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Dalcin RR, Petrillo Y, Alves L, Fonseca MK, Almeida AS, Corso CO. Selective nonoperative versus operative management of liver gunshot injuries: a retrospective cohort study. Ann R Coll Surg Engl 2024. [PMID: 38787286 DOI: 10.1308/rcsann.2022.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Experience accumulated over the last decades suggests nonoperative management (NOM) of civilian gunshot liver injuries can be safely applied in selected cases. This study aims to compare the outcomes of selective NOM versus operative management (OM) of patients sustaining gunshot wounds (GSW) to the liver. METHODS A registry-based retrospective cohort analysis was performed for the period of 2008 to 2016 in a Brazilian trauma referral. Patients aged 16-80 years sustaining civilian GSW to right-sided abdominal quadrants and liver injury were included. Baseline data, vital signs, grade of liver injury, associated injuries, injury severity scores, blood transfusion requirements, liver- and non-liver-related complications, length-of-stay (LOS), and mortality were retrieved from individual registries. RESULTS A total of 54 patients were eligible for analysis, of which 37 underwent NOM and 17 underwent OM. The median age was 25 years and all were male. No statistically significant differences were observed between groups regarding patients' demographics, injury scores, grade of liver injury and associated lesions. NOM patients tended to sustain higher-grade injuries (86.5% vs 64.7%; p = 0.08), and failure of conservative management was recorded in two (5.4%) cases. The rate of complications was 48% with no between-group statistically significant difference. Blood transfusion requirements were significantly higher in the OM group (58.8% vs 21.6%; p = 0.012). The median LOS was seven days. No deaths were recorded. CONCLUSION Patients with liver GSW who are haemodynamically stable and without peritonitis are candidates for NOM. In this study, NOM was safe and effective even in high-grade injuries.
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Affiliation(s)
- R R Dalcin
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Hospital de Pronto Socorro de Porto Alegre, Brazil
| | - Ytm Petrillo
- Hospital de Pronto Socorro de Porto Alegre, Brazil
| | - Lac Alves
- Hospital de Pronto Socorro de Porto Alegre, Brazil
| | - M K Fonseca
- Hospital de Pronto Socorro de Porto Alegre, Brazil
| | - A S Almeida
- Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | - C O Corso
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Zhao K, Mabud TS, Patel N, Bernstein MP, McDermott M, Bryk H, Taslakian B. Predictors of need for endovascular intervention in hepatic trauma. Abdom Radiol (NY) 2023; 48:1131-1139. [PMID: 36520161 DOI: 10.1007/s00261-022-03765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/24/2022] [Accepted: 11/26/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma. MATERIALS AND METHODS The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE. RESULTS In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE. CONCLUSION In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.
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Affiliation(s)
- Ken Zhao
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave. H-118H, New York, NY, 10065, USA.
| | - Tarub S Mabud
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, 10016, USA
| | - Nihal Patel
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, 10016, USA
| | - Mark P Bernstein
- Department of Radiology, Boston Medical Center, Boston University, Boston, MA, 02118, USA
| | - Meredith McDermott
- Department of Radiology, Denver Health and Hospital Authority, University of Colorado Denver School of Medicine, Denver, CO, 80204, USA
| | - Hillel Bryk
- Department of Radiology, New York University Grossman School of Medicine and Bellevue Hospital, New York, NY, 10016, USA
| | - Bedros Taslakian
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, 10016, USA
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Gunshot wound versus blunt liver injuries: different liver-related complications and outcomes. Eur J Trauma Emerg Surg 2023; 49:505-512. [PMID: 36115907 DOI: 10.1007/s00068-022-02096-6] [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: 06/01/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe hepatic injury due to gunshot (GSW) compared to blunt mechanism may have significantly different presentation, management, complications, and outcomes. The aim of this study was to identify the differences. METHODS Retrospective single-center analysis June 1, 2015-June 30, 2020, included all patients with Grade III-V liver injuries due to GSW or blunt mechanism. Clinical characteristics, severity of injury, liver-related complications (rebleeding, necrosis/abscess, bile leak/biloma, pseudoaneurysm, acute liver failure) and overall outcomes (mortality, hospital length of stay, intensive care unit length of stay, and ventilatory days) were compared. RESULTS Of 879 patients admitted with hepatic trauma, 347 sustained high-grade injury and were included: 81 (23.3%) due to GSW and 266 (76.7%) due to blunt force. A significantly larger proportion of patients with GSW were managed operatively (82.7 vs. 36.1%, p < 0.001). GSW was associated with significantly more liver-related complications (40.7% vs. 27.4%, p = 0.023), specifically liver necrosis/abscess (18.5% vs. 7.1%, p = 0.003) and bile leak/biloma (12.3% vs. 5.3%, p = 0.028). On subgroup analysis, in patients with grade III injury, the incidence of liver necrosis/abscess and bile leak/biloma remained significantly higher after GSW (13.9% vs. 3.1%, p = 0.008 and 11.1% vs. 2.5%, p = 0.018, respectively). In sub analysis of 88 patients with leading severe liver injuries, GSW had a significantly longer hospital length of stay, ICU length of stay, and ventilator days. CONCLUSION GSW mechanism to the liver is associated with a higher incidence of liver-related complications than blunt force injury.
