An ASER AI/ML expert panel formative user research study for an interpretable interactive splenic AAST grading graphical user interface prototype.

PURPOSE: The AAST Organ Injury Scale is widely adopted for splenic injury severity but suffers from only moderate inter-rater agreement. This work assesses SpleenPro, a prototype interactive explainable artificial intelligence/machine learning (AI/ML) diagnostic aid to support AAST grading, for effects on radiologist dwell time, agreement, clinical utility, and user acceptance. METHODS: Two trauma radiology ad hoc expert panelists independently performed timed AAST grading on 76 admission CT studies with blunt splenic injury, first without AI/ML assistance, and after a 2-month washout period and randomization, with AI/ML assistance. To evaluate user acceptance, three versions of the SpleenPro user interface with increasing explainability were presented to four independent expert panelists with four example cases each. A structured interview consisting of Likert scales and free responses was conducted, with specific questions regarding dimensions of diagnostic utility (DU); mental support (MS); effort, workload, and frustration (EWF); trust and reliability (TR); and likelihood of future use (LFU). RESULTS: SpleenPro significantly decreased interpretation times for both raters. Weighted Cohen's kappa increased from 0.53 to 0.70 with AI/ML assistance. During user acceptance interviews, increasing explainability was associated with improvement in Likert scores for MS, EWF, TR, and LFU. Expert panelists indicated the need for a combined early notification and grading functionality, PACS integration, and report autopopulation to improve DU. CONCLUSIONS: SpleenPro was useful for improving objectivity of AAST grading and increasing mental support. Formative user research identified generalizable concepts including the need for a combined detection and grading pipeline and integration with the clinical workflow.

Interrater Agreement of CT Grading of Blunt Splenic Injuries: Does the AAST Grading Need to Be Reimagined?

Introduction: The Revised Organ Injury Scale (OIS) of the American Association for Surgery of Trauma (AAST) is the most widely accepted classification of splenic trauma. The objective of this study was to evaluate inter-rater agreement for CT grading of blunt splenic injuries. Methods: CT scans in adult patients with splenic injuries at a level 1 trauma centre were independently graded by 5 fellowship trained abdominal radiologists using the AAST OIS for splenic injuries - 2018 revision. The inter-rater agreement for AAST CT injury score, as well as low-grade (IIII) versus high-grade (IV-V) splenic injury was assessed. Disagreement in two key clinical scenarios (no injury versus injury, and high versus low grade) were qualitatively reviewed to identify possible sources of disagreement. Results: A total of 610 examinations were included. The inter-rater absolute agreement was low (Fleiss kappa statistic 0.38, P < 0.001), but improved when comparing agreement between low and high grade injuries (Fleiss kappa statistic of 0.77, P < .001). There were 34 cases (5.6%) of minimum two-rater disagreement about no injury vs injury (AAST grade ≥ I). There were 46 cases (7.5%) of minimum two-rater disagreement of low grade (AAST grade I-III) versus high grade (AAST grade IV-V) injuries. Likely sources of disagreement were interpretation of clefts versus lacerations, peri-splenic fluid versus subcapsular hematoma, application of adding multiple low grade injuries to higher grade injuries, and identification of subtle vascular injuries. Conclusion: There is low absolute agreement in grading of splenic injuries using the existing AAST OIS for splenic injuries.

Machine Learning Detection and Characterization of Splenic Injuries on Abdominal Computed Tomography.

