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Sethi I, Aicher AE, Zawin M, Samuel M, Mukhi A, Vosswinkel J, Jawa RS. Index CT-Based Scoring Systems in Operative Blunt Bowel and Mesenteric Injury Identification. J Surg Res 2024; 294:240-246. [PMID: 37924561 DOI: 10.1016/j.jss.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Determining the need for surgical management of blunt bowel and mesenteric injury (BBMI) remains a clinical challenge. The Faget score and Bowel Injury Prediction Score (BIPS) have been suggested to address this issue. Their efficacy in determining the need for surgery was examined. METHODS A retrospective review of all adult blunt trauma patients hospitalized at a level 1 trauma center between January 2009 and August 2019 who had small bowel, colon, and/or mesenteric injury was conducted. We further analyzed those who underwent preoperative computed tomography (CT) scanning at our institution. Final index CT reports were retrospectively reviewed to calculate the Faget and BIPS CT scores. All images were also independently reviewed by an attending radiologist to determine the BIPS CT score. RESULTS During the study period, 14,897 blunt trauma patients were hospitalized, of which 91 had BBMI. Of these, 62 met inclusion criteria. Among patients previously identified as having BBMI in the registry, the retrospectively applied Faget score had a sensitivity of 39.1%, specificity of 81.2%, positive predictive value (PPV) of 85.7%, and negative predictive value (NPV) of 31.7% in identifying patients with operative BBMI. The retrospectively applied BIPS score had a sensitivity of 47.8%, specificity of 87.5%, PPV of 91.7%, and NPV of 36.8% in this cohort. When CT images were reviewed by an attending radiologist using the BIPS criteria, sensitivity was 56.5%, specificity 93.7%, PPV 96.3%, and NPV 42.8%. CONCLUSIONS Existing BBMI scoring systems had limited sensitivity but excellent PPV in predicting the need for operative intervention for BBMI. Attending radiologist review of CT images using the BIPS scoring system demonstrated improved accuracy as opposed to retrospective application of the BIPS score to radiology reports.
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Affiliation(s)
- Ila Sethi
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Aidan E Aicher
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Marlene Zawin
- Department of Radiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Michael Samuel
- Department of Radiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Ambika Mukhi
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - James Vosswinkel
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York.
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Lansier A, Bourillon C, Cuénod CA, Ragot E, Follin A, Hamada S, Clément O, Soyer P, Jannot AS. CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma. Eur Radiol 2023; 33:1918-1927. [PMID: 36305900 DOI: 10.1007/s00330-022-09200-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/06/2022] [Accepted: 09/22/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma. METHODS This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort. RESULTS CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI. CONCLUSIONS An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination. KEY POINTS • A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.
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Affiliation(s)
- Alexandre Lansier
- Department of Medical Imaging, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France.
| | - Camille Bourillon
- Department of Medical Imaging, Hôpital de la Croix Saint Simon, 75020, Paris, France
| | - Charles-André Cuénod
- Department of Medical Imaging, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Emilia Ragot
- Department of Visceral Surgery, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
| | - Arnaud Follin
- Department of Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
| | - Sophie Hamada
- Department of Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
| | - Olivier Clément
- Department of Medical Imaging, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France.,Faculté de Médecine, Université Paris Cité, 75006, Paris, France
| | - Philippe Soyer
- Faculté de Médecine, Université Paris Cité, 75006, Paris, France.,Department of Radiology, Hôpital Cochin, AP-HP, 75014, Paris, France
| | - Anne-Sophie Jannot
- Faculté de Médecine, Université Paris Cité, 75006, Paris, France.,Department of Medical Informatics and Public Health, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
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3
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Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds. J Trauma Acute Care Surg 2023; 94:156-161. [PMID: 35838238 DOI: 10.1097/ta.0000000000003743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW. METHODS This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed. RESULTS Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99). CONCLUSION While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level II.
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Kim HW, Park BR, Hong TH. Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.