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Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature. Chin J Traumatol 2022; 25:257-263. [PMID: 35487854 PMCID: PMC9458985 DOI: 10.1016/j.cjtee.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 01/30/2022] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. METHODS A systematic literature review searched "liver trauma", "hepatic trauma", "conservative management", "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. RESULTS A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. CONCLUSION NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
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LA-Falce TS, Martini Filho D, Botter M, Saad Junior R. Natural evolution of perforating wounds of 30% extension of the left diaphragm and the anatomopathological characteristics of its healing. Experimental Study. Rev Col Bras Cir 2022; 49:e20223162. [PMID: 35792805 PMCID: PMC10578814 DOI: 10.1590/0100-6991e-20223162-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: 08/18/2021] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism? OBJECTIVE to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm. METHOD 50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar. RESULTS it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples. CONCLUSION Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.
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Affiliation(s)
- Thiago Souza LA-Falce
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Dino Martini Filho
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ciências Patológicas - São Paulo - SP - Brasil
| | - Marcio Botter
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Roberto Saad Junior
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
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Clements TW, Ball CG, Nicol AJ, Edu S, Kirkpatrick AW, Navsaria P. Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota's fascia. World J Emerg Surg 2022; 17:35. [PMID: 35725557 PMCID: PMC9208135 DOI: 10.1186/s13017-022-00439-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. Methods A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. Results A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8–99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota’s fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. Conclusions NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota’s fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.
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Affiliation(s)
- Thomas W Clements
- Cumming School of Medicine, University of Calgary, Calgary, Canada.,Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Chad G Ball
- Cumming School of Medicine, University of Calgary, Calgary, Canada.,Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Andrew J Nicol
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Sorin Edu
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Andrew W Kirkpatrick
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Pradeep Navsaria
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa.
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Braschi C, Keeley JA, Balan N, Perez LC, Neville A. Outcomes of Highest Grade (IV and V) Liver Injuries in Blunt and Penetrating Trauma. Am Surg 2022; 88:2551-2555. [PMID: 35589607 DOI: 10.1177/00031348221103653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High-grade hepatic trauma can be devastating, with complications being common if patients survive. Studies comparing outcome differences between blunt and penetrating mechanism are lacking. This study aimed to describe and evaluate the association of traumatic mechanism with complications in patients sustaining grades IV and V liver injuries. METHODS A retrospective review of all adults who suffered grades IV and V liver injury from 2015-2020 was performed at a level I trauma center in an urban area. Outcomes in patients with blunt and penetrating mechanisms were compared. RESULTS A total of 103 patients were included, of which 44 (43%) were penetrating and the remainder blunt. Patients with penetrating injuries were younger, more often male, and more likely to undergo initial operative management (82% vs 40%, P < .001). Regardless of mechanism, high grade liver injuries had similar rates of complications, including bile leak (17% vs 23%, P = .559) and intrabdominal abscess (7% vs 16%, P = .239), and similar need for endoscopic retrograde cholangiopancreatography (12% vs 19%, P = .379). Penetrating injuries required more re-interventions (42% vs 19%, P = .033), specifically more percutaneous drainage procedures (36% vs 12%, P = .016). Overall mortality was 29% and did not differ by mechanism. DISCUSSION Morbidity and mortality are high for grades IV and V liver injuries. Penetrating high-grade hepatic injuries are more likely to be managed operatively, but mortality and overall complications are similar to blunt mechanisms. This may allow for uniform algorithms to define management strategies regardless of mechanism.
