt Trauma: Correlation With Trauma Surgery Findings in 163 Patients.

BACKGROUND AND AIMS: Laparotomy can detect bowel and mesenteric injuries in 1.2%-5% of patients following blunt abdominal trauma. Delayed diagnosis in such cases is strongly related to increased risk of ongoing sepsis, with subsequent higher morbidity and mortality. Computed tomography (CT) scanning is the gold standard in the evaluation of blunt abdominal trauma, being accurate in the diagnosis of bowel and mesenteric injuries in case of hemodynamically stable trauma patients. Aims of the present study are to 1) review the correlation between CT signs and intraoperative findings in case of bowel and mesenteric injuries following blunt abdominal trauma, analysing the correlation between radiological features and intraoperative findings from our experience on 25 trauma patients with small bowel and mesenteric injuries (SBMI); 2) identify the diagnostic specificity of those signs found at CT with practical considerations on the following clinical management; and 3) distinguish the bowel and mesenteric injuries requiring immediate surgical intervention from those amenable to initial nonoperative management. MATERIALS AND METHODS: Between January 1, 2008, and May 31, 2010, 163 patients required laparotomy following blunt abdominal trauma. Among them, 25 patients presented bowel or mesenteric injuries. Data were analysed retrospectively, correlating operative surgical reports with the preoperative CT findings. RESULTS: We are presenting a pictorial review of significant and frequent findings of bowel and mesenteric lesions at CT scan, confirmed intraoperatively at laparotomy. Moreover, the predictive value of CT scan for SBMI is assessed. CONCLUSIONS: Multidetector CT scan is the gold standard in the assessment of intra-abdominal blunt abdominal trauma for not only parenchymal organs injuries but also detecting SBMI; in the presence of specific signs it provides an accurate assessment of hollow viscus injuries, helping the trauma surgeons to choose the correct initial clinical management.

Are We Missing Traumatic Bowel and Mesenteric Injuries?

PURPOSE: Traumatic bowel and mesenteric injury (TBMI), although an uncommon entity, can be lethal if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the detection of TBMI in patients at our level 1 trauma centre. METHODS: We used our hospital's trauma registry to identify patients with a diagnosis of TBMI from January 1, 2006, to June 30, 2013. Only patients who had a 64-slice MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in the study cohort. Using the surgical findings as the gold standard, the accuracy of prospective radiology reports was analyzed. RESULTS: Of the 4781 trauma patients who presented to our institution, 44 (0.92%) had surgically proven TBMI. Twenty-two of 44 were excluded as they did not have MDCT before surgery. The study cohort consisted of 14 males and 8 females with a median age of 41.5 years and a median injury severity score of 27. In total 17 of 22 had blunt trauma and 5 of 22 had penetrating injury. A correct preoperative imaging diagnosis of TBMI was made in 14 of 22 of patients. The overall sensitivity of the radiology reports was 63.6% (95% confidence interval [CI]: 41%-82%), specificity was 79.6% (95% CI: 67%-89%), PPV was 53.9% (95% CI: 33%-73%), and the NPV was 85.5% (95% CI: 73%-94%). Accuracy was calculated at 75.3%. However, only 59% (10 of 17) of patients with blunt injury had a correct preoperative diagnosis. Review of the findings demonstrated that majority of patients with missed blunt TBMI (5 of 7) demonstrated only indirect signs of injury. CONCLUSION: The detection of TBMI in trauma patients on 64-slice MDCT can be improved, especially in patients presenting with blunt injury. Missed cases in this population occurred because the possibility of TBMI was not considered despite the presence of indirect imaging signs. The prospective diagnosis of TBMI remains challenging despite advances in CT technology and widespread use of 64-slice MDCT.