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Leenellett E, Rieves A. Occult Abdominal Trauma. Emerg Med Clin North Am 2021; 39:795-806. [PMID: 34600638 DOI: 10.1016/j.emc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.
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Affiliation(s)
- Elizabeth Leenellett
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Room 1505, Cincinnati, OH 45267-0769, USA.
| | - Adam Rieves
- Department of Emergency Medicine, Washington University in Saint Louis, 660 South Euclid Avenue, BC 8072, Saint Louis, MO 63110, USA
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Li YG, Wang ZY, Tian JG, Su YH, Sang XG. Iliac ecchymosis, a valuable sign for hollow viscus injuries in blunt pelvic trauma patients. Chin J Traumatol 2021; 24:136-139. [PMID: 33745761 PMCID: PMC8173585 DOI: 10.1016/j.cjtee.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/11/2021] [Accepted: 02/28/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities. METHODS We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted. RESULTS In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001). CONCLUSION IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.
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Affiliation(s)
- Yong-Gang Li
- Department of Emergency Surgery & Traumatic Orthopaedics, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Zhi-Yong Wang
- Department of Emergency Surgery & Traumatic Orthopaedics, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Ji-Guang Tian
- Department of Emergency Surgery & Traumatic Orthopaedics, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Yu-Hang Su
- Department of Emergency Surgery & Traumatic Orthopaedics, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Xi-Guang Sang
- Department of Emergency Surgery & Traumatic Orthopaedics, Qilu Hospital of Shandong University, Jinan, 250012, China.
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Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic-therapeutic algorithm. Updates Surg 2020; 73:703-710. [PMID: 33340338 PMCID: PMC8005390 DOI: 10.1007/s13304-020-00929-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/11/2020] [Indexed: 11/23/2022]
Abstract
Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.
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8
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Stefanou CK, Stefanou SK, Tepelenis K, Flindris S, Tsiantis T, Spyrou S. A big mesenteric rupture after blunt abdominal trauma: A case report and literature review. Int J Surg Case Rep 2019; 61:56-59. [PMID: 31336242 PMCID: PMC6656956 DOI: 10.1016/j.ijscr.2019.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION A blunt abdominal trauma especially in organs less commonly injured (such as small bowel and mesentery injury), are difficult to diagnose. PRESENTATION OF CASE We report a case of a blunt abdominal trauma, in a 43 year old male presented in the Emergency Department after a truck vehicle accident. He sustained a chest injury, a pelvic fracture and diffuse abdominal tenderness. The patient had tachycardia (120 pulses/min) and normal blood pressure (120/90mmHg). The computed tomography (CT) showed only free fluid. We placed two chest tubes (due to pneumothorax and hemothorax at both sides) and the patient went to the operating room (OP). An external pelvic osteosynthesis was performed first and then we did an exploratory laparotomy, which revealed a big mesenteric rupture. Finally, an enterectomy (circa 2m) with a fist stage side to side anastomosis was performed. DISCUSSION Mesentery and bowel injury constitutes 3-5% of blunt abdominal injuries. The main diagnostic challenge is to identify lesions that require surgery. Diagnostic delay over 8h can lead to high morbidity and mortality rates. Laparotomy is the standard of care in hemodynamically unstable patients. CONCLUSION In polytrauma cases with abdominal pain and unclear CT findings the decision to proceed with exploratory laparotomy is better than a conservative treatment, because any surgical delay can lead to severe complications.
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Affiliation(s)
- Christos K Stefanou
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece.
| | - Stefanos K Stefanou
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
| | - Kostas Tepelenis
- Department of Surgery, Filiates General Hospital, Mpempi 1, 45600 Filiates, Greece
| | - Stefanos Flindris
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
| | - Thomas Tsiantis
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
| | - Spyridon Spyrou
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
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9
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Abstract
Trauma is the leading cause of morbidity and mortality in the pediatric population. Due to a variety of factors, many pediatric trauma patients are initially evaluated and stabilized at adult hospitals that lack pediatric specific emergency medicine and surgical expertise. While similar to adult patients, the initial evaluation and resuscitation of pediatric patients does differ. Many of these key differences contribute to missed injury and susceptibility to error in the treatment of children. Here, we highlight a variety of differences between pediatric and adult trauma patients and clarify reasoning for these differences. Error traps that are discussed include missed cases of non-accidental trauma, missed blunt cerebrovascular injury, over use of CT (computed tomography) scans with unnecessary radiation exposure, missed small bowel or mesenteric injury, and unrecognized hemodynamic instability.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA.
