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Fabig S, Weigert N, Migliorini F, Kleeff J, Hofmann GO, Schenk P, Hilbert-Carius P, Kobbe P, Mendel T. Predictive parameters for early detection of clinically relevant abdominal trauma in multiple-injury or polytraumatised patients: a retrospective analysis. Eur J Med Res 2024; 29:394. [PMID: 39080791 PMCID: PMC11288090 DOI: 10.1186/s40001-024-01969-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 07/10/2024] [Indexed: 08/03/2024] Open
Abstract
Diagnosis of relevant organ injury after blunt abdominal injury (AI) in multiple-injury/polytraumatised patients is challenging. AI can be distinguished between injuries of parenchymatous organs (POI) of the upper abdomen (liver, spleen) and bowel and mesenteric injuries (BMI). Still, such injuries may be associated with delays in diagnosis and treatment. The present study aimed to verify laboratory parameters, imaging diagnostics, physical examination and related injuries to predict intraabdominal injuries. This retrospective, single-centre study includes data from multiple-injury/polytraumatised patients between 2005 and 2017. Two main groups were defined with relevant abdominal injury (AI+) and without abdominal injury (AI-). The AI+ group was divided into three subgroups: BMI+, BMI+/POI+, and POI+. Groups were compared in a univariate analysis for significant differences. Logistic regression analysis was used to determine predictors for AI+, BMI+ and POI+. 26.3% (271 of 1032) of the included patients had an abdominal injury. Subgroups were composed of 4.7% (49 of 1032) BMI+, 4.7% (48 of 1032) BMI+/POI+ and 16.8% (174 of 1032) POI+. Pathological abdominal signs had a sensitivity of 48.7% and a specificity of 92.4% for AI+. Transaminases were significantly higher in cases of AI+. Pathological computed tomography (CT) (free fluid, parenchymal damage, Bowel Injury Prediction Score (BIPS), CT Grade > 4) was summarised and had a sensitivity of 94.8%, a specificity of 98%, positive predictive value (PPV) of 94.5% and, negative predictive value (NPV) of 98.2% for AI+. The detected predictors for AI+ were pathological abdominal findings (odds ratio (OR) 3.93), pathological multi-slice computed tomography (MSCT) (OR 668.9), alanine (ALAT) ≥ 1.23 µmol/ls (OR 2.35) and associated long bone fractures (OR 3.82). Pathological abdominal signs, pathological MSCT and lactate (LAC) levels ≥ 1.94 mmol/l could be calculated as significant risk factors for BMI+. For POI+ pathological abdominal MSCT, ASAT ≥ 1.73 µmol/ls and concomitant thoracic injuries had significant relevance. The study presents reliable risk factors for abdominal injury and its sub-entities. The predictors can be explained by the anatomy of the trunk and existing studies. Elevated transaminases predicted abdominal injury (AI+) and, specifically, the POI+. The pathological MSCT was the most reliable predictive parameter. However, it was essential to include further relevant parameters.
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Affiliation(s)
- Stefan Fabig
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Nadja Weigert
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
- Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy
| | - Jörg Kleeff
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Gunther Olaf Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, 74771, Jena, Germany
| | - Philipp Schenk
- Department of Science, Research and Education, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Philipp Kobbe
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany.
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany.
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Agri F, Pache B, Bourgeat M, Darioli V, Demartines N, Schmidt S, Zingg T. Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study. J Trauma Acute Care Surg 2024; 96:820-830. [PMID: 38111096 DOI: 10.1097/ta.0000000000004231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS). METHODS A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance. RESULTS The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively. CONCLUSION The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Fabio Agri
- From the Department of Visceral Surgery (F.A., M.B., N.D., T.Z.), Department of Administration and Finance (F.A.), Department of Women-Mother-Child (B.P.), Gynecology and Obstetrics Unit, Department of Emergency Medicine (V.D.), and Department of Diagnostic and Interventional Radiology (S.S.), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Rodriguez VI, Perez B, Fernandez A, Varela C, Teran A. Hollow viscus perforation in blunt abdominal trauma: A 14-year experience from a trauma center. World J Surg 2024; 48:855-862. [PMID: 38353292 DOI: 10.1002/wjs.12096] [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: 09/23/2023] [Accepted: 01/15/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Isolated perforations of hollow viscus (HV) represent less than 1% of injuries in blunt abdominal trauma (BAT). When they do present, they are generally due to high-impact mechanisms in the segments of the intestine that are fixed. The aim of this study is to determine the incidence of major HV injuries in BAT at the "Dr. Domingo Luciani" General Hospital (HDL), and address the literature gap regarding updated HV perforations following BAT, especially in low-income settings. METHODS A retrospective review was conducted on the medical records of patients admitted to our trauma center with a diagnosis of complicated BAT with HV perforation over 14 years. RESULTS AND DISCUSSION Seven hundred sixty-one patients were admitted under the diagnosis of BAT. Of them, 36.79% underwent emergency surgical resolution, and 6.04% had HV perforation as an operative finding. Almost half (44.44%) of these cases presented as a single isolated injury, while the remaining were associated with other intra-abdominal organ injuries. The most common lesions were Grade II-III jejunum and Grade I transverse colon, affecting an equal proportion of patients at 13.33%. In recent years, an increased incidence of HV injuries secondary to BAT has been observed. Despite this, in many cases, the diagnosis is delayed, so even in the presence of negative diagnostic studies, the surgical approach based on the trauma mechanism, hemodynamic status, and systematic reevaluation of the polytraumatized patient should prevail.
