Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients.

BACKGROUND: Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE. MATERIALS AND METHODS: Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability. RESULTS: There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE. CONCLUSION: Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.

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.

Commotio cordis as a rare cause of traumatic cardiac arrest in motorbike crashes: Report of a case.

It is futile to attempt resuscitation in a blunt injury patient with no vital signs upon arriving at the emergency department. Therefore, it is recommended that resuscitation be withheld in any blunt trauma patient without vital signs while emergency medical technicians arrive at the scene of the accident. This report presents a case of a blunt torso trauma patient who lost vital signs at the scene and still received cardiopulmonary resuscitation until recovery of spontaneous circulation at the emergency department. The patient was later diagnosed with commotio cordis, and survived to be discharged without any neurological sequelae. Therefore, aggressive resuscitation should be continued until a diagnosis and differential diagnosis of blunt trauma-related cardiac arrest are made by a thorough examination in the emergency department.

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.

Concomitant aortic valve and internal mammary artery injuries in blunt chest trauma: report of a case.

We report a case of concomitant injury to the aortic valve and internal mammary artery (IMA) from nonpenetrating chest trauma. To our knowledge, this is the first such case to be reported. Transcatheter arterial embolization (TAE) following diagnostic angiography offers an effective and minimally invasive treatment for traumatic IMA injuries. Because there might be an asymptomatic interval after traumatic aortic valve injuries, serial physical examinations and repeated echocardiography should be mandatory for patients with de novo heart failure after blunt chest trauma. Transesophageal echocardiography can provide a clearer image of cardiac injuries than transthoracic echocardiography, particularly if there is extensive anterior mediastinal hematoma resulting from IMA trauma.

Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on plain film have an increased probability of requiring angioembolization.

BACKGROUND: The use of pelvic x-rays (PXRs) as an early diagnostic adjunct in the evaluation of blunt trauma patients has become widely accepted, and computed tomographic (CT) scanning is now used universally in the assessment of abdominal and pelvic injuries. In this study, we have attempted to identify patients with pelvic fractures who might be at risk for vessel hemorrhage and determine if early angioembolization was required in these patients. MATERIAL AND METHODS: We retrospectively reviewed patients who presented with pelvic fractures from June 2005 to August 2007. Both PXRs and CT scans were reviewed. Patients who presented with bleeding due to other associated injuries or who did not receive a CT scan were excluded. Patients with either initial hemodynamic instability or contrast extravasation on enhanced CT scan underwent angioembolization. Patient demographics, Injury Severity Score, the amount of blood transfused, and the relationship between the fracture pattern and angioembolization were analyzed. RESULTS: A total of 54 patients were enrolled. A diagnosis of an unstable pelvic fracture on PXR was associated with a higher probability of angioembolization. Seven patients received incompatible diagnoses from the PXR and CT scan; these patients received larger amounts of transfused blood and demonstrated an increased need for angioembolization. CONCLUSIONS: Although CT scan is more sensitive in the identification of acetabular or small pelvic fractures, PXR is sufficient for the early evaluation of pelvic fracture stability. Based on the current series, early angioembolization is suggested for patients with an initial diagnosis of an unstable pelvic fracture. In addition, patients receiving large amounts of transfused blood are more likely to require early angioembolization.

Obscure gastrointestinal bleeding caused by small bowel lipoma.

Obscure gastrointestinal bleeding is a very rare entity which accounts for less than 5% of all gastrointestinal bleeding cases. Small bowel tumors are rare but a serious source of obscure gastrointestinal bleeding. Lipomas are the second most common benign tumors in the small bowel and can produce many complications, including gastrointestinal bleeding. Herein, we describe a case of obscure gastrointestinal bleeding caused by a small bowel tumor which was detected by capsule endoscopy and double-balloon enteroscopy preoperatively. Finally, the tumor was surgically confirmed to be a lipoma.

Retroperitoneal abscess resulting from perforated acute appendicitis: analysis of its management and outcome.

BACKGROUND: Acute appendicitis may become life threatening if it is complicated by retroperitoneal abscess. To the best of our knowledge, only case reports have been documented; thus, we analyzed the published experiences and reviewed this issue. MATERIALS AND METHODS: In addition to two patients treated at our institution, a PubMed search identified 22 cases of acute appendicitis, complicated by retroperitoneal abscess, reported by 18 authors between 1955 and 2005. The patients' characteristics, onset of symptoms, timing and methods of diagnosis and management, and outcome are reviewed and analyzed. RESULTS: Most of the patients were adults (21/24, 87.5%), of whom seven were older than 65 years. None of the patients presented with the classical symptoms of acute appendicitis at the onset of the disease, and less than half (9/24) reported abdominal pain. The average interval between the onset of symptoms and diagnosis was 16 days, and the most effective diagnostic tool was computed tomography. Pathogens were usually polymicrobial, and appendectomy followed by adequate drainage of the abscess was the best treatment. The mortality rate was 16.7% (4/24), and all deaths were caused by profound sepsis. According to the available data, the average hospital stay was 27.3 days for the survivors. CONCLUSION: The formation of complicated retroperitoneal abscesses involving thigh, psoas muscle, perinephric space, or even the lateral abdominal wall is a serious complication of perforated acute appendicitis. An intra-abdominal pathological abnormality cannot be excluded in a patient presenting without abdominal symptoms. The mortality rate can only be reduced by a high index of suspicion, accurate diagnosis, and appropriate treatment.