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10
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Lannes F, Scemama U, Maignan A, Boyer L, Beyer-Berjot L, Berdah SV, Chaumoître K, Leone M, Bège T. Value of early repeated abdominal CT in selective non-operative management for blunt bowel and mesenteric injury. Eur Radiol 2019; 29:5932-5940. [PMID: 31025065 DOI: 10.1007/s00330-019-06212-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI). METHODS This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test). RESULTS Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94). CONCLUSION In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment. KEY POINTS • Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. • An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.
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Affiliation(s)
- F Lannes
- Aix-Marseille University, Marseille, France. .,Department of General Surgery, APHM, CHU Nord, Marseille, France.
| | - U Scemama
- Aix-Marseille University, Marseille, France.,Department of Radiology, APHM, CHU Nordz, Marseille, France
| | - A Maignan
- Aix-Marseille University, Marseille, France.,Department of General Surgery, APHM, CHU Timone, Marseille, France
| | - L Boyer
- Aix-Marseille University, Marseille, France.,Public Health and Chronic Disease Research Unit, APHM, CHU Timone, Marseille, France
| | - L Beyer-Berjot
- Department of General Surgery, APHM, CHU Nord, Marseille, France.,LBA UMR T24, Aix-Marseille University, Marseille, France
| | - S V Berdah
- Department of General Surgery, APHM, CHU Nord, Marseille, France.,LBA UMR T24, Aix-Marseille University, Marseille, France
| | - K Chaumoître
- Aix-Marseille University, Marseille, France.,Department of Radiology, APHM, CHU Nordz, Marseille, France
| | - M Leone
- Aix-Marseille University, Marseille, France.,Department of Anesthesiology and Reanimation, APHM, CHU Nord, Marseille, France
| | - T Bège
- Department of General Surgery, APHM, CHU Nord, Marseille, France.,LBA UMR T24, Aix-Marseille University, Marseille, France
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11
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Ahmed N, Greenberg P. Examining the impact of small bowel resection procedure timing in patients with blunt traumatic injury: a propensity-matched analysis. Eur J Trauma Emerg Surg 2019; 46:615-620. [PMID: 30683959 DOI: 10.1007/s00068-018-1056-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/04/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the impact of the timing of small bowel resection in small bowel injury on patients' outcomes. METHODS This study was performed using data from patients included in the National Trauma Data Bank (2007-2010) who sustained blunt injuries and underwent a small bowel resection (SBR) within 24 h of arrival to the hospital. The patients' characteristics and outcomes were compared between two groups: SBR within 4 h (Group 1) and SBR between 4 and 24 h (Group 2) using Chi-square, Fisher exact, and Wilcoxon rank-sum tests. However, in an attempt to better balance the groups, propensity score matching was performed using baseline characteristics and a follow-up paired analysis was performed using McNemar, Stuart-Maxwell, and Wilcoxon signed-rank tests. RESULTS A total of 1774 patients qualified for the study. Of those, 1,292 (72.8%) patients underwent SBR within 4 h and 482 (27.2%) underwent SBR between 4 and 24 h after arrival. There were significant baseline differences between the two groups regarding Injury Severity Score (ISS) [Median (IQR)19 (10, 29) vs 14 (9, 25), P < 0.001], Glasgow Coma Scale (GCS) [15 (13, 15) vs 15 (15, 15), P < 0.001] and the proportion of patients with an initial systolic blood pressure (SBP) < 90 mmHg (18.3% vs 8.7%, P < 0.001). Given these clear differences, 482 patients from each group were pair-matched using propensity score matching on age, sex, race, ISS, GCS, and SBP. After matching, there were no significant differences observed in the matching variables, patient mortality rate (8.3% vs 7.9%, P = 0.90), or discharge disposition (home with no services: 63.1% vs 64.9%, P = 0.90); however, there was a significantly shorter hospital length of stay for those patients in Group 1 compared to Group 2 [9 (6, 15) vs 10 (7, 19), P = 0.03]. CONCLUSION More than 70% of the patient cases examined underwent SBR within 4 h of hospital arrival. However, there were no significant differences identified in the mortality rate or the discharge disposition regardless of the timing of the SBR (≤ 4 vs > 4-24 h). However, the patients whose SBR was performed within 4 h of arrival had a lower hospital length of stay when compared with those whose procedure was delayed.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma and Surgical Critical Care, Department of Surgery, Jersey Shore University Medical Center, 1945 State Route 33, Neptune, NJ, 07754, USA.