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Affiliation(s)
- Veronica I Rodriguez
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
- Catherine and Joseph Aresty Department of Urology, Keck Medicine of USC, Los Angeles, California, USA
| | - Barbara Perez
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| | - Andrea Fernandez
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| | - Cristopher Varela
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
| | - Adrian Teran
- Department of General Surgery, Hospital General del Este "Dr. Domingo Luciani", Universidad Central de Venezuela, Caracas, Venezuela
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O'Toole DM, Warrington NV, Matthees NG, Kupanoff KM, Bogert JN, Jones MD, Soe-Lin H, Huang DD, Weinberg JA. Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury. Emerg Radiol 2024; 31:193-201. [PMID: 38374481 PMCID: PMC10995023 DOI: 10.1007/s10140-023-02197-8] [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: 11/07/2023] [Accepted: 12/22/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE Blunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI. METHODS We conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI. RESULTS One hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67-0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64-0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75-0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55). CONCLUSION Radiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist's impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.
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Affiliation(s)
- Devin M O'Toole
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
| | | | | | - Kristina M Kupanoff
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - James N Bogert
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Michael D Jones
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Hahn Soe-Lin
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Dih-Dih Huang
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA
| | - Jordan A Weinberg
- Creighton University School of Medicine, Phoenix Campus, Phoenix, AZ, USA.
- Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ, 85013, USA.
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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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Chowdhury A, Burford C, Pangeni A, Shrestha A. Bucket-Handle Mesenteric Tears: A Comprehensive Review of Their Presentation and Management. Cureus 2022; 14:e28692. [PMID: 36199643 PMCID: PMC9527005 DOI: 10.7759/cureus.28692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/30/2022] Open
Abstract
Bucket-handle mesenteric tears remain a diagnostic challenge for clinicians. We aim to review the literature, including a single-surgeon series, to better understand their presentation and management. Three electronic databases (Ovid Medline, Embase, and PubMed) were searched for original research articles, describing relevant cases, from database inception to October 2021 using the following Medical Subject Heading (MeSH) terms: mesenteric avulsion, mesenteric tear, and blunt abdominal trauma. A retrospective review of cases managed under a single surgeon at our unit was also performed. Data extracted included demographics, mechanism of injury, presenting features, diagnostic imaging, surgical management, and patient outcome. In total, 19 studies were identified, including 22 patients (median age 34.5 years). The most common cause of injury was seat-belted road traffic accidents (77.3%), and patients commonly presented with abdominal pain (72.7%), tenderness (50%), positive seat-belt sign (54.5%), and haemodynamic compromise (45.5%). Computerised tomography scanning was the main imaging modality (68%), and the most common findings reported were abdominal free fluid (36.4%) and abdominal wall hernia (27.3%). The majority of patients were operated on within 24 hours of injury (68%), had a median length of stay of 14.5 days, and experienced an uncomplicated recovery (68%). There was no association between the development of complications and delayed surgical intervention >24 hours (p = 0.145). Our institution’s experience was similar, with 50% of patients undergoing surgical intervention within 24 hours. The median age was 32.5 years (50% female), and the median length of stay was 11 days. A high index of suspicion, serial monitoring, including blood tests, and imaging, with a low threshold for early repeat imaging, can provide a useful guide for identifying patients with bucket-handle tears.
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Shuwelif A, Maikhan A, Mihson H. Procalcitonin as predictor of bowel injury in penetrating abdominal injury. MUSTANSIRIYA MEDICAL JOURNAL 2022. [DOI: 10.4103/mj.mj_47_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Diagnostic Accuracy of Computed Tomography for the Prediction of the Need for Laparotomy for Traumatic Hollow Viscus Injury: Systematic Review and Meta-Analysis. J Pers Med 2021; 11:jpm11121269. [PMID: 34945741 PMCID: PMC8708608 DOI: 10.3390/jpm11121269] [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: 11/02/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI. METHOD A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models. RESULTS Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501-0.809) and 0.969 (95% CI: 0.920-0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011-0.071). CONCLUSION In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.