BACKGROUND: Multi-detector contrast-enhanced abdominal computed tomography (CT) allows for the accurate detection and classification of traumatic splenic injuries, leading to improved patient management. Their effective use requires rapid study interpretation, which can be a challenge on busy emergency radiology services. A machine learning system has the potential to automate the process, potentially leading to a faster clinical response. This study aimed to create such a system. METHOD: Using the American Association for the Surgery of Trauma (AAST), spleen injuries were classified into 3 classes: normal, low-grade (AAST grade I-III) injuries, and high-grade (AAST grade IV and V) injuries. Employing a 2-stage machine learning strategy, spleens were initially segmented from input CT images and subsequently underwent classification via a 3D dense convolutional neural network (DenseNet). RESULTS: This single-centre retrospective study involved trauma protocol CT scans performed between January 1, 2005, and July 31, 2021, totaling 608 scans with splenic injuries and 608 without. Five board-certified fellowship-trained abdominal radiologists utilizing the AAST injury scoring scale established ground truth labels. The model achieved AUC values of 0.84, 0.69, and 0.90 for normal, low-grade injuries, and high-grade splenic injuries, respectively. CONCLUSIONS: Our findings demonstrate the feasibility of automating spleen injury detection using our method with potential applications in improving patient care through radiologist worklist prioritization and injury stratification. Future endeavours should concentrate on further enhancing and optimizing our approach and testing its use in a real-world clinical environment.

Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study.

INTRODUCTION: The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach. METHODS: This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared. RESULTS: An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy. CONCLUSIONS: AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.

Severity of traumatic adrenal injury does not meaningfully affect clinical outcomes.

PURPOSE: There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury. METHODS: After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded. RESULTS: A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p < 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10 days vs. 16 days, p = 0.03). CONCLUSION: The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

CT findings in renovascular injuries following abdominal trauma: a pictorial review.

Renal vascular injuries are more devastating than parenchymal injuries alone, thus account for higher injury grade and require prompt recognition. Revised AAST organ injury scale (OIS) for renal trauma has incorporated CT-diagnosed vascular injuries into renal injury grading which includes pseudoaneurysm and arteriovenous fistula, along with addition of some new descriptors of renovascular injury. Dual-phase contrast-enhanced CT (with both arterial and venous phase) can easily pick up renovascular injuries and is the modality of choice for imaging renovascular trauma. Radiologist should be well versed with the imaging findings of renovascular injuries so that accurate injury grading can be done and further management can be planned at the earliest.

[Late complications after blunt renal trauma: A French multicenter study]. / Complications tardives après traumatisme fermé du rein : résultats de l'étude observationnelle nationale multicentrique TraumAFUF.

INTRODUCTION: Among genitourinary traumas, blunt trauma to the kidney are the most frequent: their initial management has been well studied but their development at a distance is poorly documented. The objective of this study was to assess the late complications of blunt renal trauma, and to investigate their predictive factors for occurrence. MATERIALS AND METHODS: A retrospective observational study of the TraumAFUF project was conducted, including, between 2005 and 2018, all blunt renal trauma treated in 18 French hospitals and followed for more than 3 months. The characteristics of the initial trauma, as well as any complications occurring after three months, were identified. The patients were divided into two groups: onset of a late complication (LC) or uncomplicated (UC). The groups were compared in univariate and multivariate analyses to identify the risk factors for the occurrence of these complications. RESULTS: Among the 454 patients included, 50 presented with LC (11%), as symptomatic morphologically altered kidney (2.9%), secondarily impaired biological renal function (2.9%), or secondary arterial hypertension (2.4%). The risk factors identified were, during initial medical care, a high-grade renal trauma≥IV (OR=2.4, P=0.025), active bleeding (OR=2.6, P=0.007), the need for transfusion (OR=2.3, P=0.001), or interventional (R=1.7, P=0.09) or endoscopic treatment (OR=2.0, P=0.035). CONCLUSION: In this study, late complications occurred in 11% of cases after blunt renal trauma. The risk factors identified make it possible to draw up a patient profile who would benefit from prolonged follow-up to detect these complications.

Readmission After Emergency General Surgery: NSQIP Review of Risk, Cause and Ideal Follow-Up.

