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Zhang Y, Cui YF. Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma: A case report. World J Clin Cases 2024; 12:5821-5831. [DOI: 10.12998/wjcc.v12.i25.5821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/12/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Pancreatic trauma (PT) is rare among traumatic injuries and has a low incidence, but it can still lead to severe infectious complications, resulting in a high mortality rate. Acute pancreatitis (AP) is a common complication after PT, and when combined with organ dysfunction and sepsis, it will result in a poorer prognosis.
CASE SUMMARY We report a 25-year-old patient with multiple organ injuries, including the pancreas, due to abdominal trauma, who developed necrotising pancreatitis secondary to emergency caesarean section, combined with intra-abdominal infection (IAI). The patient underwent performed percutaneous drainage, pancreatic necrotic tissue debridement, and abdominal infection foci debridement on the patient.
CONCLUSION We report a case of severe AP and IAI secondary to trauma. This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery, and a better outcome was obtained.
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Affiliation(s)
- Yu Zhang
- Department of Surgery, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin 300070, China
| | - Yun-Feng Cui
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin 300100, China
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Sarquis LM, Collaço IA, Toderke EL, Fontes HS, Nassif AT, Freitas ACTDE. Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality. Rev Col Bras Cir 2024; 51:e20243734. [PMID: 38808820 PMCID: PMC11185065 DOI: 10.1590/0100-6991e-20243734-en] [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: 02/04/2024] [Accepted: 03/18/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients. METHODS This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention. RESULTS A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention. CONCLUSION The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.
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Affiliation(s)
- Lucas Mansano Sarquis
- - Universidade Federal do Paraná, Clínica Cirúrgica - Curitiba - PR - Brasil
- - Complexo Hospitalar do Trabalhador, Cirurgia Geral e Cirurgia do Trauma - Curitiba - PR - Brasil
| | - Iwan Augusto Collaço
- - Complexo Hospitalar do Trabalhador, Cirurgia Geral e Cirurgia do Trauma - Curitiba - PR - Brasil
| | | | | | - André Tha Nassif
- - Universidade Federal do Paraná, Clínica Cirúrgica - Curitiba - PR - Brasil
| | - Alexandre Coutinho Teixeira DE Freitas
- - Universidade Federal do Paraná, Clínica Cirúrgica - Curitiba - PR - Brasil
- - Complexo Hospitalar do Trabalhador, Cirurgia Geral e Cirurgia do Trauma - Curitiba - PR - Brasil
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Lokuhetty N, Philip MT, Paynter JA, Owen AR. A case report of successful splenic artery embolization for atraumatic splenic rupture secondary to Epstein Barr virus infection in a haemodynamically unstable patient. Radiol Case Rep 2024; 19:1970-1974. [PMID: 38434780 PMCID: PMC10909597 DOI: 10.1016/j.radcr.2024.02.016] [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: 10/10/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Splenic rupture in haemodynamically unstable patients has traditionally been managed with splenectomy. This case report discusses the successful management of atraumatic splenic rupture, a rare but life-threatening complication of Epstein-Barr virus (EBV) infection, in a hemodynamically unstable patient. The patient, diagnosed with infectious mononucleosis (IM) secondary to EBV, presented with severe abdominal pain and a syncopal episode. Imaging revealed an American Association for the Surgery of Trauma (AAST) grade III splenic injury, which was subsequently upgraded to a grade IV injury on repeat imaging. The patient's condition deteriorated even with initial resuscitation, leading to splenic angioembolization. The procedure was successful and the patient was discharged after 5 days. This case highlights the efficacy of splenic artery embolization (SAE) in haemodynamically unstable patients with atraumatic splenic rupture, particularly in centers with interventional radiology resources, offering an alternative to splenectomy and its associated complications.
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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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Ehrsam JP, Meier Adamenko O, Schlumpf RB, Schöb OM. Foreign Glass Bodies in Pleura and Pancreas: Systematic Review for Entry Hypotheses and Treatment Options in an Unresolved Case. Surg Laparosc Endosc Percutan Tech 2024; 34:206-221. [PMID: 38450728 PMCID: PMC10986785 DOI: 10.1097/sle.0000000000001275] [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: 11/08/2023] [Accepted: 12/19/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Foreign bodies within the pleura and pancreas are infrequent, and the approaches to their treatment still a subject of debate. There is limited knowledge particularly regarding glass foreign bodies. METHODS We present a case involving large glass splinters in the pleura and pancreas, with an unknown entry point. In addition, a systematic review was conducted to explore entry hypotheses and management options. RESULTS In addition to our case, our review uncovered eight incidents of intrapleural glass, and another eight cases of glass in other intrathoracic areas. The fragments entered the body through impalement (81%), migrated through the diaphragm after impalement (6%), or caused transesophageal perforation (19%) following ingestion. Eight instances of glass inside the abdominal cavity were documented, with seven resulting from impalement injuries and one from transintestinal migration. There were no recorded instances of glass being discovered within the pancreas. Among the 41 nonglass intrapancreatic foreign bodies found, sewing needles (34%) and fish bones (46%) were the most common; following ingestion, they had migrated through either a transgastric or transduodenal perforation. In all these cases, how the foreign bodies were introduced was often poorly recalled by the patient. Many nonglass foreign bodies tend to become encapsulated by fibrous tissue, rendering them inert, though this is less common with glass. Glass has been reported to migrate through various tissues and cavities, sometimes with a significant delay spanning even decades. There are cases of intrapleural migration of glass causing hemothorax, pneumothorax, and heart and major blood vessels injury. For intrapleural glass fragment management, thoracoscopy proved to be effective in 5 reported cases, in addition to our patient. Most intrapancreatic nonglass foreign bodies tend to trigger pancreatitis and abscess formation, necessitating management ranging from laparoscopic procedures to subtotal pancreatectomy. There have been only four documented cases of intrapancreatic needles that remained asymptomatic with conservative management. There is no direct guidance from the existing literature regarding management of intrapancreatic glass foreign bodies. Consequently, our patient is under observation with regular follow-ups and has remained asymptomatic for the past 2 years. CONCLUSIONS Glass foreign bodies in the pleura are rare, and our report of an intrapancreatic glass fragment is the first of its kind. Impalement is the most likely method of introduction. As glass has significant migration and an ensuing complication potential, preventive removal of intrapleural loose glass should be considered. However, intrapancreatic glass fragment management remains uncertain.