| | - Patricia Greenberg
- Department of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, USA
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12
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Bekker W, Hernandez MC, Zielinski MD, Kong VY, Laing GL, Bruce JL, Manchev V, Smith MTD, Clarke DL. Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for surgical-decision making. Injury 2019; 50:27-32. [PMID: 30253868 DOI: 10.1016/j.injury.2018.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/07/2018] [Accepted: 08/17/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system. METHODS A modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010-2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearman's rho. RESULTS There were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (n = 37, 73%), pedestrian vehicle accidents (n = 7, 13%), assaults (n = 4, 8%), falls (n = 2, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10-25] and GCS at hospital admission was 15 [15-15]. The median [IQR] international normalized ratio was 1.2 [1.1-1.5], lactate was 2.7 [1.7-4.9], and hemoglobin was 11.4 [8.6-12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy. CONCLUSIONS We developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed.
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Affiliation(s)
- Wanda Bekker
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - Matthew C Hernandez
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, United States.
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, United States.
| | - Victor Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.
| | - Grant L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - John L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - Vassil Manchev
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - Michelle T D Smith
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - Damian L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
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Nixon R, Rossanese M, Mesquita L, Burrow R. CT evaluation of mesenteric avulsion after abdominal blunt trauma in a dog. VETERINARY RECORD CASE REPORTS 2018. [DOI: 10.1136/vetreccr-2018-000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Rachel Nixon
- Leahurst Small Animal Teaching HospitalUniversity of LiverpoolNestonUK
| | - Matteo Rossanese
- Leahurst Small Animal Teaching HospitalUniversity of LiverpoolNestonUK
| | - Luis Mesquita
- Radiology DepartmentWillows Veterinary Centre and Referrals ServiceSolihullUK
| | - Rachel Burrow
- School of Veterinary ScienceUniversity of LiverpoolNestonUK
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Abdel-Aziz H, Dunham CM. Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review. Am J Surg 2018; 218:201-210. [PMID: 30201138 DOI: 10.1016/j.amjsurg.2018.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/02/2018] [Accepted: 08/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial. DATA SOURCES A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI. CONCLUSIONS Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.
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Affiliation(s)
- Hiba Abdel-Aziz
- Department of Surgical Education, Northeast Ohio Medical University, 4209 State Route 44, Rootstown, OH, USA.
| | - C Michael Dunham
- Trauma/Neuroscience Research Department, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, USA.
