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Schild-Suhren S, Yilmaz E, Biggemann L, Seif A, Torsello GF, Uhlig A, Ghadimi M, Bösch F. [Management of Injuries to the Parenchymal Abdominal Organs]. Zentralbl Chir 2024. [PMID: 38684170 DOI: 10.1055/a-2301-7951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.
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Affiliation(s)
- Stina Schild-Suhren
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Elif Yilmaz
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Lorenz Biggemann
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Ali Seif
- Institut für Diagnostische und Interventionelle Radiologie, Georg-August-Universität Göttingen, Gottingen, Deutschland
| | - Giovanni Federico Torsello
- Institut für Diagnostische und Interventionelle Radiologie, Georg-August-Universität Göttingen, Gottingen, Deutschland
| | - Annemarie Uhlig
- Klinik für Urologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Michael Ghadimi
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
| | - Florian Bösch
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Gottingen, Deutschland
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Thomas MN, Whaba R, Datta RR, Bunck AC, Stippel DL, Bruns CJ. [Management and treatment of liver injuries after blunt abdominal trauma]. CHIRURGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00104-023-01858-1. [PMID: 37142798 DOI: 10.1007/s00104-023-01858-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 05/06/2023]
Abstract
The liver is involved in about 20% of cases of blunt abdominal trauma. The management of liver trauma has changed significantly in the past three decades towards conservative treatment. Up to 80% of all liver trauma patients can now be successfully treated by nonoperative management. Decisive for this is the adequate screening and assessment of the patient and the injury pattern as well as the provision of the appropriate infrastructure. Hemodynamically unstable patients require immediate exploratory surgery. In hemodynamically stable patients, a contrast-enhanced computed tomography (CT) should be performed. If active bleeding is detected angiographic imaging and embolization should be performed to stop the bleeding. Even after initially successful conservative management of liver trauma, subsequent complications can occur that make surgical inpatient treatment necessary.
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Affiliation(s)
- M N Thomas
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
| | - R Whaba
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - R R Datta
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - A C Bunck
- Institut für Diagnostische und Interventionelle Radiologie, Uniklinik Köln, Köln, Deutschland
| | - D L Stippel
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - C J Bruns
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland
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Chu M, How N, Laviolette A, Bilic M, Tang J, Khalid M, Bos C, Rice TJ, Engels PT. Delayed laparoscopic peritoneal washout in non-operative management of blunt abdominal trauma: a scoping review. World J Emerg Surg 2022; 17:37. [PMID: 35780121 PMCID: PMC9250192 DOI: 10.1186/s13017-022-00441-z] [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: 04/17/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Non-operative management (NOM) of blunt abdominal trauma has become increasingly common in hemodynamically stable patients. There are known complications of NOM from undrained intra-abdominal fluid accumulations including hemorrhage and peritonitis that require delayed operation. Thus, delayed operation can be considered as part of the overall management plan, instead of failure, of NOM. The aim of this scoping review is to establish key concepts regarding delayed laparoscopic peritoneal washout (DLPW) following NOM of blunt abdominal trauma patients. METHODS MEDLINE, EMBASE, CENTRAL, and gray literature were systematically searched. Studies were included if they investigated or reported on the use of delayed laparoscopy involving peritoneal washout following NOM of blunt abdominal trauma patients. Bibliographies of included studies were manually reviewed to identify additional articles for inclusion. RESULTS From 910 citations, 28 studies met inclusion criteria. This included seven case reports, eleven case series or observational cohort studies, six review articles, two management guidelines, one textbook chapter, and one randomized clinical trial. For those reported, medium grade liver injuries proved most common (95.2%). Indications for DLPW were primarily clinical features and changes in imaging findings, highlighting the importance of close observation. Authors reported clinical improvement after DLPW regarding symptomatology, vital signs, and biochemistry. A relatively high transfusion demand was reported with a mean of four units of packed red blood cells pre-operatively. Length of stay and post-operative complications were consistent with previously reported experiences with blunt abdominal injuries. CONCLUSIONS DLPW is beneficial in blunt abdominal trauma patients following NOM with improvement in symptoms, SIRS features, and a possible reduction in hospital length of stay. This study is limited by low-quality evidence and skewing of data toward isolated hepatic injuries. Future prospective cohort study comparing NOM with and without DLPW is required.