BACKGROUND: The Emergency General Surgery (EGS) population is particularly at high risk for readmission. Currently, no system exists to predict which EGS patients are most at risk. We hypothesized that a subset of EGS patients could be identified with increased 30-day unplanned readmission. We also hypothesized that a majority of readmissions occur sooner than the conventional 2-week follow-up period. METHODS: National Surgical Quality Improvement Program (NSQIP) nonelective general surgery patients were analyzed. Multivariable logistic regression identified factors with increased odds of unplanned readmission. AAST EGS Diagnosis Categories were used to categorize postop ICD-9 codes, and the top 10 CPT codes in each group were analyzed. Readmission rate, the reason for unplanned readmission, and time to readmission were analyzed. RESULTS: A total of 383,726 patients were identified with a readmission rate of 8.1% within 30 d of their primary procedure. The top 50 CPT codes accounted for 84% of EGS readmissions. Increased readmission risk was demonstrated for underweight patients (OR = 1.15, P < 0.05). High-risk hospital characteristics were LOS >2 d, any inpatient pulmonary complications, and discharge to any facility or rehab (all P < 0.05). Surgical site infections cause nearly 25% of readmissions. Intestinal procedures are most frequently readmitted (22% of EGS readmissions), with colorectal procedures having the higher odds of readmission. Most readmissions occur <10 d after discharge. CONCLUSIONS: A high-risk subpopulation exists within EGS, and most readmissions occur sooner than a typical 2-week follow-up. Early interventions for high-risk EGS subpopulations may allow for early intervention and reduction of unnecessary healthcare utilization.

Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record. METHODS: Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications. RESULTS: 67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%). CONCLUSIONS: This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.

Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know.

This review aims to examine the challenges facing radiologists interpreting trauma computed tomography (CT) images in this era of a changing approach to management of solid organ trauma. After reviewing the pearls and pitfalls of CT imaging protocols for detection of traumatic solid organ injuries, we describe the key changes in the 2018 American Association for the Surgery of Trauma Organ Injury Scales for liver, spleen, and kidney and their implications for management strategies. We then focus on the important imaging findings in observed in patients who undergo nonoperative management and patients who are imaged post damage control surgery.

NSTI Organisms and Regions: A Multicenter Study From the American Association for the Surgery of Trauma.

BACKGROUND: Conflicting data on the microbiology and epidemiology of necrotizing soft tissue infections (NSTIs) appear to stem from the heterogeneity in microbiology observed in regions across the United States. Our goal was to determine current differences in organism prevalence and outcomes for NSTI and non-necrotizing severe soft tissue infections across the United States. We hypothesized that there were geographical differences in organism prevalence that would lead to differences in outcomes. MATERIALS AND METHODS: This study was a retrospective multi-institutional trial from centers across the United States and Canada. Demographic, clinical, and outcomes data were collected. Bivariate and multivariable analyses were performed to determine the effects of region and microbiology on outcomes. RESULTS: A total of 622 patients were included in this study. Polymicrobial infections (45%) were the most prevalent infections in all regions. On bivariate analysis, Clostridium and polymicrobial infections had higher mean Laboratory Risk Indicator for Necrotizing Fasciitis scores and American Association for the Surgery of Trauma grades (P < 0.001 for both) than other organisms. Patients in the South were more likely to be uninsured and had worse unadjusted outcomes. In a risk-adjusted model, increasing American Association for the Surgery of Trauma grade was predictive of mortality (OR, 2.3; 95% CI, 1.6-3.1; P < 0.001), as was age ≥ 55 y (OR 2.7, 95% CI 1.3-5.3, P = 0.006), but region and organism type were not associated with mortality. CONCLUSIONS: We found important regional differences with respect to organism type and demographics. However, on risk-adjusted models, neither region nor organism type predicted mortality.

Blunt chest trauma: classification and management.

Blunt chest wall injuries are a significant cause of mortality and morbidity in trauma patients. Accurate identification and description of chest wall injuries by the radiologist can aid in guiding proper patient management. The American Association for the Surgery of Trauma (AAST) has devised a classification system based on severity. This article describes the features of each injury grade according to the AAST injury scale and discusses the implications for management. Additionally, common mechanisms of blunt chest trauma and multimodal imaging techniques are discussed.

Inter-rater reliability in the radiological classification of renal injuries.

