Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review.

BACKGROUND: Gastrointestinal injury following blunt abdominal trauma is uncommon; a combined stomach and duodenal perforating injury is even more rare. Because these two organs are located in different spaces in the abdomen, such injuries are difficult to identify. CASE PRESENTATION: A young woman involved in a motor vehicle crash presented to our emergency department with concerns of severe peritonitis. Contrast-enhanced computed tomography of the abdomen revealed pneumoperitoneum and retroperitoneal hematoma in zone 1. An emergency laparotomy was performed, revealing a stomach-perforating injury, which was resolved with primary repair. No obvious injury was observed on retroperitoneal exploration. However, peritonitis presented again on the second postoperative day, and a second laparotomy was performed, revealing a duodenum-perforating injury in its third portion. We performed primary repair with multi-tube-ostomy. The patient recovered well without permanent tube placement or internal bypass. CONCLUSIONS: Assessing associated injuries in blunt abdominal trauma is crucial because they may be fatal if timely intervention is not undertaken. These types of complicated injuries require a feasible surgical strategy formulated by experienced surgeons, which gives the patient a better chance of survival.

The Effectiveness of a Simulation-Based Flipped Classroom in the Acquisition of Laparoscopic Suturing Skills in Medical Students-A Pilot Study.

OBJECTIVE: To evaluate the effectiveness of a simulation-based flipped classroom in gaining the laparoscopic skills in medical students. DESIGN: An intervention trial. SETTING: Taipei Medical University Hospital, an academic teaching hospital. PARTICIPANTS AND METHODS: Fifty-nine medical students participating in a 1-hour laparoscopic skill training session were randomly assigned to a conventional classroom (n = 29) or a flipped classroom approach (n = 30) based on their registered order. At the end of the session, instructors assessed participants' performance in laparoscopic suturing and intracorporeal knot-tying using the assessment checklist based on a modified Objective Structured Assessment of Technical Skills tool. RESULTS: Students in the flipped group completed more numbers of stitches (mean [M] = 0.47; standard deviation [SD] = 0.507) than those in the conventional group (M = 0.10; SD = 0.310) (mean difference: 0.37; 95% CI: 0.114-582; p = 0.002). Moreover, students in the flipped group also had higher stitch quality scores (M = 7.17; SD = 2.730) than those in the conventional group (M = 5.14; SD = 1.767) (mean difference = 2.03; 95% CI: 0.83-3.228; p = 0.001). Meanwhile, students in the flipped group had higher pass rates for the second throw (p < 0.001), third throw (p = 0.002), appropriate tissue reapproximation without loosening or strangulation (p < 0.001), needle cut from suture under direct visualization (p = 0.004), and needle safely removed under direct visualization (p = 0.018) than those in the conventional group. CONCLUSIONS: Comparing with traditional approach, a simulation-based flipped classroom approach may improve laparoscopic intracorporeal knot-tying skill acquisition in medical students.

Therapeutic effectiveness of percutaneous drainage and factors for performing an interval appendectomy in pediatric appendiceal abscess.

BACKGROUND: In this study, we studied the therapeutic effectiveness of percutaneous drainage with antibiotics and the need for an interval appendectomy for treating appendiceal abscess in children with a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA). METHODS: We identified 1225 patients under 18 years of age who had non-surgical treatment for an appendiceal abscess between 2007 and 2012 in a Taiwan CCHIA dataset. The treatment included percutaneous drainage with antibiotics or antibiotics alone. We also analyzed data of patient's baseline characteristics, outcomes of percutaneous drainage, and indicating factors for performing an interval appendectomy. RESULTS: Totally, 6190 children had an appendiceal abscess, an 1225 patients received non-operative treatment. Of 1225 patients, 150 patients received treatment with percutaneous drainage and antibiotics, 78 had recurrent appendicitis, 185 went on to receive an interval appendectomy, and 10 had postoperative complications after the interval appendectomy. We found that patients treated with percutaneous drainage and antibiotics had a significantly lower rate of recurrent appendicitis (p < 0.05), a significantly smaller chance of receiving an interval appendectomy (p < 0.05), and significantly fewer postoperative complications after the interval appendectomy (p < 0.05) than those without percutaneous drainage treatment. Older children (13 ~ 18 years) patients were found to have a significantly smaller need to receive an interval appendectomy than those who were ≤ 6 years of age (odd ratio (OR) = 2.071, 95 % confidence interval (CI) = 1.34-3.19, p < 0.01), and those who were 7 ~ 12 years old (OR = 1.662, 95 % CI = 1.15-2.41, p < 0.01). In addition, those treated with percutaneous drainage were significantly less indicated to receive an interval appendectomy later (OR = 2.249, 95 % CI = 1.19 ~ 4.26, p < 0.05). In addition, those with recurrent appendicitis had a significantly increased incidence of receiving an interval appendectomy later (OR = 3.231, 95 % CI = 1.95 ~ 5.35, p < 0.001). CONCLUSIONS: In this study, we used nationwide data to demonstrate therapeutic effectiveness of percutaneous drainage and antibiotics was more beneficial than only antibiotics in treating patients with an appendiceal abscess. We also found three factors that were significantly associated with receiving an interval appendectomy: recurrent appendicitis, being aged ≤ 13 years, and treatment with antibiotics only.

