The selection of diagnostic modalities in the management of pelvic fracture patients requiring transfers.

INTRODUCTION: Pelvic fractures can result in life-threatening hemorrhages. Therefore, pelvic fracture patients must usually be transferred to a trauma center for additional management. We attempted to analyze transferred pelvic fracture patients to determine which diagnostic modalities to use in different treatment settings. MATERIALS AND METHODS: From May 1, 2008, to February 28, 2014, patients with pelvic fractures who were transferred from other local hospitals within 24 hours after the trauma were enrolled. We compared the pre-transfer conditions and pelvic X-ray results from the local hospitals between the group of patients that underwent further angioembolization at the trauma center and the group that did not. The role of computed tomography (CT) in the decision-making process (i.e., regarding additional angioembolization) at the different institutions was discussed. RESULTS: In total, 751 patients were enrolled in the current study. Of the patients who received further angioembolization at the trauma center, 77.6 % (121/156) had sacro-iliac (SI) joint disruption on their pre-transfer pelvic X-ray; this rate was significantly higher than that of the patients who did not undergo further embolization (77.6 % vs. 25.5 %, p < 0.001). There was no significant difference in the use of pre-transfer CT scans at the local hospitals between the patients who underwent angioembolization and those who did not (53.8 % vs. 50.3 %, p = 0.472). Furthermore, of these patients, there was no significant difference in the length of emergency department stay (from arrival to angioembolization) at the trauma center among the patients who underwent pre-transfer CT scans and those who did not (97.4 ± 69.3 minutes vs. 108.6 ± 21.8 minutes, p = 0.461). CONCLUSION: When managing patients with pelvic fractures, the more attention should be paid to those with SI joint disruption on pelvic X-ray. Because these patients are more likely to require further angioembolization, they should be transferred earlier. Additional CT may be performed after the patient's transfer to the trauma center to determine subsequent treatment.

The risk factors of concomitant intraperitoneal and retroperitoneal hemorrhage in the patients with blunt abdominal trauma.

INTRODUCTION: Intraperitoneal and retroperitoneal hemorrhages may occur simultaneously in blunt abdominal trauma (BAT) patients. These patients undergo emergency laparotomies because of concomitant unstable hemodynamics and positive sonographic examination results. However, if the associated retroperitoneal hemorrhage is found intraoperatively and cannot be controlled surgically, then the patients require post-laparotomy transcatheter arterial embolization (TAE). In the current study, we attempted to determine the risk factors for post-laparotomy TAE. MATERIALS AND METHODS: Patients with concomitant BAT and unstable hemodynamic were retrospectively analyzed. The characteristics of the patients who underwent laparotomy or who required post-laparotomy TAE were investigated and compared. The Tile classification system was used to evaluate the pelvic fracture patterns. RESULTS: Seventy-four patients were enrolled in the study. Fifty-nine (79.7%) patients underwent laparotomy to treat intra-abdominal hemorrhage, and fifteen (20.3%) patients underwent additional post-laparotomy TAE because of concomitant retroperitoneal hemorrhage. Pelvic fracture was present in 80.0% of the post-laparotomy TAE patients. This percentage was significantly greater than that of the laparotomy only patients (80.0% vs. 30.5%, p < 0.001). Furthermore, 30 patients (40.5%, 30/74) had concomitant pelvic fracture diagnoses. Of these patients, eighteen (60%, 18/30) underwent laparotomy only, while the other twelve patients (40%, 12/30) required post-laparotomy TAE. Compared with the patients who underwent laparotomy only, more patients with Tile B1-type pelvic fractures (58.3% vs. 11.1%, p = 0.013) required post-laparotomy TAE. CONCLUSION: Regarding BAT patient management, the likelihood of post-laparotomy TAE should be considered in patients with concomitant pelvic fractures. Furthermore, more attention should be directed toward patients with Tile B1-type pelvic fractures because of the specific fracture pattern and impaction force.

Adrenal gland trauma: is extravasation an absolute indication for intervention?