INTRODUCTION: Although many radiologists invoke the surgical classification of renal injury proposed by the American Association for Surgery in Trauma (AAST), there has been only limited work on the role of the AAST system as an imaging stratification. The aim was to determine the inter-rater reliability (IRR) amongst radiologists and urologists using the AAST system. METHODS: A 1-year retrospective study of consecutive patients with computed tomography (CT) evidence of renal trauma managed at a Level 1 trauma center. Three radiologists and three urologists independently stratified the presentation CT findings according to the AAST renal trauma classification. Agreement between independent raters and mutually exclusive groups was determined utilizing weighted kappa coefficients. RESULTS: One hundred and one patients were included. Individual inter-observer agreements ranged from 54/101 (53.4%) to 62/101 (61.4%), with corresponding weighted kappa values from 0.61 to 0.69, constituting substantial agreement. Urologists achieved intra-disciplinary agreement in 49 cases (48.5%) and radiologists in 36 cases (35.6%). Six-reader agreement was achieved in 24 cases (23.7%). The AAST grade I injuries had the highest level of agreement, overall. CONCLUSION: The finding of substantial IRR amongst radiologists and urologists utilizing the AAST system supports continued use of the broad parameters of the AAST system, with some modification in specific categories with lower agreement.

Validation of the American Association for the Surgery of Trauma's emergency general surgery breast infection grading system.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed emergency general surgery (EGS) grading systems for multiple diseases to standardize classification of disease severity. The grading system for breast infections has not been validated. We aimed to validate the AAST breast infection grading system. METHODS: Multi-institutional retrospective review of all adult patients with a breast infection diagnosis at Mayo Clinic Rochester 1/2015-10/2015 and Pietermaritzburg South African Hospital 1/2010-4/2016 was performed. AAST EGS grades were assigned by two independent reviewers. Inter-rater reliability was measured using the agreement statistic (kappa). Final AAST grade was correlated with patient and treatment factors using Pearson's correlation coefficient. RESULTS: Two hundred twenty-five patients were identified: grade I (n = 152, 67.6%), II (n = 44, 19.6%), III (n = 25, 11.1%), IV (n = 0, 0.0%), and V (n = 4, 1.8%). At Mayo Clinic Rochester, AAST grades ranged from I-III. The kappa was 1.0, demonstrating 100% agreement between reviewers. Within the South African patients, grades included II, III, and V, with a kappa of 0.34, due to issues of the grading system application to this patient population. Treatment received correlated with AAST grade; less severe breast infections (grade I-II) received more oral antibiotics (correlation [-0.23, P = 0.0004]), however, higher AAST grades (III) received more intravenous antibiotics (correlation 0.29, P <0.0001). CONCLUSIONS: The AAST EGS breast infection grading system demonstrates reliability and ease for disease classification, and correlates with required treatment, in patients presenting with low-to-moderate severity infections at an academic medical center; however, it needs further refinement before being applicable to patients with more severe disease presenting for treatment in low-/middle-income countries.

The American Association for the Surgery of Trauma Emergency General Surgery Anatomic Severity Scoring System as a predictor of cost in appendicitis.

BACKGROUND: The World Society for Emergency Surgery determined that for appendicitis managed with appendectomy, there is a paucity of evidence evaluating costs with respect to disease severity. The American Association for the Surgery of Trauma (AAST) disease severity grading system is valid and generalizable for appendicitis. We aimed to evaluate hospitalization costs incurred by patients with increasing disease severity as defined by the AAST. We hypothesized that increasing disease severity would be associated with greater cost. METHODS: Single-institution review of adults (≥ 18 years old) undergoing appendectomy for acute appendicitis during 2010-2016. Demographics, comorbidities, operative details, hospital stay, complications, and institutional cost data were collected. AAST grades were assigned by two independent reviewers based on operative findings. Total cost was ascertained from billing data and normalized to median grade I cost. Non-parametric linear regression was utilized to assess the association of several covariates and cost. RESULTS: Evaluated patients (n = 1187) had a median [interquartile range] age of 37 [26-55] and 45% (n = 542) were female. There were 747 (63%) patients with Grade I disease, 219 (19%) with Grade II, 126 (11%) with Grade III, 50 (4%) with Grade IV, and 45 (4%) with Grade V. The median normalized cost of hospitalization was 1 [0.9-1.2]. Increasing AAST grade was associated with increasing cost (ρ = 0.39; p < 0.0001). Length of stay exhibited the strongest association with cost (ρ = 0.5; p < 0.0001), followed by AAST grade (ρ = 0.39), Clavien-Dindo Index (ρ = 0.37; p < 0.0001), age-adjusted Charlson score (ρ = 0.31; p < 0.0001), and surgical wound classification (ρ = 0.3; p < 0.0001). CONCLUSIONS: Increasing anatomic severity, as defined by AAST grade, is associated with increasing cost of hospitalization and clinical outcomes. The AAST grade compares favorably to other predictors of cost. Future analyses evaluating appendicitis reimbursement stand to benefit from utilization of the AAST grade.