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Zhao Z, Han L, Xin M, Zhou L, Jiang K, Huang Q, Dai R. Still water run deep: Therapeutic TP effect of ucMSC-Ex via regulating mTOR to enhance autophagy. J Cell Mol Med 2024; 28:e18120. [PMID: 38358010 PMCID: PMC10868142 DOI: 10.1111/jcmm.18120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Abstract
Our previous study confirmed that umbilical cord mesenchymal stem cells-exosomes (ucMSC-Ex) inhibit apoptosis of pancreatic acinar cells to exert protective effects. However, the relationship between apoptosis and autophagy in traumatic pancreatitis (TP) has rarely been reported. We dissected the transcriptomics after pancreatic trauma and ucMSC-Ex therapy by high-throughput sequencing. Additionally, we used rapamycin and MHY1485 to regulate mTOR. HE, inflammatory factors and pancreatic enzymatic assays were used to comprehensively determine the local versus systemic injury level, fluorescence staining and electron microscopy were used to detect the effect of autophagy, and observe the expression levels of autophagy-related markers at the gene and protein levels. High-throughput sequencing identified that autophagy played a crucial role in the pathophysiological process of TP and ucMSC-Ex therapy. The results of electron microscopy, immunofluorescence staining, polymerase chain reaction and western blot suggested that therapeutic effect of ucMSC-Ex was mediated by activation of autophagy in pancreatic acinar cells through inhibition of mTOR. ucMSC-Ex can attenuate pancreas injury by inhibiting mTOR to regulate acinar cell autophagy after TP. Future studies will build on the comprehensive sequencing of RNA carried by ucMSC-Ex to predict and verify specific non-coding RNA.
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Affiliation(s)
- Zhirong Zhao
- Research Institute of General SurgeryJinling Hospital, Affiliated Hospital of Medical School, Nanjing UniversityNanjingJiangsu ProvinceChina
| | - Li Han
- General Surgery CenterGeneral Hospital of Western Theater CommandChengduSichuan ProvinceChina
| | - Mei Xin
- General Surgery CenterGeneral Hospital of Western Theater CommandChengduSichuan ProvinceChina
| | - Lichen Zhou
- General Surgery CenterGeneral Hospital of Western Theater CommandChengduSichuan ProvinceChina
| | - Kexin Jiang
- General Surgery CenterGeneral Hospital of Western Theater CommandChengduSichuan ProvinceChina
- College of MedicineSouthwest Jiaotong UniversityChengduSichuan ProvinceChina
| | - Qian Huang
- Research Institute of General SurgeryJinling Hospital, Affiliated Hospital of Medical School, Nanjing UniversityNanjingJiangsu ProvinceChina
| | - Ruiwu Dai
- General Surgery CenterGeneral Hospital of Western Theater CommandChengduSichuan ProvinceChina
- College of MedicineSouthwest Jiaotong UniversityChengduSichuan ProvinceChina
- Clinical Medical CollegeChengdu Medical CollegeChengduSichuan ProvinceChina
- Pancreatic injury and repair Key laboratory of Sichuan ProvinceGeneral Hospital of Western Theater CommandChengduSichuan ProvinceChina
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Clements W, Fitzgerald M, Chennapragada SM, Mathew J, Groombridge C, Ban EJ, Lukies MW. A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury. CVIR Endovasc 2023; 6:62. [PMID: 38103054 PMCID: PMC10725392 DOI: 10.1186/s42155-023-00414-6] [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: 10/20/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality. METHODS The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument. RESULTS Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275. CONCLUSIONS This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.
- National Trauma Research Institute, Melbourne, Australia.
| | - Mark Fitzgerald
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - S Murthy Chennapragada
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
- Department of Medical Imaging, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Joseph Mathew
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Christopher Groombridge
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Ee Jun Ban
- National Trauma Research Institute, Melbourne, Australia
- Acute General Surgical Unit, Alfred Health, Melbourne, Australia
| | - Matthew W Lukies
- Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
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Migliorini F, Cocconi F, Schipper I, Ten Duis K, Marzi I, Komadina R, Hildebrand F, Wendt K. Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02389-4. [PMID: 37962595 DOI: 10.1007/s00068-023-02389-4] [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: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital. METHODS All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint. RESULTS Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups. CONCLUSION Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted. LEVEL OF EVIDENCE Level IV, meta-analysis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Federico Cocconi
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Inger Schipper
- Department of Orthopaedic and Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Kaj Ten Duis
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Ingo Marzi
- Department of Orthopaedic and Trauma Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Radko Komadina
- Department of Orthopaedic and Trauma Surgery, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Klaus Wendt
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Dixe de Oliveira Santo I, Sailer A, Solomon N, Borse R, Cavallo J, Teitelbaum J, Chong S, Roberge EA, Revzin MV. Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney. Radiographics 2023; 43:e230040. [PMID: 37590162 DOI: 10.1148/rg.230040] [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: 08/19/2023]
Abstract
According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Irene Dixe de Oliveira Santo
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Anne Sailer
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Nadia Solomon
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Riddhi Borse
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Joe Cavallo
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Jason Teitelbaum
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Suzanne Chong
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Eric A Roberge
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
| | - Margarita V Revzin
- From the Section of Interventional Radiology (I.D.d.O.S., A.S.), Department of Radiology and Biomedical Imaging (I.D.d.O.S., A.S., N.S., R.B., J.C., J.T., M.V.R.), Yale School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520; Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Ind (S.C.); and Department of Radiology, University of Washington School of Medicine, Seattle, Wash (E.A.R.)
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Meijer LL, Vaalavuo Y, Regnér S, Sallinen V, Lemma A, Arnelo U, Valente R, Westermark S, An D, Moir JA, Irwin EA, Biesel EA, Hopt UT, Fichtner-Feigl S, Wittel UA, Weniger M, Karle H, Bloemers FW, Sutton R, Charnley RM, Ruess DA, Szatmary P. Clinical characteristics and long-term outcomes following pancreatic injury - An international multicenter cohort study. Heliyon 2023; 9:e17436. [PMID: 37408878 PMCID: PMC10318511 DOI: 10.1016/j.heliyon.2023.e17436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/07/2023] Open
Abstract
Background Trauma to the pancreas is rare but associated with significant morbidity. Currently available management guidelines are based on low-quality evidence and data on long-term outcomes is lacking. This study aimed to evaluate clinical characteristics and patient-reported long-term outcomes for pancreatic injury. Methods A retrospective cohort study evaluating treatment for pancreatic injury in 11 centers across 5 European nations over >10 years was performed. Data relating to pancreatic injury and treatment were collected from hospital records. Patients reported quality of life (QoL), changes to employment and new or ongoing therapy due to index injury. Results In all, 165 patients were included. The majority were male (70.9%), median age was 27 years (range: 6-93) and mechanism of injury predominantly blunt (87.9%). A quarter of cases were treated conservatively; higher injury severity score (ISS) and American Association for the Surgery of Trauma (AAST) pancreatic injury scores increased the likelihood for surgical, endoscopic and/or radiologic intervention. Isolated, blunt pancreatic injury was associated with younger age and pancreatic duct involvement; this cohort appeared to benefit from non-operative management. In the long term (median follow-up 93; range 8-214 months), exocrine and endocrine pancreatic insufficiency were reported by 9.3% of respondents. Long-term analgesic use also affected 9.3% of respondents, with many reported quality of life problems (QoL) potentially attributable to side-effects of opiate therapy. Overall, impaired QoL correlated with higher ISS scores, surgical therapy and opioid analgesia on discharge. Conclusions Pancreatic trauma is rare but can lead to substantial short- and long-term morbidity. Near complete recovery of QoL indicators and pancreatic function can occur despite significant injury, especially in isolated, blunt pancreatic injury managed conservatively and when early weaning off opiate analgesia is achieved.