BACKGROUND: Adrenal gland trauma (AGT) is potentially devastating if unrecognized during the treatment of trauma patients. Because of the adrenal glands' rich vascularity, they often hemorrhage upon traumatic impact. However, there has been no conclusion about the indications for intervention in cases of hemorrhage after AGT. METHODS: We conducted a prospective collection with a retrospective review in a Level I trauma center in Taiwan. This study enrolled all of the patients who suffered from AGT from May 2008 to May 2013. We retrieved and analyzed the patient demographic data, clinical presentation, AGT grade, injury severity score, management, hospital stay, and mortality. RESULTS: The cohort consisted of 60 patients. The mean age was 31.0 ± 15.9 years. There were 32 patients (53.3 %) with extravasated AGT, which was associated with a high injury severity score, a high possibility of associated lung injury, and more than one accompanying trauma. Most of the patients could be treated conservatively. Five of these patients needed surgical hemostasis, and four of them needed angiographic embolization. Extravasation combined with a mean arterial pressure <70 mmHg was a predictor of the need for intervention (relative risk: 9.52, 95 % CI 1.64-55.56, p = 0.011). CONCLUSION: In conclusion, AGT is a rare injury with a good prognosis. Most AGT patients can be treated conservatively. Extravasation in AGT is not only a sign of hemorrhage, but also an indicator of severe associated injuries. However, extravasation in AGT does not always require further treatment. When intractable hypotension simultaneously occurs, further treatment should be considered.

The current status and management of blunt adrenal gland trauma.

BACKGROUND: Blunt adrenal gland trauma (BAGT) is a potentially devastating event if unrecognized during the treatment course of patients with trauma. Because of its rarity, no current algorithm or consensus exists for BAGT. In the present study, we demonstrated the feasibility and safety of transcatheter angiographic embolization (TAE) in BAGT and analyzed the clinical presentation and outcome of BAGT. METHODS: We conducted a prospective collection and retrospective review at a level I trauma center in Taiwan. This study included all of the patients that sustained BAGT from May 2004 to May 2013. We retrieved and analyzed the patient demographic data, clinical presentation, BAGT grade, injury severity score, management, hospital stay, and mortality. RESULTS: The cohort consisted of 77 patients: 59 men and 18 women. The mean age was 34.3 ± 15.5 years. The right side was the predominant site of injury (59/77; 76.6%). Six patients underwent operation; 18 patients underwent angiography, including four TAEs, and the remaining patients underwent conservative management. The mortality rate was 9.1% (7/77), and a high injury severity score was an independent factor to predict mortality. CONCLUSION: In conclusion, BAGT is a rare injury with a benign prognosis. Most patients can be treated conservatively. Furthermore, this study demonstrates that both TAE and operation can be used to achieve hemostasis. The mortality of BAGT was related to severe associated injuries. BAGT is an indicator of severe multiple trauma; however, it does not increase mortality or prolong hospital stay.

Hypotension does not always make computed tomography scans unfeasible in the management of blunt abdominal trauma patients.

INTRODUCTION: Computed tomography (CT) scans have been used worldwide to evaluate patients with blunt abdominal trauma (BAT). However, CT scans have traditionally been considered to be a part of a secondary survey that can only be performed after the patient's haemodynamics have stabilised. In this study, we attempted to evaluate the role of the CT scan in managing BAT patients with hypotension. MATERIAL AND METHODS: Patients who fulfilled the criteria for a major torso injury in our institution were treated according to the Advanced Trauma Life Support guidelines. The selection of diagnostic modalities for patients with stable and unstable haemodynamics was discussed. Furthermore, patients with hypotension after resuscitation who were administered haemostasis procedures were the focus of our analysis. We also delineated the influence of CT scans on the time interval between arrival and definitive treatment for these patients. RESULTS: During the study period, 909 patients were enrolled in this study. Ninety-one patients (10.0%, 91/909) had a systolic blood pressure (SBP) <90mmHg after resuscitation. Fifty-eight of the patients (63.7%) received CT scans before they received definitive treatment. There was no significant difference in the CT scan application rate between the patients with and without hypotension after resuscitation (63.7% vs. 68.8%, p=0.382). Among the 79 patients with hypotension after resuscitation who underwent a haemostasis procedure (surgery or angioembolisation), there was no significant difference in the time between arrival and definitive haemostasis between the patients who received CT scans and those who did not (surgery: 57.8 (standard deviation (SD) 6.4) vs. 61.6 (SD 14.5)min, p=0.218; angioembolisation: [147.0 (SD 33.4) vs. 139.3 (SD 16.7)min, p=0.093). CONCLUSION: The traditional priority of diagnostic modalities used to manage BAT patients should be reconsidered because of advancements in facilities and understanding of BAT. With shorter scanning times and transportation distances, hypotension does not always make performing a CT scan unfeasible.