Image-guided prediction of pseudocyst formation in pediatric pancreatic trauma.

BACKGROUND: To determine if there is an effective alternative to the current standard of computed tomography (CT) grading of pediatric pancreatic injuries. We hypothesized that the Wong grading scale, which is based on the depth and location of the pancreatic laceration, is more predictive of pseudocyst formation than the American Association for the Surgery of Trauma (AAST) scale after nonoperative management of traumatic pancreatic injury in children. MATERIALS AND METHODS: A retrospective review of children admitted for pancreatic trauma to two level 1 pediatric trauma centers between 2000 and 2012 was conducted. Patients who underwent primary operation were excluded. Initial CT scans were reviewed by two radiologists blinded to clinical outcomes, and injury grades from both scales were assigned. The primary outcome was pseudocyst formation. RESULTS: Fifty-three patients (ages 7 mo-17 y) were included. As per the Wong scale, pseudocysts occurred in 0/20 patients with grade A injuries, 2/17 (12%) with BI/CI injuries, and 9/15 (60%) with BII/CII injuries. Using the AAST scale, pseudocysts developed in 2/27 (7%) patients with grade I/II injuries, 7/20 (35%) patients with III/IV/V injuries, and 1/6 (17%) patients with a scan that was indeterminate between grades II and III. Positive Predictive value, negative predictive value, sensitivity, and specificity for pseudocyst formation were all higher using the Wong scale (AAST/Wong: Positive Predictive value 42%/50%, negative predictive value 91%/94%, sensitivity 80%/82%, and specificity 65%/77%). CONCLUSIONS: The Wong CT grading scale may be superior to the AAST scale for early risk stratification for pseudocyst development after nonoperative management of pediatric pancreatic trauma; however, a larger study is needed for verification of these findings.

Early endoscopic treatment of blunt traumatic pancreatic injury.

Blunt pancreatic trauma is a rare and challenging situation. In many cases, there are other associated injuries that mandate urgent operative treatment. Morbidity and mortality rates are high and complications after acute pancreatic resections are common. The diagnosis of pancreatic injuries can be difficult and often requires multimodal approach including Computed Tomography scans, Magnetic resonance imaging and Endoscopic retrograde cholangiopancreaticography (ERCP). The objective of this paper is to review the application of endoprothesis in the settings of pancreatic injury. A review of the English literature available was conducted and the experience of our centre described. While the classical recommended treatment of Grade III pancreatic injury (transection of the gland and the pancreatic duct in the body/tail) is surgical resection this approach carries high morbidity. ERCP was first reported as a diagnostic tool in the settings of pancreatic injury but has in recent years been used increasingly as a treatment option with promising results. This article reviews the literature on ERCP as treatment option for pancreatic injury and adds further to the limited number of cases reported that have been treated early after the trauma.

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma.

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Double Trouble: An Unusual Presentation of Bilateral Penile Fracture.

A penile fracture results from the rupture of the tunica albuginea due to blunt trauma to an erect penis and is a rare urological emergency. Double penile fractures involving both corpora cavernosa injuries are extremely uncommon. We report the case of a 38-year-old male who experienced acute penile pain, swelling, and a "cracking" sound during sexual intercourse. Examination and ultrasound confirmed bilateral tunica albuginea ruptures and hematoma. The surgical repair involved hematoma evacuation and suturing of the tears. The patient recovered without complications. This case highlights the necessity for prompt recognition and surgical intervention in double penile fractures to prevent long-term complications and ensure optimal recovery.