National trends in therapeutic approaches and outcomes for pediatric appendicitis: a Taiwanese nationwide cohort study.

PURPOSE: To define the pattern of therapeutic approaches for pediatric appendicitis and compare their benefits in Taiwan, we analyzed a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA) to document the impact of the rise of laparoscopic treatment on outcomes. METHODS: We identified 22,161 patients under 18 years who had been hospitalized with a diagnosis of acute appendicitis between 2007 and 2012 in the CCHIA. Statistical comparisons between the Laparoscopic appendectomy (LA) and open appendectomy (OA, control) groups were computed using a Chi squared test. The odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for intra-abdominal abscess (IAA) and postoperative bowel obstruction (PBO) were derived from multivariate logistic regression models. RESULTS: In each respective year, the incidence of LA increased from 29.17% in 2007 to 57.4% in 2012, while that of OA decreased from 70.83% in 2007 to 42.60% in 2012; incidences of non-perforated appendicitis and perforated appendicitis with LA or OA seemed similar. The length of hospitalization between an LA and OA for non-perforated appendicitis was the same, but that with an LA was shorter for perforated appendicitis. The adjusted ORs for IAA and PBO for those patients with perforated and non-perforated appendicitis were 6.30 (95% CI = 5.09-7.78; p < 0.001) and 6.49 (95% CI = 4.45-9.48; p < 0.001); while for those cases undergoing an LA and OA, they were 0.50 (95 % CI = 0.40-0.62; p < 0.001) and 2.07 (95% CI = 1.45-2.95; p < 0.001), respectively. The ORs of IAA and PBO for those patients ≤6 and 7-12 years of age were 1.67 (95% CI = 1.23-2.25; p = 0.001) and 1.20 (95% CI = 0.97-1.49; p = 0.095), and 1.88 (95% CI = 1.08-3.24; p = 0.025) and 1.47 (95% CI = 1.01-2.14; p = 0.043), respectively, compared to those aged 13-18 years. CONCLUSIONS: Our study demonstrated that young age and perforated appendicitis can affect postoperative IAA and PBO. LA appeared beneficial in reducing the length of hospitalization and postoperative IAA, but had an increasing risk of PBO. Although laparoscopic approach for pediatric appendectomy is increasing in our country, the different hospital levels and pediatric surgeon's laparoscopic experience must be evaluated in further study.

Implementation of the acute care surgery model provides benefits in the surgical treatment of the acute appendicitis.

BACKGROUND: Several reports have indicated the benefits of the acute care surgery (ACS) model in surgical outcomes. We tried to delineate the impact of the ACS model on surgical efficiency and quality. METHODS: Before the ACS model was implemented, abdominal surgical emergencies were evaluated by an on-call nontrauma general surgeon (pre-ACS model). An in-house trauma surgeon treated all patients with trauma or nontrauma abdominal surgical emergencies after the ACS model. Patients with acute appendicitis who underwent appendectomies were included. We conducted a pre- and poststudy to compare the time patients were in the emergency department and surgical qualities. RESULTS: There were 146 and 159 patients enrolled in the pre-ACS model and ACS model, respectively. The overall ED length of stay in the ACS model was significantly shorter than that in the pre-ACS model (300.3 ± 61.7 vs 719.1 ± 339.0 minutes, P < .001). Hospital LOS was also significantly shorter in the ACS model than in the pre-ACS model (2.44 ± 1.39 vs 3.83 ± 2.21 days, P = .022). CONCLUSION: The ACS model may improve abdominal surgical efficiency and quality. Our study results echoed the benefits of the implementation of the ACS model shown in North America.

The effects of repeat laparoscopic surgery on the treatment of complications resulting from laparoscopic surgery.

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.

Selective computed tomography and angioembolization provide benefits in the management of patients with concomitant unstable hemodynamics and negative sonography results.