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Affiliation(s)
- Laura L. Meijer
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yrjö Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sara Regnér
- Department of Surgery, Institution of Clinical Sciences Malmö, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ville Sallinen
- Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Finland
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Aurora Lemma
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Urban Arnelo
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - Roberto Valente
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - Sofia Westermark
- Department of Surgical and Perioperative Sciences, Department of Surgery, Örnsköldsvik, Umeå University, Umeå, Sweden
| | - David An
- Department of Surgery, Linköping University and Department of Surgery, Vasterviks Sjukhus, Vastervik, Sweden
| | - John A.G. Moir
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Ellen A. Irwin
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Esther A. Biesel
- Center of Surgery, Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Ulrich T. Hopt
- Center of Surgery, Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Center of Surgery, Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Uwe A. Wittel
- Center of Surgery, Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Maximilian Weniger
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Henning Karle
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Frank W. Bloemers
- Department of Trauma Surgery, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, The Netherlands
| | - Robert Sutton
- Department of Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust and Department of Clinical and Molecular Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Richard M. Charnley
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Dietrich A. Ruess
- Center of Surgery, Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Peter Szatmary
- Department of Pancreatic Surgery, Liverpool University Hospitals NHS Foundation Trust and Department of Clinical and Molecular Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
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Popa C, Schlanger D, Chirică M, Zaharie F, Al Hajjar N. Emergency pancreaticoduodenectomy for non-traumatic indications—a systematic review. Langenbecks Arch Surg 2022; 407:3169-3192. [DOI: 10.1007/s00423-022-02702-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/04/2022] [Indexed: 11/25/2022]
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Arnold P, Belchos J, Meagher A, Robbins C, Sparks Joplin T, Ortiz D, Ferries I, Hartwell J. Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication. J Surg Res 2022; 280:35-43. [PMID: 35952555 DOI: 10.1016/j.jss.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence. METHODS Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development. RESULTS Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence. CONCLUSIONS Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.
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Affiliation(s)
- Peter Arnold
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana.
| | - Jessica Belchos
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Ashley Meagher
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Christopher Robbins
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Tasha Sparks Joplin
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Damaris Ortiz
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Sidney & Lois Eskenazi Hospital, Indianapolis, Indiana
| | - Ian Ferries
- Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Jennifer Hartwell
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
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Sedai H, Poddar E, Shrestha S, Koirala D, Gautam A. Delayed presentation of isolated ductal rupture of pancreatic head from blunt abdominal trauma managed conservatively: A case report. Ann Med Surg (Lond) 2022; 80:104249. [PMID: 36045849 PMCID: PMC9422292 DOI: 10.1016/j.amsu.2022.104249] [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] [Received: 06/17/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and Importance: Blunt abdominal injury causing significant and isolated major pancreatic injury is rare in adolescents and young adults, with a controversial approach to its management. Case presentation We present our experience of diagnosis and management of the ductal injury of the pancreatic head (Grade III) in the setting of blunt abdominal trauma in a 20-year-old male diagnosed by a series of various tests including magnetic resonance cholangiopancreatography (MRCP) and managed by pigtail drainage and octreotide alone; contrary to the previous recommendations of management of high-grade pancreatic trauma through surgical approach or endoscopic retrograde cholangiopancreatography (ERCP) and stenting. Clinical discussion Isolated ductal rupture of the pancreatic head can have delayed presentation within a window of time and can be diagnosed by a series of tests including hematological, biochemical, and radiological investigations. Conservative treatment is generally recommended for Grade I and II whereas a surgical approach is preferred for higher grade pancreatic injury. Conclusions Pancreatic ductal injury must be kept in mind when present with vague symptoms in the setting of blunt abdominal trauma. Magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice for the diagnosis of pancreatic ductal injury. Even higher-grade pancreatic injury (grade III) can be managed with a conservative approach with pigtail drainage and an appropriate dosage of octreotide. Isolated ductal rupture of the pancreatic duct is very rare with delayed manifestations. MRCP is the investigation of choice for diagnosis. Conservative approach with pigtail drainage and octreotide can be successful in grade III injury.
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Affiliation(s)
- Hari Sedai
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Elisha Poddar
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Suraj Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
- Corresponding author. Maharajgunj Medical Campus, Institute of Medicine, P.O.Box: 1524, Kathmandu, Nepal.
| | - Dinesh Koirala
- Department of Gastroenterology and Hepatology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Abishkar Gautam
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
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14
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Pancreatic Fistula and Biochemical Leak after Splenectomy: Incidence and Risk Factors-A Retrospective Single-Center Analysis. Langenbecks Arch Surg 2022; 407:2517-2525. [PMID: 35508768 PMCID: PMC9468060 DOI: 10.1007/s00423-022-02531-7] [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: 06/09/2021] [Accepted: 04/21/2022] [Indexed: 11/24/2022]
Abstract
Purpose Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet. Methods This retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL). Results Over ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy. Conclusion With an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients’ informed consent and treated at centers with experience in pancreatic surgery. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02531-7.