Lesser-sac lavage for intraoperative detection of blunt pancreatic duct injury.

BACKGROUND/AIMS: Blunt pancreatic duct injury is difficult to differentiate, especially during surgery. In terms of demonstration of pancreatic duct injury, endoscopic retrograde pancreatography (ERP) is the gold standard imaging study, however, availability can be problematic. Therefore, we have designed a method utilizing lesser-sac lavage to differentiate pancreatic duct injury. METHODOLOGY: Patients sustaining blunt pancreatic trauma treated at our institution over a two-year period were retrospectively enrolled in this study. Based on computed tomography (CT), these patients were divided into two groups: deep laceration or complete transection (Group 1) and superficial laceration (Group 2). Additionally, ten patients sustaining blunt abdominal trauma who had undergone emergency laparotomy for other visceral organ injury (Group 3) and four undergoing pancreatoduodenectomy (Group 4) were selected as controls. For laparotomy in Groups 1-3, the lesser sac was opened for lavage, with 50 mL of 0.9% normal saline inserted, and 3mL of the sample fluid withdrawn at four time points (15, 30, 45 and 60 mins) with the fluid immediately replaced with 3 mL of saline. Lavage-ascites amylase (LAA) and lipase (LAL) levels were measured. Serum amylase and lipase activities were measured intraoperatively from 3mL of the patient's blood. RESULTS: Over the two-year study period, there were four pancreatic duct transections (Group 1), five partial pancreatic lacerations confirmed by post-ERP CT (Group 2), ten non-pancreatic traumas (Group 3), and four pancreatoduodenectomies due to pancreatic-head cancer (Group 4). The LAA and LAL for Group 1 were significantly higher than those for Group 2 or 3 at each of the four time points. The LAA and LAL ratios for Group 1 relative to Group 2 or 3 decreased gradually over time. These LAA ratios ranged from 7-13 for Group 1 to Group 2, 138-232 for Group 1 to Group 3, and 17-21 for Group 2 to Group 3. By contrast, the LAL ratio ranged from 3.0-3.4 comparing Group 1 to Group 2, 3180-29124 for Group 1 to Group 3, and 1058-8705 for Group 2 to Group 3. CONCLUSIONS: Using lesser-sac lavage for measurement of LAA and LA L constitutes a rapid, non-invasive and effective method for detection of pancreatic duct injury, especially transection of the main duct. LAA appears to be a better indicator for differentiation of minor (superficial laceration or side branch) or major (MPD) pancreatic injury at the first time point (15 minutes post lavage) compared to LAL. By contrast, LAL appears to be a better indicator with respect to differentiation of the injured pancreas from the normal organ at this time point.

Management of right colon diverticulitis: a 10-year experience.

BACKGROUND: Controversies abound as regards the optimal treatment for patients with diverticulitis of the right colon. METHODS: This is a retrospective review of 113 patients with a diagnosis of right colonic diverticulitis who received treatment at the China Medical University Hospital from July 1994 to June 2004. RESULTS: Medical therapy was undertaken in 56 patients diagnosed preoperatively with uncomplicated diverticulitis. All but one patient was successfully treated with bowel rest and antibiotics. Of the 51 patients with a preoperative diagnosis of acute appendicitis, 32 received appendectomy along with postoperative antibiotic therapy, 8 received diverticulectomy in addition to appendectomy, and 11 received colectomy. In all, 17 patients required right hemicolectomy or ileocecal resection due to diverticulitis-related complications or suspected malignancy. Of the 87 (56-1+32) patients who responded to conservative treatment, 11 developed recurrent diverticulitis. All 11 patients were successfully treated with medical therapy, and 2 subsequently received elective right hemicolectomy. Of the 9 patients who received medical treatment alone at the second attack, 2 suffered a third attack. Both were successfully managed with medical therapy. CONCLUSIONS: For uncomplicated diverticulitis of the right colon diagnosed preoperatively, antibiotic therapy with bowel rest is an effective treatment. Once it is encountered during surgery for presumed acute appendicitis, a conservative approach involving prophylactic appendectomy and postoperative antibiotics is recommended. For patients with recurrent diseases, medical treatment is still safe and efficient. Colectomy is indicated when complications occur or when malignancy is strongly suspected.

Role of fundus-first laparoscopic cholecystectomy in the management of acute cholecystitis in elderly patients.