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Affiliation(s)
- Megan Chu
- Division of General Surgery, McMaster University, Hamilton, Canada.
| | - Nathan How
- Division of General Surgery, McMaster University, Hamilton, Canada
| | - Alysha Laviolette
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Monika Bilic
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Jennifer Tang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Maham Khalid
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Cecily Bos
- Division of General Surgery, McMaster University, Hamilton, Canada.,Trauma Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada
| | - Timothy J Rice
- Division of General Surgery, McMaster University, Hamilton, Canada.,Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Paul T Engels
- Division of General Surgery, McMaster University, Hamilton, Canada.,Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Canada
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The effect of silymarin on liver enzymes and antioxidant status in trauma patients in the intensive care unit: a randomized double blinded placebo-controlled clinical trial. Clin Exp Hepatol 2021; 7:149-155. [PMID: 34295981 PMCID: PMC8284169 DOI: 10.5114/ceh.2021.107067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/24/2021] [Indexed: 01/09/2023] Open
Abstract
Aim of the study This study was conducted to investigate the positive effect of silymarin on liver enzymes and antioxidant status in trauma patients with elevated liver enzymes due to trauma-induced liver injury, admitted to the intensive care unit. Material and methods This one-year, randomized, double-blinded, placebo-controlled clinical trial was conducted on 90 trauma patients. The participants were assigned to either receiving Livergol tablets containing 140 mg of silymarin or 140 mg of placebo three times daily for 14 days. Liver enzymes, including aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP), were measured at baseline and days 3, 7, 9 and 14 after intervention. Also, antioxidant markers were measured at baseline and day 14 after treatment. Results Receiving silymarin supplement significantly lowered the liver enzymes, compared to placebo (p < 0.05). The mean serum level of malondialdehyde (MDA) was significantly decreased and the mean serum levels of total antioxidant capacity (TAC) and thiol groups were significantly increased in the silymarin group from baseline to day 14. In the placebo group, mean serum levels of MDA and thiol groups were significantly increased, while serum level of TAC was not significantly changed at day 14, compared to baseline. Also, the mean serum level of MDA was significantly lower, while the serum levels of thiol groups and TAC were significantly higher in the silymarin group. Conclusions Silymarin supplementation significantly improved some antioxidant markers (TAC and thiol) and decreased liver enzymes in patients with trauma-induced liver injury.
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Bustos-Guerrero AM, Guerrero-Macías SI, Manrique-Hernández EFZ. Factores asociados a sepsis abdominal en pacientes con laparotomía por trauma abdominal penetrante. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. Los pacientes que sufren algún tipo de trauma tienen una presentación clínica muy variable, por lo que se han diseñado pautas diagnósticas y terapéuticas con el fin de disminuir el número de laparotomías innecesarias. Las herramientas actuales para la predicción de infección intraabdominal, permiten intervenciones tempranas en los pacientes con alto riesgo y un mejor seguimiento clínico posoperatorio. El objetivo de este trabajo fue realizar un estudio de los factores asociados al desarrollo de las infecciones intraabdominales o sepsis abdominal posterior a laparotomía por trauma penetrante.
Métodos. Estudio descriptivo de una cohorte de pacientes atendidos por trauma abdominal penetrante en el Hospital Universitario de Santander, Bucaramanga, Colombia, entre enero de 2016 y diciembre de 2018. El análisis de datos se realizó en el software Stata®, versión 14 (StataCorp. LP, College Station, TX, USA).
Resultados. Se incluyeron 174 pacientes con edad media de 32 años, el 10,9 % (n=19) de los pacientes presentaron sepsis abdominal, de este grupo el 94,7 % (n=18) requirieron reintervención quirúrgica (p < 0,0001). La mortalidad general del grupo fue de 5,1 % (n=9), sin diferencia significativa entre los pacientes con o sin sepsis abdominal.
Discusión. Dentro de los diferentes desenlaces asociados a laparotomía por trauma, se describe la sepsis abdominal como una de las complicaciones que genera morbilidad significativa, con aumento en la estancia hospitalaria, necesidad de reintervención, aumento en los costos de atención y disminución en la calidad de vida, factores en concordancia con los hallazgos del presente estudio.