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Al-Thani H, Ramzee AF, Al-Hassani A, Strandvik G, El-Menyar A. Traumatic Pancreatic Injury Presentation, Management, and Outcome: An Observational Retrospective Study From a Level 1 Trauma Center. Front Surg 2022; 8:771121. [PMID: 35155546 PMCID: PMC8831377 DOI: 10.3389/fsurg.2021.771121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/20/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundWe aimed to study the presentation, management, and outcomes of patients with a pancreatic traumatic injury.MethodsWe retrospectively analyzed data for all patients who were admitted with pancreatic injuries between 2011 and 2017 at the only level 1 trauma center in the country.ResultsThere were 71 patients admitted with pancreatic trauma (0.6% of trauma admissions and 3.4% of abdominal injury admissions) with a mean age of 31 years. Sixty-two patients had pancreatic injury grade I–II and nine had injury grade III–IV. Thirty-eight percent had Glasgow Coma Scale (GCS) <9 and 73% had injury Severity Score (ISS) >16. The level of pancreatic enzymes was significantly proportional to the grade of injury. Over half of patients required laparotomy, of them 12 patients had an intervention on the pancreas. Eight patients developed complications related to pancreatic injuries ranging from pancreatitis to pancreatico-cutaneous fistula while 35% developed hemorrhagic shock. Mortality was 31% and regardless of the grade of injury, the mortality was associated with high ISS, low GCS, and presence of hemorrhagic shock.ConclusionPancreatic injuries following blunt trauma are rare, and the injured subjects are usually young men. However, most injuries are of low-grade severity. This study shows that regardless of the pancreatic injury grade on-admission shock, higher ISS and lower GCS are associated with worse in-hospital outcomes. Non-operative management (NOM) may suffice in patients with lower grade injuries, which may not be the case in patients with higher grade injuries unless carefully selected.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ahmed Faidh Ramzee
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Gustav Strandvik
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- *Correspondence: Ayman El-Menyar
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16
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Camejo L, Nandeesha N, Phan K, Chharath K, Tran T, Ciesla D, Velanovich V. Infectious outcomes after splenectomy for trauma, splenectomy for disease and splenectomy with distal pancreatectomy. Langenbecks Arch Surg 2022; 407:1685-1691. [PMID: 35075620 PMCID: PMC8786199 DOI: 10.1007/s00423-022-02446-3] [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: 09/20/2021] [Accepted: 01/15/2022] [Indexed: 12/01/2022]
Abstract
Introduction The spleen provides a unique immune function in its production of opsins directed against encapsulated bacteria. Splenectomy, therefore, increases the risk of infections in patients as well as post-operative complications. This study aims to assess the risk of post-operative complications within 5 years of splenectomy by indication for splenectomy: trauma, disease, or in association with a distal pancreatectomy for pancreatic disease. The relationship between vaccination and infectious outcomes was also investigated. Methods This study is a review of splenectomy cases between June 2005 and June 2015 at a single institution. Infection, splenectomy indication, and vaccination history were identified from electronic medical records and lab test confirmations. Data was analyzed using Student’s t test for continuous variables, the Mann–Whitney U test for ordinal variables, and a Chi-square/Fisher exact test for categorical variables. Results A total of 106 splenectomy patients were included: 35 traumatic (74% male) and 71 non-traumatic causes (42% male) with no significant difference in age. There were no statistical differences in complications during splenectomy and vaccination administration between the splenectomy indication groups: trauma, disease, and with distal pancreatectomy. There was a statistically significant higher infection rate within 5 years post-splenectomy in the non-traumatic vs traumatic group (42% vs 14.0%, p = 0.0040) with majority gastrointestinal (7/38) and respiratory (5/38) and surgical wound infections (3/38) observed in non-traumatic versus traumatic, respectively. Conclusion Results from data analysis show a statistically significant difference in rates of infection within 5 years post-operatively between traumatic versus non-traumatic indications for splenectomies, with the non-traumatic group experiencing a higher rate of infectious outcomes. The non-traumatic group included patients with disease and distal pancreatectomy indications. This suggests that patients who have non-traumatic causes may be at a higher risk of developing infections following splenectomy procedure. Additionally, vaccinations did not appear to have a protective effect.
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Affiliation(s)
- Leonel Camejo
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Nandini Nandeesha
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Kevin Phan
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Khattiya Chharath
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Thanh Tran
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - David Ciesla
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Vic Velanovich
- Department of Surgery, Division of Gastrointestinal Surgery, Morsani College of Medicine, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.
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Acute gastric perforation after leaving against medical advice: A case presentation. Trauma Case Rep 2022; 37:100598. [PMID: 35024408 PMCID: PMC8724944 DOI: 10.1016/j.tcr.2021.100598] [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] [Accepted: 12/18/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Gastric perforation with necrosis is rare following acute gastric dilation (AGD) and can be fatal. We present a case of a patient with AGD due to a binge-eating episode who left the emergency department (ED) against medical advice (AMA) only to return with gastric perforation and necrosis requiring total splenectomy and partial gastrectomy. Case A 28-year-old female without a remarkable past medical history presented to the ED with diffuse abdominal pain and obstipation after a three-day “food crawl.” On admission, a computerized tomography (CT) scan revealed a markedly dilated stomach from the diaphragm to the pelvis with severe mass effect. The therapeutic plan at the time was gastric decompression via a nasogastric tube. The following day, the patient reported feeling better and left AMA only to return the same evening with worsening symptoms and peritoneal signs. The patient was then emergently taken to the operating room (OR). In the OR, laparotomy revealed frank spillage of partially digested food and necrosis along the greater curvature of the stomach that extended to the spleen. Damage control surgery was performed, which required a total splenectomy and a partial gastrectomy. The patient was admitted to the intensive care unit (ICU) and subsequently underwent five more trips to the OR due to severe edema that delayed the primary closure of the fascia. Once the patient was transferred out of the ICU, she was evaluated by psychiatry and diagnosed with a binge-eating disorder. Conclusion This case demonstrates the severity of acute gastric dilation and its potentially lethal consequences. In some cases, such as this one, the patient may present with mild symptoms and not comprehend the gravity of the situation. Therefore, it is important for clinicians to recognize this condition as a true emergency and perform immediate decompression and evaluation for surgery.
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Arvieux C, Thony F. Management of splenic trauma in hemodynamically stable patients: Lessons to be drawn from the French SPLASH trial (Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) Study Group). J Visc Surg 2021; 159:43-46. [PMID: 34716120 DOI: 10.1016/j.jviscsurg.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Arvieux
- CS 10-232, General and Digestive Surgery Department, Université Grenoble-Alpes, CHU de Grenoble-Alpes, 38043 Grenoble cedex, France.
| | - F Thony
- CS 10-232, University Center of Imaging and Interventional Radiology (CURIM), CHU de Grenoble-Alpes, 38043 Grenoble cedex, France
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Cretcher M, Panick CEP, Boscanin A, Farsad K. Splenic trauma: endovascular treatment approach. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1194. [PMID: 34430635 PMCID: PMC8350634 DOI: 10.21037/atm-20-4381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/21/2020] [Indexed: 12/16/2022]
Abstract
The spleen is a commonly injured organ in blunt abdominal trauma. Splenic preservation, however, is important for immune function and prevention of overwhelming infection from encapsulated organisms. Splenic artery embolization (SAE) for high-grade splenic injury has, therefore, increasingly become an important component of non-operative management (NOM). SAE decreases the blood pressure to the spleen to allow healing, but preserves splenic perfusion via robust collateral pathways. SAE can be performed proximally in the main splenic artery, more distally in specific injured branches, or a combination of both proximal and distal embolization. No definitive evidence from available data supports benefits of one strategy over the other. Particles, coils and vascular plugs are the major embolic agents used. Incorporation of SAE in the management of blunt splenic trauma has significantly improved success rates of NOM and spleen salvage. Failure rates generally increase with higher injury severity grades; however, current management results in overall spleen salvage rates of over 85%. Complication rates are low, and primarily consist of rebleeding, parenchymal infarction or abscess. Splenic immune function is felt to be preserved after embolization with no guidelines for prophylactic vaccination against encapsulated bacteria; however, a complete understanding of post-embolization immune changes remains an area in need of further investigation. This review describes the history of SAE from its inception to its current role and indications in the management of splenic trauma. The endovascular approach, technical details, and outcomes are described with relevant examples. SAE is has become an important part of a multidisciplinary strategy for management of complex trauma patients.