BACKGROUND: Conversion from laparoscopic cholecystectomy to open cholecystectomy leads to the loss of the advantages of this minimally invasive procedure and significantly increases length of hospital stay as well as cost. The conversion from laparoscopic to open cholecystectomy is more frequent among patients with acute cholecystitis and in elderly patients. This study evaluated whether fundus-first laparoscopic cholecystectomy could lower the conversion rate in geriatric patients with acute cholecystitis. MATERIALS AND METHODS: During a twelve-month period, 112 patients (36 of them age 65 years or older) underwent fundus-first laparoscopic cholecystectomy for acute cholecystitis in a tertiary care university hospital in central Taiwan. RESULTS: The conversion rate in the elderly patients was 2.7% (1/36). No major perioperative complications were observed. Minor complications--port-site infection and subhepatic fluid collection-occurred in two patients (5.5%). CONCLUSION: Laparoscopic cholecystectomy with a fundus-first approach is a safe, effective operative procedure for elderly patients with acute cholecystitis when performed by an experienced laparoendoscopic surgeon.

Extensive retroperitoneal and right thigh abscess in a patient with ruptured retrocecal appendicitis: an extremely fulminant form of a common disease.

As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.

Laboratory tests in patients with acute appendicitis.

BACKGROUND: Laboratory measurements such as leucocyte count, neutrophil percentage and C-reactive protein (CRP) concentration are commonly used as diagnostic aids in patients with suspected acute appendicitis. The present study aimed to clarify the role of these laboratory tests in diagnosing acute appendicitis. METHODS: The medical records of 897 patients who underwent appendicectomy for suspected acute appendicitis during a 30-month period were retrospectively reviewed. The laboratory findings were correlated with the histopathology of the excised appendices. Data were analysed to calculate the sensitivity and specificity of the individual tests, as well as the test combinations. RESULTS: Histologically verified appendicitis was found in 740 of the 897 patients (82.5%). The rise in leucocyte count and neutrophil percentage correlated with the degree of appendiceal inflammation. The median CRP level was much higher in the patients with ruptured appendicitis compared with that in patients with a normal appendix (96.8 vs 39.6 mg/L, P < 0.001). However, patients with uncomplicated appendicitis had a lower median CRP concentration than those with a normal appendix, although the difference was not statistically significant (24.1 vs 39.6 mg/L, P = 0.079). The sensitivity of leucocyte count, neutrophil percentage and CRP in diagnosing acute appendicitis was 85.8, 87.2 and 76.5%, respectively, whereas the specificity was 31.9, 33.1 and 26.1%, respectively. Of the 740 patients with acute appendicitis, only six had all three tests simultaneously within the reference interval. CONCLUSIONS: Abnormal laboratory findings cannot reliably deliver a diagnosis of acute appendicitis. However, acute appendicitis is very unlikely when leucocyte count, neutrophil percentage and CRP level are simultaneously normal.

Laparoscopic appendectomy using the LigaSure Vessel Sealing System.

BACKGROUND: Laparoscopic appendectomy is increasingly being employed to treat acute appendicitis. The aim of the present study was to evaluate the efficacy and safety of the LigaSure Vessel Sealing System (Valleylab, Boulder, CO) in laparoscopic appendectomy. PATIENTS AND METHODS: Laparoscopic appendectomy was performed using the LigaSure system in 15 patients who had a preoperative diagnosis of acute appendicitis. RESULTS: In two patients, the operation was converted to open appendectomy. The mean operative time was 47 minutes (range, 22-120 minutes). There was no evidence of any complications related to the use of the LigaSure system. Neither surgical endoclips nor an endostapler were used in any patient. CONCLUSION: Laparoscopic appendectomy using the LigaSure system is a safe and efficient procedure for acute appendicitis. Use of the LigaSure system in laparoscopic appendectomy may simplify the operative procedure and reduce the operative time.

Role of leukocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of acute appendicitis in the elderly.

Leukocyte count, neutrophil percentage, and C-reactive protein (CRP) have been shown to give valuable information in the diagnosis of acute appendicitis. However, whether these laboratory tests have the same clinical applicability in the elderly as in young patients remains unclear. This retrospective study aimed to clarify the role of these tests in the diagnosis of acute appendicitis in patients aged 60 years or over. Eighty-five consecutive elderly patients underwent appendectomy for suspected acute appendicitis during a 30-month period. Histologically verified appendicitis was found in 77 of the 85 patients (90.6%). There was no significant difference in leukocyte counts or CRP values between patients with acute appendicitis and those with a normal appendix. The sensitivities of leukocyte count, neutrophil percentage, and CRP in the diagnosis of acute appendicitis were 71.4 per cent, 88.3 per cent, and 90 per cent, respectively, while the specificities were 37.5 per cent, 25 per cent, and 37.5 per cent, respectively. Of 77 patients with acute appendicitis, only two had all three tests simultaneously normal. In conclusion, patients with normal results in all three tests are highly unlikely to have acute appendicitis and should be evaluated with extra caution before surgery.