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Hu W, Xu Z, Shen X, Gu Y, Dai Z, Chen J, Zhu Z, Zhou Y, Zhao W, Chen C. Accident-related hepatic trauma in a medical clinical center in eastern China: a cross-sectional study. BMC Surg 2021; 21:16. [PMID: 33407367 PMCID: PMC7789588 DOI: 10.1186/s12893-020-01043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/28/2020] [Indexed: 11/11/2022] Open
Abstract
Background The treatment of hepatic injury can be complex. Medical clinical centers are often the first line hospitals for the diagnosis and treatment of hepatic trauma in China. The aim of the study is to summarize the experience in the diagnosis and treatment of hepatic trauma in one medical clinical center in China. Methods This retrospective study included patients with hepatic trauma admitted between January 2002 and December 2019 at the Xishan People’s Hospital of Wuxi. The outcomes were cure rate and death within 14 days post-discharge. Results Among the 318 patients with hepatic trauma, 146 patients underwent surgical treatment, and 172 received conservative treatment; three patients were transferred to other hospitals for further treatment; 283 patients were cured, and 35 died. Severe hepatic trauma occurred in 74 patients, with a mortality rate of 31.1% and accounting for 65.7% of total mortality. American Association for the Surgery of Trauma (AAST) grading ≥ III (OR = 3.51, 95%CI: 1.32–9.37, P = 0.012) and multiple organ injury (OR = 7.51, 95%CI: 2.51–22.46, P < 0.001) were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death (OR = 0.08, 95%CI: 0.01–0.45, P = 0.004). Among patients with ASST ≥ III and who underwent surgery, age (OR = 5.29, 95%CI: 1.37–20.33, P = 0.015) and peri-hepatic packing (PHP) (OR = 5.54, 95%CI: 1.43–21.487, P = 0.013) were independently associated with death. Conclusions AAST grading ≥ III and multiple organ injury were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death. Among patients with ASST ≥ III and who underwent surgery, age and PHP were independently associated with death.
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Affiliation(s)
- Weidong Hu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Zipeng Xu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Xu Shen
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Yanyan Gu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Zhengxing Dai
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Jie Chen
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Zhenghai Zhu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Ying Zhou
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Wanwen Zhao
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Chaobo Chen
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China. .,Department of Immunology, Ophthalmology and ORL, Complutense University School of Medicine, 28040, Madrid, Spain.
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Schembari E, Sofia M, Latteri S, Pesce A, Palumbo V, Mannino M, Russello D, La Greca G. Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases. Updates Surg 2020; 72:1065-1071. [PMID: 32851597 DOI: 10.1007/s13304-020-00861-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.
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Affiliation(s)
- Elena Schembari
- General Surgery, Barts Health NHS Trust, Whipps Cross Hospital, London, UK.
| | - Maria Sofia
- General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Saverio Latteri
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Antonio Pesce
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Valentina Palumbo
- General Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Maurizio Mannino
- General Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Domenico Russello
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gaetano La Greca
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
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Domanin M, Antonelli B, Crotti S, D'Alessio I, Fornoni G, Bottino N, Settembrini AM, Marongiu I, Suriano G, Tagliabue P, Carrara A, Alagna L, Trimarchi S, Pesenti A, Rossi G. Concurrent Thoracic Endovascular Aortic Repair and Liver Transplant: Multidisciplinary Management of Multiple Posttraumatic Lesions. Ann Vasc Surg 2020; 72:662.e7-662.e14. [PMID: 33227463 DOI: 10.1016/j.avsg.2020.09.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023]
Abstract
Association of thoracic and abdominal injuries in patients with major trauma is common. Under emergency conditions, it is often difficult to promptly perform a certain diagnosis and identify treatment priorities of life-threatening lesions. We present the case of a young man with combined thoracic and abdominal injuries after a motorcycle accident. Primary evaluation through echography and X-ray showed fluid within the hepatorenal recess and an enlarged mediastinum. Volume load, blood transfusions, and vasoactive agents were initiated to sustain circulation. Despite hemodynamic instability, we decided to perform computed tomographic angiography (CTA) scan that revealed a high-grade traumatic aortic pseudoaneurysm, multiple and severe areas of liver contusion, and a small amount of hemoperitoneum, without active bleeding spots. The patient was successfully submitted to thoracic endovascular aortic repair (TEVAR). Immediately after the end of the successful TEVAR, signs of massive abdominal bleeding revealed. Immediate explorative laparotomy was performed showing massive hepatic hemorrhage. After liver packing and Pringle's maneuver, control of bleeding was lastly obtained with hemostatic devices and selective cross-clamping of the right hepatic artery. The patient was then transferred to intensive care unit where, despite absence of further hemorrhage, hemodynamic instability, anuria, severe lactic acidosis together with liver necrosis indices appeared. A new CTA demonstrated massive parenchymal disruption within the right lobe of the liver and multiple hematomas in the left lobe. Considering the high-grade lesions of the hepatic vascular tree and liver failure, patient was listed for emergency liver transplantation (LT). LT occurred few hours later, and patient's clinical conditions rapidly improved even if the subsequent clinical course was characterized by a severe fungal infection because of immunosuppression. Evaluation of life-threatening lesions and treatment priorities, availability of different excellence skills, and multidisciplinary collaboration have a key role to achieve clinical success in such severe cases.