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Affiliation(s)
- Maxwell Cretcher
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| | - Catherine E P Panick
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| | - Alexander Boscanin
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| | - Khashayar Farsad
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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21
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Liao CA, Kuo LW, Wu YT, Liao CH, Cheng CT, Wang SY, Hsieh CH, Bajani F, Fu CY. Unstable Hemodynamics is not Always Predictive of Failed Nonoperative Management in Blunt Splenic Injury. World J Surg 2021; 44:2985-2992. [PMID: 32383055 DOI: 10.1007/s00268-020-05562-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The advanced technology of interventional radiology may contribute to a rapid and timely angioembolization for hemostasis. We hypothesized that unstable hemodynamics is no longer an absolute contraindication of nonoperative management (NOM) in blunt splenic injury patients using rapid angioembolization. METHODS From January 2009 to December 2019, blunt splenic injury patients with unstable hemodynamics [initial pulse >120 beats/min or systolic blood pressure <90 mm Hg] were included. Either emergency surgery or angioembolization was performed for hemostasis because of their unstable status. The characteristics of patients who underwent angioembolization or surgery were compared in each group (all patients, patients with hypotension, patients without response to resuscitation and hypotensive patients without response to resuscitation). RESULTS A total of 73 patients were included in the current study. With respect to all patients, 68.5% (N = 50) of patients underwent NOM with angioembolization for hemostasis. Patients who underwent angioembolization for hemostasis had a significantly lower base deficit (5.3 ± 3.8 vs. 8.3 ± 5.2 mmol/L, p = 0.006) and a higher proportion of response to resuscitation (82.0% vs. 30.4%, p < 0.001) than did patients who underwent surgery. However, there was no significant difference in the proportion of hypotension (58.0% vs. 65.2%, p = 0.558) between these two groups. There were 44 patients with hypotension, and the angioembolization could be performed in 65.9% (N = 29) of them. Patients who underwent angioembolization had a significantly higher proportion of response to resuscitation than did patients who underwent surgery (89.7% vs. 33.3%, p < 0.001). In hypotensive patients without response to resuscitation (N = 13), 23.1% (N = 3) of the patients underwent angioembolization successfully. There was no significant difference in time to hemostasis procedure between patients who underwent angioembolization or surgery (24.7 ± 2.1 vs. 26.3 ± 16.7 min, p = 0.769). The demographics, vital signs, blood transfusion amount, injury severity, mortality rate and length of stay of patients who underwent angioembolization were not significantly different from patients who underwent surgery in each group. CONCLUSIONS With a short preparation time of angioembolization, the NOM could be performed selectively for hemodynamically unstable patients with blunt splenic injury. The base deficit serves as an early detector of the requirement of surgical treatment.
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Affiliation(s)
- Chien-An Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Yu-Tung Wu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Francesco Bajani
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan.
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22
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Pancreatic Trauma: Proposal for Management Algorithm. Int Surg 2020. [DOI: 10.9738/intsurg-d-20-00015.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction
Pancreatic trauma is potentially lethal despite recent improvements in surgical techniques and conservative management. However, no guidelines for the management of pancreatic trauma have been established. In this report, we propose an algorithm for the management of pancreatic trauma based on our experience of 9 cases and 1 literature review.
Case presentation
This study included 9 patients with pancreatic trauma (5 men and 4 women). The patient median age was 40 years (range, 17–75 years). The overall mortality rate was 22.2%, and the postoperative mortality rate was 16.7%. Superficial trauma was present in 2 patients. Deep trauma without injury to the main pancreatic duct was present in 1 patient, and this patient was treated successfully with endoscopic nasopancreatic drainage. Active bleeding was present in 2 patients and controlled by interventional radiology. Deep trauma with injury to the main pancreatic duct was present in 6 patients. Among them, 1 patient died after conservative treatment with endoscopic nasopancreatic drainage. The other 5 patients underwent surgery (pancreatic resection in 4 and necrosectomy in 1).
Conclusion
The herein-described algorithm recommends interventional radiology for active arterial bleeding, conservative management for trauma without ductal injury, and surgery for trauma with ductal injury. This algorithm may provide a basis for future establishment of guidelines.
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23
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Jing W, Guo X, Qin F, Li Y, Wang G, Bi Y, Jin X, Han L, Dong X, Zhao Y. G-CSF shifts erythropoiesis from bone marrow into spleen in the setting of systemic inflammation. Life Sci Alliance 2020; 4:4/1/e202000737. [PMID: 33234677 PMCID: PMC7723243 DOI: 10.26508/lsa.202000737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022] Open
Abstract
The anemia of inflammation is related in part to abnormal erythropoiesis in bone marrow. G-CSF regulates granulopoiesis and is increased during systemic inflammation. Here, we have showed that high levels of G-CSF are associated with repression of bone marrow erythropoiesis and expansion of splenic erythropoiesis in Escherichia coli-infected mice and lipopolysaccharide-treated mice. Under lipopolysaccharide-induced systemic inflammatory conditions in mice, G-CSF neutralization with antibody alleviated the blockage of bone marrow erythropoiesis, prevented the enhancement of splenic erythropoiesis, ameliorated splenomegaly, and reduced the brittleness of spleen. We further demonstrated that after lipopolysaccharide treatment, TLR4-knockout mice display low levels of G-CSF, healthy bone marrow erythropoiesis, almost no stress erythropoiesis in the spleen, and normal size and toughness of spleen. In addition, we found HIF-mediated erythropoietin production is essential for splenic erythropoiesis in the setting of G-CSF-induced suppression of bone marrow erythropoiesis. Our findings identify G-CSF as a critical mediator of inflammation-associated erythropoiesis dysfunction in bone marrow and offer insight into the mechanism of G-CSF-induced splenic erythropoiesis. We provide experimentally significant dimension to the biology of G-CSF.