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Chen SA, Wang CY, Hsu CP, Lin JY, Cheng CT, Ouyang CH, Huang JF, Liao CH. The Current Diagnostic Accuracy on Free Peritoneal Fluid in Computed Tomography to Determinate the Necessity of Surgery in Blunt Bowel and Mesenteric Trauma-Systemic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11112028. [PMID: 34829375 PMCID: PMC8620381 DOI: 10.3390/diagnostics11112028] [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: 09/12/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
Traumatic bowel mesenteric injury (TBMI) is a challenge in trauma care. The presence of free peritoneal fluid (FF) in computed tomography (CT) was considered the indication for surgical intervention. However, conservative treatment should be applied for minor injuries. We conduct a systematic review to analyze how reliable the FF is to assess the TBMI. Publications were retrieved by structured searching among databases, review articles and major textbooks. For statistical analysis, summary receiver operating characteristic curves (SROCs) were computed using hierarchical models. Fourteen studies enrolling 4336 patients were eligible for final qualitative analysis. The SROC line was created by a hierarchical summary receiver operating characteristic model. The summary sensitivity of FF to predict surgical TBMI was 0.793 (95% CI: 0.635-0.894), and the summary specificity of FF to predict surgical TBMI was 0.733 (95% CI: 0.468-0.896). The diagnostic odds ratio was 10.531 (95% CI: 5.556-19.961). This study represents the most robust evidence (level 3a) to date that FF is not the absolute but an acceptable indicator for surgically important TBMI. However, there is still a need for randomized controlled trials to confirm.
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Affiliation(s)
- Szu-An Chen
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chen-Yu Wang
- Department of Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan;
| | - Chih-Po Hsu
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Jia-Yen Lin
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chi-Tung Cheng
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Jen-Fu Huang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chien-Hung Liao
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
- Correspondence: ; Tel.: +886-3281200 (ext. 3651)
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Weinberg JA, Peck KA, Ley EJ, Brown CV, Moore EE, Sperry JL, Rizzo AG, Rosen NG, Brasel KJ, Hartwell JL, de Moya MA, Inaba K, Martin MJ. Evaluation and management of bowel and mesenteric injuries after blunt trauma: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2021; 91:903-908. [PMID: 34162796 DOI: 10.1097/ta.0000000000003327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jordan A Weinberg
- From the Department of Surgery, Creighton University School of Medicine Phoenix Regional Campus (J.A.W.), Phoenix, Arizona; Department of Surgery, Scripps Mercy Hospital (K.A.P., M.J.M.), San Diego; Department of Surgery, Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Department of Surgery, Dell Medical School, University of Texas (C.V.B.), Austin, Texas; Department of Surgery, Ernest E. Moore Shock Trauma Center (E.E.M.), Denver, Colorado; Department of Surgery, University of Pittsburgh School of Medicine, (J.L.S.), Pittsburgh, Pennsylvania; Department of Surgery, Inova Trauma Center (A.G.R.), Falls Church, Virginia; Department of Surgery, Cincinnati Children's Hospital (N.G.R.), Cincinnati, Ohio; Department of Surgery, Oregon Health Science University (K.J.B.), Portland, Oregon; Department of Surgery, Indiana University School of Medicine (J.L.H.), Indianapolis, Indiana; Department of Surgery, Medical College of Wisconsin (M.A.d.M.), Milwaukee, Wisconsin; Department of Surgery, University of Southern California (K.I.), Los Angeles, California
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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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Keller N, Zingg T, Agri F, Denys A, Knebel JF, Schmidt S. Significant blunt bowel and mesenteric injury - Comparison of two CT scoring systems in a trauma registry cohort. Eur J Radiol Open 2021; 8:100380. [PMID: 34646913 PMCID: PMC8496098 DOI: 10.1016/j.ejro.2021.100380] [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: 07/20/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study evaluated and compared two imaging-based scoring systems for the detection of significant blunt bowel and mesenteric injury (sBBMI) by emergency computed tomography (CT). METHODS AND MATERIALS We included all consecutive adult polytrauma patients admitted to our emergency department following a road traffic accident from January 2008 to June 2015, provided that intravenously contrast-enhanced whole-body CT examination was performed immediately after hospital admission. Two radiologists, blinded to patients' outcome, reviewed the CT examinations for distinctive direct intestinal or mesenteric vascular injury and indirect signs of abdominal injury. These findings were correlated with the patients' surgical or interventional radiology findings, autopsy, or clinical follow-up (>24 h). Two previously validated imaging-based bowel-injury scoring systems, the CT-based Faget score and the clinically and radiologically based Mc Nutt score (BIPS), were compared by applying each to our trauma cohort. Student t-test, chi-squared, and logistic regression were used in analyses. RESULTS Twenty-one of 752 analysed patients (2.8 %) had confirmed sBBMI. Active mesenteric bleeding, mesenteric and free pneumoperitoneum, small haemoperitoneum, non-focal bowel wall thickening, mesenteric/pericolic fat stranding, and anterior abdominal wall injury were significantly correlated with sBBMI, as did the two evaluated scoring systems (p < 0.001). However, multivariate logistic regression revealed the superiority of the Faget score to the McNutt score. CONCLUSION The prevalence of sBBMI among polytrauma patients is low. Early diagnosis is necessary to avoid increased mortality. Certain CT features are pathognomic of sBBMI and must not be overlooked. Scoring systems are helpful, especially when they are based on radiological signs.