BACKGROUND: The FAST (focused assessment of sonography for trauma) examination can rapidly identify free fluid in the abdominal or thoracic cavity, which is indicative of hemorrhage requiring emergency surgery in multiple-trauma patients. In patients with negative FAST examination results, it is difficult to identify the site of the hemorrhage and to plan treatment accordingly. We attempted to delineate the role of selective computed tomography (CT) and transarterial angioembolization (TAE) in the management of such unstable patients. METHODS: From January 2005 to April 2011 patients with concomitant unstable hemodynamics and negative FAST examination results were identified. Their demographic and time to start of embolization were recorded. The initial systolic blood pressure (SBP) in emergency department patients was compared with the SBP after TAE. RESULTS: A total of 33 patients were enrolled, and 85% required TAE. SBP improved significantly after TAE. There were 18 patients who received TAE without CT scan because the site of hemorrhage was obvious. Fifteen patients received a CT scan during the time required for angiography preparation. Ten of them received subsequent TAE based on the CT scan findings, and the treatment plan was changed in the other five patients. There was no significant difference between patients with or without a CT scan with respect to the time interval between arrival and starting embolization. CONCLUSIONS: Transarterial angioembolization is suggested in the management of patients with concomitant unstable hemodynamics and negative FAST examination results. During the time interval required for angiography preparation, a CT scan can be performed. This approach provides valuable information for further decision making without delaying definitive treatment.

Late initiation of continuous veno-venous hemofiltration therapy is associated with a lower survival rate in surgical critically ill patients with postoperative acute kidney injury.

There is controversy about the appropriate timing for renal replacement therapy in patients with acute kidney injury (AKI). We are interested in the appropriate timing for initiation of continuous renal replacement therapy in critically ill surgical patients with postoperative acute kidney injury. Seventy-three critically ill surgical patients with postoperative AKI who received continuous renal replacement therapy (CRRT) were enrolled. Indications for CRRT were: 1) AKI with hyperkalemia, 2) metabolic acidosis, 3) pulmonary edema refractory to diuretics, and 4) oliguria with progressive azotemia, especially in unstable hemodynamics. Using RIFLE (Risk, Injury, Failure, Loss, End stage) classification, patients who received CRRT in the "Risk" stage were defined as early group, whereas those in the "Injury/ Failure" stage were labeled as late group. We used continuous veno-venous hemofiltration as CRRT in this series. There were 20 patients in the early group and 53 patients in the late group. The mean ages were 61.5 ± 21.8 years versus 60.8 ± 17.5 years. The mortality rate was 50 per cent versus 84.9 per cent. There were no significant differences in demographic characteristics or type of surgery or physiological scores. Our data show that late initiation of CRRT is associated with a lower survival rate in critically ill surgical patients with postoperative AKI; however, further studies are required.

Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.

BACKGROUND: Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan. METHODS: From January 2005 to September 2009, patients with CE noted on a CT scan as a result of BHI were studied retrospectively. Physiological parameters, severity of injury, amount of transfusion, type of contrast extravasation, as well as treatment outcome were compared between patients with NOM failure and NOM success. RESULTS: A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma. CONCLUSIONS: Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.

Laparoscopic appendectomy provides better outcomes than open appendectomy in elderly patients.

The incidence of acute appendicitis in elderly patients is increasing due to prolonged life span. The associated morbidity and mortality related to perforation of acute appendicitis continue to present challenges to physicians. The role of laparoscopic appendectomy is still controversial. This study aimed to compare the postoperative outcomes of elderly patients who received either a laparoscopic or an open appendectomy. We retrospectively reviewed charts of patients with acute appendicitis between January 2005 and February 2009. Elderly patients who received laparoscopic or open appendectomies were enrolled. The demographics, preoperative condition, operating time, intraoperative blood loss, and postoperative course were analyzed. A total of 150 patients were enrolled in this study. On average, patients who received a laparoscopic appendectomy had fewer hospital days and lower rates of postoperative ventilator dependence than patients who received an open appendectomy. In the management of elderly patients with acute appendicitis, laparoscopic appendectomy provides better outcomes than open appendectomy.

Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer.

BACKGROUND: Helicobacter pylori (H.P.) eradication has led to a significant decline in peptic ulcer prevalence; however, the number of patients requiring surgical intervention remains relatively unchanged. Laparoscopy suture repair is the most commonly used procedure for perforated peptic ulcer (PPU). Whether omental patch adds any benefit than simple closure alone is not answered. METHODS: From July 2007 to August 2010, patients received emergency surgeries for PPU in our department were enrolled in this study. The demographic data, disease pattern, surgical outcomes were retrospectively collected. Patients who had previous multiple operations, with profound shock, and complicated ulcers were excluded. RESULTS: Totally 73 patients were enrolled. 26 of them received simple closure and the other 47 received simple closure plus an omental patch. There were no difference in age, gender, ASA, Boey risk score, and incidence of co-morbidities. The Mannheim Peritonitis index, median operation time and length of stay were not different between groups. CONCLUSIONS: In terms of leakage rate and surgical outcome, the maneuver to cover an omental patch on the repaired PPU did not show additional advantages compared to simple closure alone. Further prospective randomized study is required to clarify the safety and feasibility of simple closure alone without buttressing an omentum patch.