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Affiliation(s)
- Weiqiang Jing
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xing Guo
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fei Qin
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue Li
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ganyu Wang
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuxuan Bi
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xing Jin
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Lihui Han
- Department of Immunology, Shandong Key Laboratory of Infection and Immunity, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyuan Dong
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yunxue Zhao
- Department of Pharmacology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China .,Department of Immunology, Shandong Key Laboratory of Infection and Immunity, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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Chikhladze S, Ruess DA, Schoenberger J, Fichtner-Feigl S, Pratschke J, Hopt UT, Bahra M, Wittel UA, Globke B. Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma. Injury 2020; 51:1979-1986. [PMID: 32336477 DOI: 10.1016/j.injury.2020.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/11/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Pancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures. PATIENTS AND METHODS We retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003-2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification. RESULTS The median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety. CONCLUSIONS Often extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.
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Affiliation(s)
- S Chikhladze
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - D A Ruess
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Schoenberger
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - S Fichtner-Feigl
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - U T Hopt
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - M Bahra
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - U A Wittel
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - B Globke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
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25
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Splenic rupture caused by pancreatic pseudocyst successfully treated by endoscopic ultrasound-guided drainage. Clin J Gastroenterol 2020; 13:981-984. [PMID: 32514684 DOI: 10.1007/s12328-020-01152-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/03/2020] [Indexed: 01/10/2023]
Abstract
A 43-year-old man was admitted to a local hospital because of acute left abdominal pain. Chronic alcoholic pancreatitis and a 10-cm pancreatic pseudocyst in the tail of the pancreas had been found 5 years previously. He had not stopped drinking alcohol since then. On admission, laboratory tests revealed severe anemia, and contrast-enhanced computed tomography showed extravasation in the pancreatic pseudocyst. The spleen was retracted by the pancreatic pseudocyst, and its configuration was indistinct. The patient was diagnosed with acute bleeding within the pancreatic pseudocyst and splenic rupture. He was transferred to our university hospital on an emergency basis. Abdominal angiography of the splenic artery was immediately performed, but the bleeding point was not found. Although the bleeding stopped spontaneously, an infection of the pancreatic pseudocyst and a splenic hematoma subsequently developed. Endoscopic ultrasound-guided pseudocyst drainage was performed. The infection improved after the drainage, and the size of the pancreatic pseudocyst and splenic hematoma decreased. Five months later, the pancreatic pseudocyst had almost disappeared, and the splenic hematoma was even smaller. We herein report a rare case of splenic rupture caused by a pancreatic pseudocyst. Although the patient's condition became complicated by severe infection, treatment by endoscopic ultrasound-guided drainage was successful.
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26
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Wang Y, Cao R, Ye N, Lv D, Zhao T, Chen D. Efficacy evaluation of different conservative treatments for blunt spleen rupture. Minerva Med 2020; 112:615-621. [PMID: 32486610 DOI: 10.23736/s0026-4806.20.06574-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aims to provide a reference for the clinical treatment of patients with spleen ruptures by analyzing and discussing the clinical effects of the conservative treatment. METHODS The clinical data of 93 patients with blunt spleen rupture treated in the First Affiliated Hospital of University of Science and Technology of China from April 2015 to April 2018 were retrospectively analyzed. Among them, 84 cases were treated conservatively and 9 cases were treated surgically. The general information of conservative treatment and surgical treatment were compared. The relationship between different conservative treatment methods and CT classification of spleen rupture and the changes of abdominal drainage were analyzed. RESULTS The CT classification grade and trauma score of patients with spleen rupture in surgical treatment were higher than those in conservative treatment group (P <0.05). A total of 90.3% patients were treated conservatively. Among them, 7.1% (83.4% were in CT classification of spleen injury grade 1-2) were from the observation group, 14.3% (83.3% were in CT classification of spleen injury grade 1-2) were from abdominal drainage group, 3.6% were from splenic artery embolization group, and 75% (9.5% were in CT classification of spleen injury grade 2, 77.8% in grade 3 and 12.7% in grade 4) were from splenic artery embolization plus abdominal drainage group. There was no significant difference in the total amount of abdominal drainage on Day 1, Day 2 and Day3, and the CT classification of spleen rupture (P>0.05). However, there significant differences on the amount of abdominal drainage among Day 1, Day 2 and Day3 (P <0.05). Meanwhile, 2 complications occurred in the splenic artery embolization plus abdominal drainage group. CONCLUSIONS Conservative treatment is feasible in blunt spleen rupture patients of CT classification grade of 1-4 with stable hemodynamical. Splenic rupture patients of CT classification grade 4-5 with instable hemodynamical should be treated surgically.
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Affiliation(s)
- Ying Wang
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China -
| | - Rongge Cao
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Ning Ye
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Dechao Lv
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Tao Zhao
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Dong Chen
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
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27
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Jing W, Guo X, Wang G, Bi Y, Han L, Zhu Q, Qiu C, Tanaka M, Zhao Y. Breast cancer cells promote CD169 + macrophage-associated immunosuppression through JAK2-mediated PD-L1 upregulation on macrophages. Int Immunopharmacol 2019; 78:106012. [PMID: 31865052 DOI: 10.1016/j.intimp.2019.106012] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/27/2019] [Accepted: 10/27/2019] [Indexed: 01/10/2023]
Abstract
Macrophages are recognized as one of the major cell types in tumor microenvironment, and macrophage infiltration has been predominantly associated with poor prognosis among patients with breast cancer. Using the murine models of triple-negative breast cancer in CD169-DTR mice, we found that CD169+ macrophages support tumor growth and metastasis. CD169+ macrophage depletion resulted in increased accumulation of CD8+ T cells within tumor, and produced significant expansion of CD8+ T cells in circulation and spleen. In addition, we observed that CD169+ macrophage depletion alleviated tumor-induced splenomegaly in mice, but had no improvement in bone loss and repression of bone marrow erythropoiesis in tumor-bearing mice. Cancer cells and tumor associated macrophages exploit the upregulation of the immunosuppressive protein PD-L1 to subvert T cell-mediated immune surveillance. Within the tumor microenvironment, our understanding of the regulation of PD-L1 protein expression is limited. We showed that there was a 5-fold higher relative expression of PD-L1 on macrophages as compared with 4T1 tumor cells; coculture of macrophages with 4T1 cells augmented PD-L1 levels on macrophages, but did not upregulate the expression of PD-L1 on 4T1 cells. JAK2/STAT3 signaling pathway was activated in macrophages after coculture, and we further identified the JAK2 as a critical regulator of PD-L1 expression in macrophages during coculture with 4T1 cells. Collectively, our data reveal that breast cancer cells and CD169+ macrophages exhibit bidirectional interactions that play a critical role in tumor progression, and inhibition of JAK2 signaling pathway in CD169+ macrophages may be potential strategy to block tumor microenvironment-derived immune escape.