Effectiveness and feasibility of laparoscopic distal pancreatectomy on patients at high anesthetic risk.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is the most acceptable procedure in laparoscopic pancreatic surgery. Nevertheless, knowledge regarding patients at a high anesthetic risk during lengthy and technically demanding LDP is controversial. This study aims to assess the feasibility and safety of LDP in patients with high anesthetic risk. PATIENTS AND METHODS: We conducted a prospective collection retrospective review of patients underwent LDP and open distal pancreatectomy (ODP) from January 2011 until December 2013. By the American Society of Anesthesiologists score, patients were divided into low- and high-risk patients. We compared the clinical, perioperative, and postoperative results in these patients. RESULTS: The cohort included 77 patients: 20 underwent LDP, and 57 underwent ODP. There were 30 patients in the low-risk group and 47 patients in the high-risk group. In high-risk patients, LDP, compared with ODP, presented a shorter operating time (mean, 220.8±101.1 minutes versus 299.4±124.3 minutes; P=.038), less blood loss (409.3±569.9 mL versus 1083.1±1583.0 mL; P=.039), higher rate of spleen preservation (73.3% versus 43.8%, P=.037), and shorter length of postoperative hospital stay (LOS) (9.5±3.0 days versus 15.7±9.4 days; P=.044). CONCLUSIONS: In conclusion, LDP provides early recovery and better cosmetic appearance. In high anesthetic risk patients, LDP shows less operative time, less perioperative blood loss, a higher rate of spleen preservation, slighter complication, and shorter LOS, which might explain why LDP is a feasible and effective procedure.

Risk factors for late death of patients with abdominal trauma after damage control laparotomy for hemostasis.

INTRODUCTION: In this study, we explored the possible causes of death and risk factors in patients who overcame the initial critical circumstance when undergoing a damage control laparotomy for abdominal trauma and succumbed later to their clinical course. METHODS: This was a retrospective study. We selected patients who fulfilled our study criteria from 2002 to 2012. The medical and surgical data of these patients were then reviewed. Fifty patients (survival vs. late death, 39 vs. 11) were enrolled for further analysis. RESULTS: In a univariable analysis, most of the significant factors were noted in the initial emergency department (ED) stage and early intensive care unit (ICU) stage, while an analysis of perioperative factors revealed a minimal impact on survival. Initial hypoperfusion (pH, BE, and GCS level) and initial poor physiological conditions (body temperature, RTS, and CPCR at ED) may contribute to the patient's final outcome. An analysis and summary of the causes of death were also performed. CONCLUSIONS: According to our study, the risk factors for late death in patients undergoing DCL may include both the initial trauma-related status and clinical conditions after DCL. In our series, the cause of death for patients with late mortality included the initial brain insult and later infectious complications.

Gasless laparoscopic assisted surgery for abdominal trauma.

BACKGROUND: Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma. MATERIALS AND METHODS: This was a retrospective, 1:2 matched case-control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed. RESULTS: A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9min, and the mean operative time was 109.7, SD 33.5min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6min; p=0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p=0.030). CONCLUSION: GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.

Adenosquamous carcinoma of the ampulla of Vater - a rare disease at unusual location.

Adenosquamous carcinoma is defined as a tumor in which both glandular and squamous elements are histologically malignant. Although some published studies have analyzed and discussed adenosquamous carcinomas, hybrid malignancy of the ampulla of Vater has rarely been discussed thus far in the literature. In this study, we report the case of a 64-year-old man who presented with jaundice and intermittent abdominal dull pain that persisted for several weeks. The patient was diagnosed with adenosquamous carcinoma of the ampulla of Vater and underwent pancreaticoduodenectomy. The final diagnosis was adenosquamous carcinoma of the ampulla of Vater, T3N1M0, stage IIB. Although R0 resection was performed, he had multiple liver metastases 2 months after the operation; he died 4 months later. Upon reviewing the medical records of our institute, we identified 4 patients who were diagnosed with adenosquamous carcinoma of the ampulla of Vater in the past 2 decades. We also identified only five reported cases of this lesion in the English literature. Adenosquamous carcinoma of the ampulla of Vater is a rare disease with a dismal prognosis. Surgical intervention does not appear to prolong patient survival. Early recurrence and distal metastasis may be encountered after surgery.