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Bennett AE, Levenson RB, Dorfman JD. Multidetector CT Imaging of Bowel and Mesenteric Injury: Review of Key Signs. Semin Ultrasound CT MR 2018; 39:363-373. [DOI: 10.1053/j.sult.2018.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tsai P, Yeh Y, Yeh C. Duodenal Perforation following Blunt Abdominal Trauma Presenting as Normal in Abdominal Computed Tomography. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791402100610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Most emergency department (ED) physicians implement the Advanced Trauma Life Support (ATLS) approach, including primary and secondary survey, for the assessment of blunt abdominal trauma (BAT) patients. This report emphasizes the need for repeat Focused Assessment with Sonography for Trauma (FAST) and abdominal computed tomography (CT) if a BAT patient's condition persists or worsens. After initial negative FAST and abdominal CT findings, it is recommended that BAT patients with suspected intraabdominal injury should receive repeat examination in an optimal time. We report a patient who sustained duodenal perforation following BAT diagnosed by repeat ultrasound examination and abdominal CT scan. (Hong Kong j.emerg.med. 2014;21:396-399)
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Affiliation(s)
| | - Yt Yeh
- Chung Shan Medical University, School of Dentistry, No.110, Section 1, Chien-Kuo N. Road, Taichung, Taiwan
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Abstract
OBJECTIVE The objective of our study was to retrospectively determine the anatomic distribution of chest wall ectopic gas resembling pneumoperitoneum (i.e., pseudopneumoperitoneum) and its relationship with trauma mechanisms and clinical outcomes using CT. MATERIALS AND METHODS Investigators from two separate trauma referral centers screened 492 chest, abdomen, and pelvis CT examinations of patients who had sustained any form of trauma between 2010 and 2015. After excluding 186 patients with recognized causes of ectopic gas, 306 patients (211 men and 95 women; mean age, 44.5 years; range, 6-95 years) remained for analysis by two radiology residents in center 1 and a radiology resident in center 2. Positive cases were reviewed by all investigators, including an experienced fellowship-trained abdominal radiologist. The anatomic location of the pseudopneumoperitoneum, injury severity score, trauma velocity (high speed vs low or unknown speed), trauma mechanism, clinical findings on follow-up, and exploratory laparotomy data were collected for patients with pseudopneumoperitoneum. Two hundred consecutive nontrauma CT examinations from 2015 were selected as control cases by a resident in center 1. The t test and chi-square test were used for determining associations. RESULTS Pseudopneumoperitoneum was identified in 5.2% of patients, occurring bilaterally adjacent to the lower six costochondral junctions, and was significantly more common with high-velocity trauma than with low-velocity trauma (p = 0.010). None of the patients with pseudopneumoperitoneum had evidence of perforated hollow viscus at surgery (n = 2) or on clinical follow-up (n = 14). No patients had unnecessary surgery due to pseudopneumoperitoneum. CONCLUSION Pseudopneumoperitoneum is a posttraumatic phenomenon centered near the lower six costochondral junctions. Recognizing these findings may help prevent unnecessary laparotomy in the trauma setting.
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Abstract
Hollow viscus injury is common with penetrating trauma to the torso and infrequent with a blunt traumatic mechanism of injury. The diagnosis in hemodynamically unstable patients is often made in the operating room. In hemodynamically stable patients, the diagnosis can be difficult due to additional injuries. Although computed tomography remains the diagnostic tool of choice in hemodynamically stable patients, it has lower reported sensitivity and specificity with hollow viscus injury. However, even short delays in diagnosis increase morbidity and mortality significantly. Operative management of stomach, duodenal, small bowel, and colon injuries is reviewed.
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Abstract
Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.
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Affiliation(s)
- T Bège
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - C Brunet
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - S V Berdah
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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CT imaging signs of surgically proven bowel trauma. Emerg Radiol 2016; 23:213-9. [DOI: 10.1007/s10140-016-1380-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 01/26/2016] [Indexed: 11/25/2022]
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Saturnino PP, Pinto A, Liguori C, Ponticiello G, Romano L. Role of Multidetector Computed Tomography in the Diagnosis of Colorectal Perforations. Semin Ultrasound CT MR 2015; 37:49-53. [PMID: 26827738 DOI: 10.1053/j.sult.2015.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Colonic perforations can be classified into perforations that occur at the site of a localized pathologic process and cecal perforations that occur secondary to distal colonic obstructions. Rectal perforations may result from foreign bodies inserted into the rectum; moreover, deep rectal biopsies, polypectomy, improper cleansing enema, or thermometer placement may also lead to rectal perforation. Correct identification of the cause and site of the perforation is crucial for appropriate management and surgical planning. Multidetector row computed tomography has a pivot role in planning the type of operative treatment, the prognosis, and in assessing those patients who have clinical symptoms of peritonitis but no radiographic signs of perforation.