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Affiliation(s)
- Weiqiang Jing
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Xing Guo
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Ganyu Wang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Yuxuan Bi
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Lihui Han
- Department of Immunology, Shandong Provincial Key Laboratory of Infection & Immunology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Qingfen Zhu
- Shandong Institute for Food and Drug Control, Jinan, China.
| | - Chunhong Qiu
- Department of Cell Biology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Masato Tanaka
- Laboratory of Immune Regulation, School of Life Science, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, Japan
| | - Yunxue Zhao
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China; Department of Immunology, Shandong Provincial Key Laboratory of Infection & Immunology, School of Basic Medical Sciences, Shandong University, Jinan, China.
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Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Gustavo Pereira Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Grazia Sibilla
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Peter T. Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mazyr, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Rao Ivatury
- General and Trauma Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Francesco Favi
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Uruguay
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes, UGA-Université Grenoble Alpes, Grenoble, France
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
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Abstract
We report a case of splenic trauma during the third trimester of pregnancy that was successfully treated by arterial embolization with preservation of the spleen. This rarely reported management strategy during pregnancy had a favorable outcome. Such a strategy should be discussed and considered, taking into account maternal, obstetrical and fetal factors.
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Affiliation(s)
- Y Athiel
- Service de chirurgie digestive minimale invasive, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France; Faculté de médecine Paris-Sud, université Paris-Saclay, 91405 Orsay, France
| | - A Vivanti
- Faculté de médecine Paris-Sud, université Paris-Saclay, 91405 Orsay, France; Service de gynécologie obstétrique, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France
| | - H Tranchart
- Service de chirurgie digestive minimale invasive, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France; Faculté de médecine Paris-Sud, université Paris-Saclay, 91405 Orsay, France.
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30
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Iacobellis F, Laccetti E, Tamburrini S, Altiero M, Iaselli F, Di Serafino M, Gagliardi N, Danzi R, Rengo A, Romano L, Nicola R, Scaglione M. Role of multidetector computed tomography in the assessment of pancreatic injuries after blunt trauma: a multicenter experience. Gland Surg 2019; 8:184-196. [PMID: 31183328 DOI: 10.21037/gs.2019.02.02] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pancreatic injuries can occur from either penetrating or blunt abdominal trauma. While there are rare, especially in the setting of blunt abdominal trauma, they are associated with a mortality of up to 30%, and a morbidity of 60%. Multidetector computed tomography (MDCT) is the preferred imaging modality in patients with acute blunt abdominal trauma and for the detection of acute pancreatic injury. Magnetic resonance (MR) and magnetic resonance cholangiopancreatography (MRCP) plays an important role in the follow-up of pancreatic injury. In this brief review, we discuss the main MDCT acute imaging findings as well as the complications. Finally, we discuss the role of MR and MRCP in follow up of patients with pancreatic injuries.
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Affiliation(s)
- Francesca Iacobellis
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Ettore Laccetti
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Stefania Tamburrini
- Department of Radiology, "Ospedale del Mare" ASL NA1 Centro-Napoli, Naples, Italy
| | - Michele Altiero
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Francesco Iaselli
- Department of Radiology, "Ospedale del Mare" ASL NA1 Centro-Napoli, Naples, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Nicola Gagliardi
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Roberta Danzi
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Alessandro Rengo
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Refky Nicola
- Department of Radiology, SUNY-Upstate University and Medical Center, Syracuse, NY, USA
| | - Mariano Scaglione
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy.,Department of Radiology, Sunderland Royal Hospital, NHS, Sunderland, UK
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Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: Results from an International Consensus Conference. J Trauma Acute Care Surg 2019; 84:517-531. [PMID: 29261593 DOI: 10.1097/ta.0000000000001774] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ilhan M, Sönmez RE, Kut A, Toprak S, Gök AFK, Günay MK, Ertekin C. Are radiological modalities really necessary for the long-term follow-up of patients having blunt solid organ injuries? A single center study. World J Emerg Med 2019; 10:177-181. [PMID: 31171949 PMCID: PMC6545375 DOI: 10.5847/wjem.j.1920-8642.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/10/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mehmet Ilhan
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Recep Erçin Sönmez
- Department of General Surgery, İstanbul Medeniyet University, İstanbul, Turkey
| | - Abdullah Kut
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Safa Toprak
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Ali Fuat Kaan Gök
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Mustafa Kayıhan Günay
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Cemalettin Ertekin
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
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Foo ET, Kumar V, Nanavati SM, Huo E, Wilson MW, Conrad MB. Percutaneous embolization of post traumatic splenic pseudoaneurysm. Emerg Radiol 2018; 25:719-722. [PMID: 30155849 DOI: 10.1007/s10140-018-1636-5] [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] [Received: 07/03/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022]
Abstract
Management of splenic pseudoaneurysms in hemodynamically stable patients has shifted toward nonoperative management, including watchful waiting and endovascular embolization. Standard of treatment does not include percutaneous embolization for splenic pseudoaneurysm repair. In this case report, we document a successful percutaneous embolization of a post traumatic splenic pseudoaneurysm with thrombin. Percutaneous embolization of splenic pseudoaneurysms can be considered a viable technique in patients who fail endovascular embolization or have lesions inaccessible to endovascular repair.
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Affiliation(s)
- Eric T Foo
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street NW, Suite 350, Lobby 6, San Francisco, CA, 94107, USA
| | - Vishal Kumar
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street NW, Suite 350, Lobby 6, San Francisco, CA, 94107, USA
| | - Sujal M Nanavati
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street NW, Suite 350, Lobby 6, San Francisco, CA, 94107, USA
| | - Eugene Huo
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street NW, Suite 350, Lobby 6, San Francisco, CA, 94107, USA
| | - Mark W Wilson
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street NW, Suite 350, Lobby 6, San Francisco, CA, 94107, USA
| | - Miles B Conrad
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street NW, Suite 350, Lobby 6, San Francisco, CA, 94107, USA
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Yamanaka Y, Ishida H, Naganuma H, Komatsuda T, Miyazawa H, Miyauchi T, Takahashi S, Tozawa T, Enomoto K. Superb microvascular imaging (SMI) findings of splenic artery pseudoaneurysm: a report of two cases. J Med Ultrason (2001) 2018; 45:515-523. [PMID: 29383555 DOI: 10.1007/s10396-018-0858-1] [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] [Received: 09/26/2017] [Accepted: 12/11/2017] [Indexed: 01/25/2023]
Abstract
Splenic artery pseudoaneurysm (SAPA) is a relatively infrequently encountered but clinically important vascular change, because it carries a high risk of rupture that warrants prompt treatment regardless of its size. Thus, sufficient knowledge is indispensable when seeing chronic pancreatitis patients or post-traumatic patients. Here, we report two such cases. The first case was a 52-year-old woman known to have chronic pancreatitis who presented with hematemesis and hemodynamic instability in which X-ray computed tomography (CT) and color Doppler sonography (CDS) had difficulty visualizing slow blood flow in SAPA, but superb microvascular imaging (SMI) clearly demonstrated the slow blood flow in SAPA, prompting our therapeutic decision to perform rapid embolization. The second case was a 51-year-old woman with post-traumatic SAPA in which 3D SMI enabled us to understand more clearly the topographic relationship between multiple SAPAs as compared with conventional US, leading to a decision to provide immediate surgical treatment. SMI was thought to provide a new insight into the US diagnosis of SAPA. When examining patients suspected of having a SAPA, SMI is an indispensable diagnostic tool at present.