Factors affecting outcomes in penetrating diaphragmatic trauma.

UNLABELLED: BACKGROUDS: Diagnosing penetrating diaphragmatic rupture (PDR) is a challenging aspect of managing thoracoabdominal injuries due to the lack of a typical clinical presentation. The mortality from PDR is variable and center-specific. In this study, we identified the incidence and clinical presentation of PDR at our institution and analyzed the factors that affected the length of hospital stay and mortality. METHODS: We collected all patients who were diagnosed with PDR from January 2001 through December 2010 at a Level I trauma center. We recorded demographic characteristics, clinical parameters, diagnostic images, trauma mechanism, location and severity of injuries, injury severity score (ISS), time to diagnosis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and mortality. We analyzed the risk for mortality and prolonged hospitalization. RESULTS: Forty-one patients with a median age of 37 years were included. Thirty-six patients (87.8%) had an early diagnosis, and 5 patients (12.2%) had a delayed diagnosis requiring longer than 24 h. The median ICU LOS and HLOS were 2 and 11 days, respectively. High-grade PDR and lung injury increased the ICU LOS and HLOS. The total mortality rate was 7.3%. Multivariate analysis showed that hypothermia and hypotension were independent risk factors for mortality. CONCLUSION: Overlooking diaphragmatic rupture in patients with thoracoabdominal penetrating injury is not infrequent. A high index of suspicion is important for making the diagnosis. A high-grade PDR and associated lung injury prolonged the length of hospital stay. Profound hemorrhagic shock and associated physical decompensation have an impact on mortality.

Akt pathway is required for oestrogen-mediated attenuation of lung injury in a rodent model of cerulein-induced acute pancreatitis.

BACKGROUND: The phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt) is known to be an endogenous negative feedback or compensatory mechanism that serves to limit pro-inflammatory and chemotactic events in response to injury. The aim of this study is to elucidate whether Akt plays any role in 17ß-estradiol (E2)-mediated attenuation of lung injury after acute pancreatitis (AP). MATERIALS AND METHODS: Male Sprague-Dawley rats underwent cerulein-induced AP. Rats were treated with vehicle (cyclodextrin), E2 (1 mg/kg body weight [BW]), or E2 plus PI3K/Akt inhibitor Wortmannin (100 µg/kg BW) 1h after the onset of AP. At 8 h after sham operation or AP, various parameters were measured. RESULTS: AP led to a significant decrease in lung Akt phosphorylation, which was associated with increased lung tissue myeloperoxidase (MPO) activity, wet-to-dry weight ratios, interleukin (IL)-6, tumor necrosis factor (TNF)-α, cytokine-induced neutrophil chemoattractant (CINC)-1, and CINC-3 levels. Administration of E2 after AP restored the AP-induced decrease in Akt phosphorylation and attenuated the increase in lung injury markers (MPO activity and wet-to dry weight ratios) and pro-inflammatory mediator production. The effects of E2 on the lung were abolished by co-administration of Wortmannin. CONCLUSIONS: These results collectively suggest evidences that the Akt pathway seems to be required for E2-mediated protection of lung injury after AP.

Acute psychotic state due to hyperthyroidism following excision of a mandible bone tumor: a case report.

The etiology of psychotic symptoms that emerge following surgery needs to be sought to allow physicians to provide effective treatment. We present the case of a patient who developed hyperthyroidism shortly after excision of a mandible bone tumor and discuss its clinical features, course, and management. A 48-year-old female without previous thyroid disease accidentally found a tumor over her left mandible bone and underwent excision of the tumor. Soon after surgery, she suffered from anxiety, mood swings, insomnia, and even auditory hallucinations. Through careful differential diagnosis and a series of examinations, she was shown to be in a hyperthyroid state. Her condition improved after short-term use of haloperidol, lithium, and methimazole. Her thyroid function recovered and she was free from any psychiatric symptoms during the 1-year follow-up. Hyperthyroidism following surgery is not uncommon and its possibility should be considered when making differential diagnoses.