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Affiliation(s)
- Maurizio Domanin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Vascular Surgery Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Barbara Antonelli
- General Surgery and Liver Transplant Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Crotti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilenia D'Alessio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianluca Fornoni
- General Surgery and Liver Transplant Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Bottino
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Ines Marongiu
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Grazia Suriano
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Tagliabue
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Carrara
- Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy; Department of General and Emergency Surgery, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Laura Alagna
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Vascular Surgery Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy
| | - Giorgio Rossi
- General Surgery and Liver Transplant Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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10
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Hietbrink F, Smeeing D, Karhof S, Jonkers HF, Houwert M, van Wessem K, Simmermacher R, Govaert G, de Jong M, de Bruin I, Leenen L. Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization. World J Emerg Surg 2019; 14:40. [PMID: 31428187 PMCID: PMC6694503 DOI: 10.1186/s13017-019-0257-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Diederik Smeeing
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Steffi Karhof
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Henk Formijne Jonkers
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Geertje Govaert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Miriam de Jong
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ivar de Bruin
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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11
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Ruscelli P, Gemini A, Rimini M, Santella S, Candelari R, Rosati M, Paci E, Marconi V, Renzi C, Commissari R, Cirocchi R, Santoro A, D’Andrea V, Parisi A. The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience. Medicine (Baltimore) 2019; 98:e16746. [PMID: 31464904 PMCID: PMC6736468 DOI: 10.1097/md.0000000000016746] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in "Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona" and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.
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Affiliation(s)
- Paolo Ruscelli
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Alessandro Gemini
- Department of Digestive Surgery, St. Maria Hospital, Viale Tristano di Joannuccio, Terni
| | - Massimiliano Rimini
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Sergio Santella
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Roberto Candelari
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Marzia Rosati
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Enrico Paci
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Vittorio Marconi
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Claudio Renzi
- Department of Surgical Sciences, University of Perugia, Piazza dell’Università 1, Perugia
| | - Rita Commissari
- Department of Emergency, St. Maria Hospital, Viale Tristano di Joannuccio, Terni
| | - Roberto Cirocchi
- Department of Surgical Sciences, University of Perugia, Piazza dell’Università 1, Perugia
| | - Alberto Santoro
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, Italy
| | - Vito D’Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, Italy
| | - Amilcare Parisi
- Department of Digestive Surgery, St. Maria Hospital, Viale Tristano di Joannuccio, Terni
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12
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Frink M, Lechler P, Debus F, Ruchholtz S. Multiple Trauma and Emergency Room Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:497-503. [PMID: 28818179 DOI: 10.3238/arztebl.2017.0497] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 10/16/2016] [Accepted: 04/24/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. METHODS We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. RESULTS The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo - dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. CONCLUSION The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.
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Affiliation(s)
- Michael Frink
- Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg
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13
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İflazoğlu N, Üreyen O, Öner OZ, Meral UM, Yülüklü M. Non-operative management of abdominal gunshot injuries: Is it safe in all cases? Turk J Surg 2018; 34:38-42. [PMID: 29756105 DOI: 10.5152/turkjsurg.2017.3795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/25/2017] [Indexed: 11/22/2022]
Abstract
Objective In line with advances in diagnostic methods and expectation of a decrease in the number of negative laparotomies, selective non-operative management of abdominal gunshot wounds has been increasingly used over the last three decades. We aim to detect the possibility of treatment without surgery and present our experience in selected cases referred from Syria to a hospital at the Turkish-Syrian border. Material and Methods Between February 2012 and June 2014, patients admitted with abdominal gunshot wounds were analyzed. Computed tomography was performed for all patients on admission. Patients who were hemodynamically stable and did not have symptoms of peritonitis at the time of presentation were included in the study. The primary outcome parameters were mortality and morbidity. Successful selective non-operative management (Group 1) and unsuccessful selective non-operative management (Group 2) groups were compared in terms of complications, blood transfusion, injury site, injury severity score (ISS), and hospital stay. Results Of 158 truncal injury patients, 18 were considered feasible for selective non-operative management. Of these, 14 (78%) patients were treated without surgery. Other Four patients were operated upon progressively increasing abdominal pain and tenderness during follow-up. On diagnostic exploration, all of these cases had intestinal perforations. No mortality was observed in selective non-operative management. There was no statistically significant difference between Group 1 and Group 2, in terms of length of hospital stay (96 and 127 h, respectively). Also, there was no difference between groups in terms of blood transfusion necessity, injury site, complication rate, and injury severity score (p>0.05). Conclusion Decision making on patient selection for selective non-operative management is critical to ensure favorable outcomes. It is not possible to predict the success of selective non-operative management in advance. Cautious clinical examination and close monitoring of these patients is vital; however, emergency laparotomy should be performed in case of change in vital signs and positive symptoms concerning peritonitis.
