Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study.

BACKGROUND: Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. METHODS: This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III-V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. RESULTS: Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV-V were predictors of complications (OR, 6.61; p < 0.01). CONCLUSIONS: TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

Usefulness of lavage and drainage using video-assisted thoracoscopic surgery for Boerhaave's syndrome: a retrospective analysis.

BACKGROUND: Boerhaave's syndrome has a high mortality rate due to respiratory failure, septic shock, and multiple organ failure. We had previously carried out primary repair with laparotomy and postoperative computed tomography-guided drainage for mediastinal abscess and empyema. However, this treatment prolonged mechanical ventilator days and length of intensive care unit stay. Therefore, we decided to carry out primary repair with laparotomy and add lavage and drainage using video-assisted thoracoscopic surgery. METHODS: From April 2004 to September 2018, 18 patients with Boerhaave's syndrome were treated; 6 patients treated conservatively were excluded. Thus, 12 patients who underwent surgical treatment were divided into the computed tomography-guided drainage group (D group) (6 patients) and the lavage and drainage using video-assisted thoracoscopic surgery group (VATS group) (6 patients), and the two groups were retrospectively compared. RESULTS: The VATS group had significantly longer operation time than the D group {359 [328, 387] vs. 220 [155, 235] min, P=0.004}, but the ventilator-free days (VFDs) were significantly extended {24 [21, 24] vs. 10 [0, 17] days, P=0.02}, and the length of intensive care unit stay was significantly shortened {14 [8, 14] vs. 35 [29, 55] days, P=0.01}. CONCLUSIONS: Lavage and drainage using video-assisted thoracoscopic surgery is an effective surgical method for Boerhaave's syndrome.

Use of Multimodal Interventional Radiology with an Intracerebral Artery Stent Retriever for Acute Superior Mesenteric Artery Thrombosis: A Case Report.

Acute superior mesenteric artery thrombosis is usually fatal; however, early intravascular treatment using a mechanical thrombectomy device can be an effective intervention. A 70-year-old man with atrial fibrillation presented with sudden abdominal pain; superior mesenteric artery thrombosis was confirmed using contrast-enhanced computed tomography. Thrombolysis, mechanical fragmentation, aspiration, and thrombectomy were successfully performed using the Trevo® XP ProVue stent retriever via a brachial approach, and intestinal necrosis was avoided. Thus, intravascular treatment of superior mesenteric artery thrombosis can be performed using a relatively low-profile catheter and a brachial artery approach, allowing the implementation of a multimodal interventional radiological approach tailored for individual cases.

A case of intestinal obstruction due to inflammatory changes in the small intestine from alkaline ingestion.

CASE: Alkaline ingestion frequently causes corrosive esophagitis but rarely causes lower digestive tract injury. In this case, a 79-year-old man accidentally drank kitchen detergent. After 3 h, lower abdominal pain occurred and gradually worsened. He was taking a proton pump inhibitor after proximal gastrectomy for gastric cancer. He had local tenderness in the left lower abdomen. Abdominal computed tomography showed expansion of the small intestine, thickening of the intestinal wall, and inflammatory changes. Upper gastrointestinal endoscopy showed no obvious injury to the esophagus or stomach. OUTCOME: Conservative treatment with an ileus tube was undertaken for intestinal obstruction caused by alkaline ingestion. There were no complications, such as gastrointestinal perforation, and he was discharged on day 17. CONCLUSION: Alkaline ingestion may cause injuries not only to the upper but also to the lower digestive tract in patients who are taking proton pump inhibitors or have had gastrectomy.

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma.

OBJECT: To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. PATIENTS AND METHODS: The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). RESULTS: Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group. CONCLUSION: Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

[FAST for abdominal trauma].

Japanese Association for Acute Medicine and Japanese Association for The Surgery of Trauma developed JATEC (Japan Advanced Trauma Evaluation and Care) course as an off-the-job training to improve trauma care in Japan. In this course, the trauma patients undergo primary survey and secondary survey. FAST (focused assessment with sonography for trauma) is performed to detect hemoperitoneum during primary survey. In this article, we describe FAST in the evaluation and care for abdominal trauma. If the patient becomes hemodynamically unstable during the survey or the intraoperative period, we have to repeat primary survey and FAST.