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Key Words
- AAWI, Anterior abdominal wall injury
- AMB, Active mesenteric bleeding
- ATMV, Abrupt termination of mesenteric vessels
- BIPS, Bowel Injury Prediction Score
- BWD, Bowel wall discontinuity
- BWT, Bowel wall thickening
- CT, Multidetector computed tomography
- DBWE, Decreased bowel wall enhancement
- FF, (Non-haematic) free fluid
- FPP, Free pneumoperitoneum
- HP, Haemoperitoneum
- IBMV, Irregular beading of mesenteric vessels
- Intestine, large
- Intestine, small
- MFS, Mesenteric (pericolic) fat stranding
- MPP, Mesenteric pneumoperitoneum
- Mesentery
- Multidetector computed tomography
- Polytrauma
- SB, Small bowel
- WBC, White blood cell
- sBBMI, Significant blunt bowel and mesenteric injury
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Affiliation(s)
- Nathalie Keller
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Francois Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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13
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Liao CH, Hsieh FJ, Chen CC, Cheng CT, Ooyang CH, Hsieh CH, Yang SJ, Fu CY. The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey. J Clin Med 2019; 8:jcm8091300. [PMID: 31450573 PMCID: PMC6780049 DOI: 10.3390/jcm8091300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/01/2019] [Accepted: 08/22/2019] [Indexed: 11/28/2022] Open
Abstract
Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.
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Affiliation(s)
- Chien-Hung Liao
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Feng-Jen Hsieh
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chun-Hsiang Ooyang
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Shang-Ju Yang
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
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14
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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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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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16
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Loftus TJ, Morrow ML, Lottenberg L, Rosenthal MD, Croft CA, Smith RS, Moore FA, Brakenridge SC, Borrego R, Efron PA, Mohr AM. Occult bowel injury after blunt abdominal trauma. Am J Surg 2018; 218:266-270. [PMID: 30509454 DOI: 10.1016/j.amjsurg.2018.11.018] [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: 09/18/2018] [Revised: 10/31/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan. METHODS Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%). RESULTS The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37-10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03-5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52-13.13). CONCLUSIONS Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.
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Affiliation(s)
- Tyler J Loftus
- University of Florida Health, Department of Surgery, Gainesville, FL, USA; University of Florida Health, Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Megan L Morrow
- Florida Atlantic University, Department of Surgery, Boca Raton, FL, USA; St. Mary's Medical Center, Department of Surgery, West Palm Beach, FL, USA.
| | - Lawrence Lottenberg
- Florida Atlantic University, Department of Surgery, Boca Raton, FL, USA; St. Mary's Medical Center, Department of Surgery, West Palm Beach, FL, USA.
| | - Martin D Rosenthal
- University of Florida Health, Department of Surgery, Gainesville, FL, USA; University of Florida Health, Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Chasen A Croft
- University of Florida Health, Department of Surgery, Gainesville, FL, USA.
| | - R Stephen Smith
- University of Florida Health, Department of Surgery, Gainesville, FL, USA.
| | - Frederick A Moore
- University of Florida Health, Department of Surgery, Gainesville, FL, USA; University of Florida Health, Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Scott C Brakenridge
- University of Florida Health, Department of Surgery, Gainesville, FL, USA; University of Florida Health, Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Robert Borrego
- Florida Atlantic University, Department of Surgery, Boca Raton, FL, USA; St. Mary's Medical Center, Department of Surgery, West Palm Beach, FL, USA.
| | - Philip A Efron
- University of Florida Health, Department of Surgery, Gainesville, FL, USA; University of Florida Health, Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
| | - Alicia M Mohr
- University of Florida Health, Department of Surgery, Gainesville, FL, USA; University of Florida Health, Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
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17
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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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