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Affiliation(s)
- Yumiko Yamanaka
- Center of Diagnostic Ultrasound, Akita Red Cross Hospital, 222-1 Kamikitade, Saruta, Nawashirosawa, Akita, 010-1495, Japan.
| | - Hideaki Ishida
- Center of Diagnostic Ultrasound, Akita Red Cross Hospital, 222-1 Kamikitade, Saruta, Nawashirosawa, Akita, 010-1495, Japan
| | - Hiroko Naganuma
- Department of Gastroenterology, Yokote Municipal Hospital, Yokote, Japan
| | - Tomoya Komatsuda
- Center of Diagnostic Ultrasound, Akita Red Cross Hospital, 222-1 Kamikitade, Saruta, Nawashirosawa, Akita, 010-1495, Japan
| | - Hideaki Miyazawa
- Department of Gastrointestinal Surgery, Akita Red Cross Hospital, Akita, Japan
| | | | - Satoshi Takahashi
- Department of Diagnostic Radiology, Akita University Hospital, Akita, Japan
| | - Tomoki Tozawa
- Department of Diagnostic Radiology, Akita University Hospital, Akita, Japan
| | - Katsuhiko Enomoto
- Department of Diagnostic Pathology, Akita Red Cross Hospital, Akita, Japan
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Oviedo RJ, Glickman AA. Emergency splenectomy for trauma in the setting of splenomegaly, axillary lymphadenopathy, and incidental B-cell chronic lymphocytic leukemia: A case report. Int J Surg Case Rep 2017; 37:161-164. [PMID: 28686924 PMCID: PMC5499106 DOI: 10.1016/j.ijscr.2017.06.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/12/2017] [Accepted: 06/12/2017] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The spleen is the most commonly injured intra-abdominal solid organ following blunt trauma. B-cell chronic lymphocytic leukemia (CLL) is the most common leukocytic dyscrasia affecting adults in Western countries. Splenomegaly with axillary and retroperitoneal lymphadenopathy are common physical findings. This case investigates an emergency splenectomy in a community hospital involving a 45-year-old man with blunt abdominal trauma following an assault with incidental splenomegaly and axillary lymphadenopathy, with surgical pathology findings of B-cell CLL. PRESENTATION OF CASE A 45- year-old man without past medical or family history who was the victim of an assault presented to the emergency department 6h later with left upper quadrant pain and radiation to the left flank and a positive Kehr sign. An elevated absolute lymphocyte count above 7×109 and CT confirmation of a Grade V splenic laceration with splenomegaly, axillary lymphadenopathy, with hemodynamic compromise led to an exploratory laparotomy and emergency splenectomy regardless of the potential for malignancy. DISCUSSION Hemoperitoneum with blunt splenic injury (BSI) caused by abdominal trauma with hemodynamic instability should be treated with exploratory laparotomy and splenectomy even in the face of potential malignancy with splenomegaly and axillary lymphadenopathy. An appropriate oncologic work up and treatment can be provided after the emergency intervention. CONCLUSION An emergency splenectomy is an appropriate operative intervention for a grade V splenic laceration with hemoperitoneum, splenomegaly, and axillary lymphadenopathy regardless of the potential for a neoplastic process such as B-cell CLL. Post-splenectomy vaccinations and oncologic follow-up for systemic chemotherapy should be facilitated after recovery.
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Affiliation(s)
- Rodolfo J Oviedo
- Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL 32306-4300, USA; Capital Regional Medical Center, 2626 Capital Medical Blvd., Tallahassee, FL 32308, USA; Capital Regional Surgical Associates, 2626 Care Drive, Suite 206, Tallahassee, FL 32308, USA.
| | - Andrew A Glickman
- Alabama College of Osteopathic Medicine, Class of 2018, 445 Health Science Blvd., Dothan, AL 36303, USA
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Treating complex pancreatic injuries. Trauma and pancreatic surgeons working together is the modern management paradigm. J Visc Surg 2017; 154:143. [PMID: 28427788 DOI: 10.1016/j.jviscsurg.2017.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nanashima A, Imamura N, Tsuchimochi Y, Hamada T, Yano K, Hiyoshi M, Fujii Y, Kawano F, MitsuruTamura. Horizontal traumatic laceration of the pancreas head: A rare case report. Int J Surg Case Rep 2017; 31:119-123. [PMID: 28135676 PMCID: PMC5279907 DOI: 10.1016/j.ijscr.2017.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This case report is intended to inform acute care surgeons about treating rare horizontal laceration of the pancreas head caused by blunt trauma. CASE PRESENTATION A 57-year-old woman who sustained blunt abdominal trauma during a car crash was transported to the emergency center of our hospital with unstable vital signs due to hemorrhagic shock. Computed tomography showed transection of the pancreas head and massive intra-abdominal hemorrhage. She was referred for emergency surgery because of a transient response. Laparotomy at five hours after the accident initially revealed consistent massive bleeding from branches of the superior mesenteric artery and vein, which we resolved by suturing the vessels without damaging the main trunks. A horizontal laceration and complete transection of the pancreatic head were then confirmed but the main pancreatic duct remained intact. The lower part of the pancreatic head including the uncus with the attached part of the duodenum was resected, and the pancreatic stump remaining after transection was fixed by suturing. The jejunal limb was attached to the remnant duodenum by side-to-side functional anastomosis. Although gastric emptying was delayed for one month after surgery, the postoperative course was good and the patient recovered at three months thereafter. The embryonic border of pancreas head accompanied with pancreatic divisum was considered for this laceration without disruption of the main pancreatic duct. DISCUSSION Blunt pancreatic trauma usually causes vertical transection and thus, horizontal transection is considered rare. The embryological anatomical border between the ventral and dorsal pancreas due to pancreatic divisum was supposed to be transected and therefore the main pancreatic duct was not damaged. CONCLUSION Hemorrhagic shock and rare pancreatic head trauma were treated by appropriate intraoperative management.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan.
| | - Naoya Imamura
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yuki Tsuchimochi
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Takeomi Hamada
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Kouichi Yano
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Masahide Hiyoshi
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yoshiro Fujii
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Fumiaki Kawano
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - MitsuruTamura
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
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