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Affiliation(s)
- Nidal İflazoğlu
- Department of General Surgery, Kilis State Hospital, Kilis, Turkey
| | - Orhan Üreyen
- Department of General Surgery, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Osman Zekai Öner
- Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ulvi Mehmet Meral
- Department of General Surgery, İzmir Military Hospital, İzmir, Turkey
| | - Murat Yülüklü
- Department of General Surgery, Afyon State Hospital, Afyonkarahisar, Turkey
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14
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Stavrou GA, Lipp MJ, Oldhafer KJ. [Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]. Chirurg 2017; 88:841-847. [PMID: 28871350 DOI: 10.1007/s00104-017-0503-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management. METHOD A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit. CONCLUSION Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.
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Affiliation(s)
- G A Stavrou
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland.
| | - M J Lipp
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland
| | - K J Oldhafer
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland
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15
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Oh SY, Suh GJ. Nonoperative Treatment for Abdominal Injury in Multiple Trauma Patients: Experience in the Metropolitan Tertiary Hospital in Korea (2009~2014). JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.4.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Seung-Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
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16
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Affiliation(s)
- A N Smolyar
- N.V. Sklifosovsky Research Institute of Emergency Care, Department of Health, Moscow
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17
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Abstract
PURPOSE OF REVIEW The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma. RECENT FINDINGS Progress in the management of trauma patients increasing survival includes a multidisciplinary approach involving multiple specialties at presentation. If immediate surgical intervention is needed, 'damage control' is the best option; if not, it has been proven that conservative management is superior to operative, in terms of survival for the majority of intraabdominal injury. 'Open abdomen' should be performed in major abdominal traumas when indicated. Early enteral feeding is beneficial, even in the presence of 'open abdomen'. SUMMARY Abdominal trauma is a complex injury; the multidisciplinary approach has made nonoperative management feasible and effective. When surgical intervention is needed, it should be performed in an orderly fashion, within the context of the overall management.
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18
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Slotta JE, Justinger C, Kollmar O, Kollmar C, Schäfer T, Schilling MK. Liver injury following blunt abdominal trauma: a new mechanism-driven classification. Surg Today 2013; 44:241-6. [PMID: 23459788 PMCID: PMC3898124 DOI: 10.1007/s00595-013-0515-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
Abstract
Purposes The current classifications for blunt liver trauma focus only on the extent of liver injury. However, these scores are independent from the localization of liver injury and mechanism of trauma. Methods The type of liver injury after blunt abdominal trauma was newly classified as type A when it was along the falciform ligament with involvement of segments IVa/b, III, or II, and type B when there was involvement of segments V–VIII. With the use of a prospectively established database, the clinical, perioperative, and outcome data were analyzed regarding the trauma mechanism, as well as the radiological and intraoperative findings. Results In 64 patients, the type of liver injury following blunt abdominal trauma was clearly linked with the mechanism of trauma: type A injuries (n = 28) were associated with a frontal trauma, whereas type B injuries (n = 36) were found after complex trauma mechanisms. The demographic data, mortality, ICU stay, and hospital stay showed no significant differences between the two groups. Interestingly, all patients with type A ruptures required immediate surgical intervention, whereas six patients (16.7 %) with type B ruptures could be managed conservatively. Conclusions This new classification for blunt traumatic hepatic injury is based on the localization of parenchymal disruption and correlates with the mechanism of trauma. The type of liver injury correlated with the necessity for surgical therapy.
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Affiliation(s)
- J E Slotta
- Department of General Surgery, Visceral, Vascular and Paediatric Surgery, University of Saarland, Homburg/Saar, 66421, Saarland, Germany,
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Zafar SN, Nabeel Zafar S, Rushing A, Haut ER, Kisat MT, Villegas CV, Chi A, Stevens K, Efron DT, Zafar H, Haider AH. Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database. Br J Surg 2012; 99 Suppl 1:155-64. [PMID: 22441871 DOI: 10.1002/bjs.7735] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure. METHODS The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality. RESULTS A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups. CONCLUSION The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended.
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Affiliation(s)
- S N Zafar
- Department of Surgery, Aga Khan University, Karachi, Pakistan
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