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Affiliation(s)
| | - Antonio Pinto
- Department of Radiology, Cardarelli Hospital, Naples, Italy
| | - Carlo Liguori
- Department of Radiology, Cardarelli Hospital, Naples, Italy
| | | | - Luigia Romano
- Department of Radiology, Cardarelli Hospital, Naples, Italy
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Faget C, Taourel P, Charbit J, Ruyer A, Alili C, Molinari N, Millet I. Value of CT to predict surgically important bowel and/or mesenteric injury in blunt trauma: performance of a preliminary scoring system. Eur Radiol 2015; 25:3620-8. [DOI: 10.1007/s00330-015-3771-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 03/24/2015] [Accepted: 04/03/2015] [Indexed: 11/28/2022]
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Hommes M, Navsaria PH, Schipper IB, Krige JEJ, Kahn D, Nicol AJ. Management of blunt liver trauma in 134 severely injured patients. Injury 2015; 46:837-42. [PMID: 25496854 DOI: 10.1016/j.injury.2014.11.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/20/2014] [Accepted: 11/14/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND In haemodynamic stable patients without an acute abdomen, nonoperative management (NOM) of blunt liver injuries (BLI) has become the standard of care with a reported success rate of between 80 and 100%. Concern has been expressed about the potential overuse of NOM and the fact that failed NOM is associated with higher mortality rate. The aim of this study was to evaluate factors that might indicate the need for surgical intervention, and to assess the efficacy of NOM. METHODS A single centre prospective study between 2008 and 2013 in a level-1 Trauma Centre. One hundred thirty four patients with BLI were diagnosed on CT-scan or at laparotomy. The median ISS was 25 (range 16-34). RESULTS Thirty five (26%) patients underwent an early exploratory laparotomy. The indication for surgery was haemodynamic instability in 11 (31%) patients, an acute abdomen in 16 (46%), and 8 (23%) patients had CT findings of intraabdominal injuries, other than the hepatic injury, that required surgical repair. NOM was initiated in 99 (74%) patients, 36 patients had associated intraabdominal solid organ injuries. Seven patients developed liver related complications. Five (5%) patients required a delayed laparotomy (liver related (3), splenic injury (2)). NOM failure was not related to the presence of shock on admission (p=1000), to the grade of liver injury (p=0.790) or associated intraabdominal injuries (p=0.866). CONCLUSION Physiologic behaviour or CT findings dictated the need for operative intervention. NOM of BLI has a high success rate (95%). Nonoperative management of BLI should be considered in patients who respond to resuscitation, irrespective of the grade of liver trauma. Associated intraabdominal solid organ injuries do not exclude NOM.
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Affiliation(s)
- Martijn Hommes
- Trauma Centre, Department of Surgery, Groote Schuur Hospital, University of Cape Town & Department of Trauma Surgery, Leiden University Medical Center, The Netherlands
| | - Pradeep H Navsaria
- Trauma Centre, Department of Surgery, Groote Schuur Hospital, University of Cape Town, South Africa
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Centre, The Netherlands
| | - J E J Krige
- Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town, South Africa
| | - D Kahn
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, South Africa
| | - Andrew John Nicol
- Trauma Centre, Department of Surgery, Groote Schuur Hospital, University of Cape Town, South Africa.
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An unduly delayed presentation of an “isolated segment of ileum” after blunt abdominal trauma with full recovery. Trauma Case Rep 2015; 1:17-20. [PMID: 30101170 PMCID: PMC6082439 DOI: 10.1016/j.tcr.2015.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 11/26/2022] Open
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Iaselli F, Mazzei MA, Firetto C, D'Elia D, Squitieri NC, Biondetti PR, Danza FM, Scaglione M. Bowel and mesenteric injuries from blunt abdominal trauma: a review. Radiol Med 2015; 120:21-32. [PMID: 25572542 DOI: 10.1007/s11547-014-0487-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/12/2014] [Indexed: 12/01/2022]
Abstract
The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.