Diagnostic accuracy, biohazard safety, and cost effectiveness-the Lodox/Statscan provides a beneficial alternative for the primary evaluation of patients with multiple injuries.

BACKGROUND: Lodox/Statscan is a new digital X-ray machine with a low dose of radiation exposure that provides rapid, whole-body scans. In the setting of acute trauma management, the importance of image study is well recognized. Here, we report the accuracy of diagnoses made using Lodox/Statscan in patients with multiple injuries. We analyze the cost effectiveness, biohazard safety, and detection rate for treatment using the Lodox/Statscan and evaluate whether it is a viable alternative to the conventional trauma X-ray. METHODS: We retrospectively reviewed patients who received a Lodox/Statscan between November 2007 and January 2009. All patients who had received both a Lodox/Statscan and a computed tomographic (CT) scan were enrolled. The CT scan was used to make the final diagnosis. The detection rate for treatment, sensitivity, and specificity of the Lodox/Statscan in diagnosis was analyzed. RESULTS: One hundred eighty-four patients were eligible for the study during the 15-month study period. The detection rates for treatment using the Lodox/Statscan for pneumothorax, pelvic fracture, cervical spine injury, and thoracic-lumbar spine injury were 95%, 96.0%, and 57.1%, and 100%, respectively. CONCLUSION: In our series, the Lodox/Statscan provided similar quality images and conventional series to the CT scans. Although the Lodox/Statscan missed some injuries, most of the subsequent treatments were not changed. Overall, there were several advantages to using this system, including the short interval of study, low-radiation exposure, and low cost. The Lodox/Statscan could therefore be used as an alternative to the traditional trauma X-ray for evaluation of acute trauma patients.

Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention.

BACKGROUND: Angioembolization is an effective adjunct to the management of blunt splenic injuries (BSI) that are not surgically treated. However, in some cases patients are unable to undergo angioembolization due to changes in their hemodynamic condition. In this study we attempt to define the characteristics of patients who need angioembolization in high-grade BSI. METHODS: We retrospectively reviewed the charts of patients with BSI between January 2004 and June 2008. Patients with contrast extravasation (CE) on computed tomography (CT) scan were enrolled. The demographics, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), the amount of blood transfused, and the type of CE were analyzed. RESULTS: A total of 69 patients were enrolled. Patients with intraperitoneal CE in BSI required a higher rate of immediate operation due to changed hemodynamics. Furthermore, these patients displayed higher ISS and higher blood transfusion amounts. CONCLUSIONS: In BSI patients, intraperitoneal CE is associated with a higher possibility of requiring surgical intervention. Early surgical intervention should be considered in BSI patients with intraperitoneal CE or with ISS ≥ 25.

Evaluation of need for angioembolization in blunt renal injury: discontinuity of Gerota's fascia has an increased probability of requiring angioembolization.

BACKGROUND: Angioembolization is an effective adjunct in the management of high-grade renal injuries not surgically treated. However, in some cases, the bleeding may stop spontaneously, without the need for embolization. The aim of this study was to define the characteristics of patients who need angioembolization for high-grade blunt renal injuries (BRIs). METHODS: Patients with BRIs between January 2004 and May 2008 were retrospectively reviewed. Patients with contrast extravasation on computed tomographic scans who then underwent angiography were enrolled. Demographics, injury severity scores, abbreviated injury scale scores, amounts of blood transfused, and need for angioembolization were analyzed. RESULTS: Twenty-six patients were enrolled. Patients with discontinuity of Gerota's fascia and pararenal hematoma expansion in BRIs required angioembolization at a higher rate. Furthermore, these patients displayed higher injury severity scores and abbreviated injury scale scores. Five patients experienced complications. CONCLUSIONS: In patients with BRIs, discontinuity of Gerota's fascia and pararenal hematoma expansion seemed to be associated with the need for angioembolization. Early angioembolization should be considered in patients with severe associated trauma with BRIs.

Experimental analysis of the oil addition effect on mycelia and polysaccharide productions in Ganoderma lucidum submerged culture.

The effect of corn oil addition on mycelium growth and polysaccharide productions in the medicinal mushroom Ganoderma lucidum was studied. The results showed that when a level of 2% corn oil was added at the beginning of culture, the biomass and polysaccharide productions reached a maximum of 12.9 and 1.038 g/L, respectively, during 13-day cultivation. The pH variation along with morphology observation in culture provided an indirect inference to the promotional effect of oil addition. Moreover, a curve fitting analysis was carried out to assay the elevated effect on biomass and exopolysaccharide productions in oil added culture. The experimental data of substrates consumption and products formation in culture with oil addition were predicted through the fitting equations obtained in single carbon source culture. The numerical results further clarified the stimulatory effects of oil addition in G. lucidum culture.