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Affiliation(s)
- Francesco Iaselli
- Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domitiana, Km 30, 81100, Castel Volturno, Italy,
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Marek AP, Deisler RF, Sutherland JB, Punjabi G, Portillo A, Krook J, Richardson CJ, Nygaard RM, Ney AL. CT scan-detected pneumoperitoneum: an unreliable predictor of intra-abdominal injury in blunt trauma. Injury 2014; 45:116-21. [PMID: 24041430 DOI: 10.1016/j.injury.2013.08.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/09/2013] [Accepted: 08/14/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Free intra-peritoneal air in blunt trauma is a classic sign associated with hollow viscus injury, traditionally mandating laparotomy. In blunt abdominal trauma, the CT scan has become the diagnostic modality of choice. The increased sensitivity of CT scans may lead to detection of free intra-peritoneal air that is not clinically significant. OBJECTIVE To characterize conditions and findings that allow for the safe observation of blunt trauma patients with free air and to propose a patient management algorithm to decrease rates of non-therapeutic laparotomy. DESIGN A retrospective review of 5877 blunt trauma patients who had an abdominal CT scan upon admission to our hospital from 2003 to 2011. A secondary CT review was performed by a single radiologist to further characterize the CT findings in the 74 patients with free air reported on initial scan. Management and hospital course were reviewed in these patients. RESULTS Of the 74 patients with intra-abdominal free air, 36 patients with a benign clinical picture were observed and 38 patients underwent urgent exploratory laparotomy. Eleven patients received a non-therapeutic laparotomy. The majority (61%) of patients, 45 of 74, had free air and no significant injury suggesting the presence of benign free air. Patients who had intra-abdominal injury also typically had other clinical or radiologic signs of injury. Findings that were highly predictive of intra-abdominal injury in the setting of free air were free fluid (P<0.001), radiographic signs of bowel trauma (P<0.001) as well as clinical and/or radiographic seatbelt sign (P=0.004). CONCLUSIONS CT scans may detect free air that is not always clinically significant. Free fluid, seatbelt sign or radiographic signs of bowel trauma in the presence of pneumoperitoneum is highly predictive of injury and these patients should be explored. Based on the results of our study, we created an algorithm to aid in identifying those patients with intra-abdominal free air who may be observed safely.
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Affiliation(s)
- Ashley P Marek
- Department of Surgery, Hennepin County Medical Center, Minneapolis, MN, United States
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Park MH, Shin BS, Namgung H. Diagnostic performance of 64-MDCT for blunt small bowel perforation. Clin Imaging 2013; 37:884-8. [DOI: 10.1016/j.clinimag.2013.06.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/25/2013] [Accepted: 06/11/2013] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Despite the availability of more accurate imaging modalities, specifically multidetector computed tomography (MDCT), the diagnosis of non-ischemic (NI-) and ischemic (I-) blunt hollow viscus and mesenteric injury (BHVMI) remains challenging. We hypothesized that BHVMI can be still missed with newer generations of MDCT and that patients with I-BHVMI have a poorer outcome than those with NI-BHVMI. METHODS We performed an eight-year retrospective review at a level 1 trauma center. Ischemic-BHVMI was defined as devascularization confirmed at laparotomy. Non-ischemic-BHVMI included perforation, laceration, and hematoma without devascularization. The sensitivity of each generation of MDCT for BHVMI was calculated. Potential predictors and outcomes of I-BHVMI were compared to the NI-BHVMI group. RESULTS Of 7,875 blunt trauma patients, 67 patients (0.8 %) were included in the BHVMI group; 13 patients did not have any CT findings suggestive of BHVMI (sensitivity 81 %), and 11 of them underwent surgical intervention without delay (<5 h). Newer generations of MDCT were not associated with higher sensitivity. Patients with I-BHVMI had a significantly higher rate of delayed laparotomy ≥ 12 h (23 % versus 2 %; p = 0.01) and a significantly longer length of hospital stay (median 14 versus 9 days; p = 0.02) than those with NI-BHVMI. CONCLUSIONS Even using an advanced imaging technique, the diagnosis of I-BHVMI can be delayed, with significant negative impact on patient outcome.
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Bège T, Chaumoître K, Léone M, Mancini J, Berdah SV, Brunet C. Blunt bowel and mesenteric injuries detected on CT scan: who is really eligible for surgery? Eur J Trauma Emerg Surg 2013; 40:75-81. [PMID: 26815780 DOI: 10.1007/s00068-013-0318-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is no consensually accepted approach to the management of blunt bowel and mesenteric injuries. Surgery is required urgently in the case of bowel perforation or haemodynamic instability, but several patients can be treated non-operatively. This study aimed to identify the risk factors for surgery in an initial assessment. METHODS We retrospectively reviewed the medical charts and computed tomography (CT) scans of adult patients presenting with a blunt abdominal trauma to our centre between the years 2004 and 2011. We included only patients with a CT scan showing suspected injury to the mesentery or bowel. RESULTS There were 43 patients (33 males and 10 females), with a mean Injury Severity Score (ISS) of 22. The most frequently suspected injuries based on a CT scan were mesenteric infiltrations in 40 (93 %) patients and bowel wall thickening in 22 (51 %) patients. Surgical therapy was required for 23 (54 %) patients. Four factors were independently associated with surgical treatment: a free-fluid peritoneal effusion without solid organ injury [adjusted odds ratio (OR) = 14.4, 95 % confidence interval (CI) [1.9-111]; p = 0.015], a beaded appearance of the mesenteric vessels (OR = 9 [1.3-63]; p = 0.027), female gender (OR = 14.2 [1.3-159]; p = 0.031) and ISS >15 (OR = 6.9 [1.1-44]; p = 0.041). Surgery was prescribed immediately for 11 (26 %) patients and with delay, after the failure of initially conservative treatment, for 12 (28 %) patients. The presence of a free-fluid peritoneal effusion without solid organ injury was also an independent risk factor for delayed surgery (OR = 9.8 [1-95]; p = 0.048). CONCLUSIONS In blunt abdominal trauma, the association of a bowel and/or mesenteric injury with a peritoneal effusion without solid organ injury on an initial CT scan should raise the suspicion of an injury requiring surgical treatment. Additionally, this finding should lead to a clinical discussion of the benefit of explorative laparotomy to prevent delayed surgery. However, these findings need validation by larger studies.
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Affiliation(s)
- T Bège
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France. .,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France.
| | - K Chaumoître
- Department of Radiology, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - M Léone
- Department of Anesthesia and Resuscitation, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - J Mancini
- Department of Public Health and Medical Information, APHM Timone, Aix-Marseille University, 13006, Marseille, France
| | - S V Berdah
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France
| | - C Brunet
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France
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Abstract
Over the history of surgery, the management of abdominal gunshot wounds in the stable evaluable patient without peritonitis has evolved. While non-operative management has been widely accepted and employed for the management of abdominal stab wounds, recently it has been deemed a safe option for abdominal gunshot wounds as well. Selective non-operative management of penetrating abdominal trauma in the appropriate setting has been shown to decrease the rate of nontherapeutic laparotomy as well as the cost and total length of hospital stay, and potentially decrease short- and long-term morbidity. This review examines the background support for non-operative management of abdominal gunshot wounds while discussing patient evaluation, selection, and clinical management.
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Affiliation(s)
- Stephen Varga
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Scott Zakaluzny
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
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Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64-slice computed tomography. J Trauma Acute Care Surg 2013; 74:1081-6. [DOI: 10.1097/ta.0b013e3182827178] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naulet P, Wassel J, Gervaise A, Blum A. Evaluation of the value of abdominopelvic acquisition without contrast injection when performing a whole body CT scan in a patient who may have multiple trauma. Diagn Interv Imaging 2013; 94:410-7. [DOI: 10.1016/j.diii.2013.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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