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Affiliation(s)
- Caitlyn Braschi
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jessica A Keeley
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Naveen Balan
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Laura C Perez
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Angela Neville
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
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Lee H, Kong V, Cheung C, Thirayan V, Rajaretnam N, Elsabagh A, Bruce J, Laing G, Manchev V, Clarke D. Trends in the Management of Abdominal Gunshot Wounds Over the Last Decade: A South African Experience. World J Surg 2022; 46:998-1005. [PMID: 35147739 DOI: 10.1007/s00268-022-06469-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to review our decade-long experience with the management of abdominal gunshot wounds (GSWs), to document trends in our approach and to develop an evidence base for our contemporary management algorithms in a major trauma in South Africa. MATERIALS AND METHODS This was a retrospective study that included all adult patients with abdominal GSWs between January 2013 and October 2020 managed at a major trauma centre in South Africa. RESULT Five hundred and ninety-six cases were included (87% male, mean age: 32 years). The median Injury Severity Score (ISS) was 12. 52% (309/596) of cases had indications of immediate laparotomy and proceeded directly to the operating room without any CT imaging. Of this cohort, the laparotomy was positive in 292 and in the remainder (5%) was negative. Of the remaining 287 cases, 209 underwent a CT scan (35%). 78 were managed without any CT imaging. Of the 78 who did not undergo CT scan, all were managed without any operation and discharged home well. Of the 209 who underwent CT scan, 99 were observed and only one case in this group subsequently required a laparotomy. The remaining 110 cases underwent a laparotomy, which was negative in 7. There were correlations with increasing use of CT, as well as a decrease in those proceeding directly to laparotomy. The overall morbidity rate was 8% (47/596). 32% (190/596) require intensive care unit (ICU) admission. The overall mortality rate was 8% (67/596). CONCLUSIONS The management of abdominal GSWs has continued to evolve. There is now a well-defined role for selective non-operative management in this group of patients and relies on accurate CT assessment. CT scan is now an important component in the management of abdominal GSW even in our resource-constrained environment.
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Affiliation(s)
- Hong Lee
- Department of Surgery, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia.
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Cynthia Cheung
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Varun Thirayan
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | | | - Abdallah Elsabagh
- Department of Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Vasil Manchev
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Gigola F, Grimaldi C, Bici K, Ghionzoli M, Spinelli C, Muiesan P, Morabito A. Epidemiology and Surgical Management of Foreign Bodies in the Liver in the Pediatric Population: A Systematic Review of the Literature. CHILDREN 2022; 9:children9020120. [PMID: 35204841 PMCID: PMC8870636 DOI: 10.3390/children9020120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/28/2021] [Accepted: 01/11/2022] [Indexed: 11/16/2022]
Abstract
Retention of foreign bodies (FB) in the liver parenchyma is a rare event in children but it can bring a heavy burden in terms of immediate and long-term complications. Multiple materials can migrate inside the liver. Clinical manifestations may vary, depending on the nature of the foreign body, its route of penetration and timing after the initial event. Moreover, the location of the FB inside the liver parenchyma may pose specific issues related to the possible complications of a challenging surgical extraction. Different clinical settings and the need for highly specialized surgical skills may influence the overall management of these children. Given the rarity of this event, a systematic review of the literature on this topic was conducted and confirmed the pivotal role of surgery in the pediatric population.
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Affiliation(s)
- Francesca Gigola
- Department of Pediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (F.G.); (K.B.); (M.G.); (A.M.)
| | - Chiara Grimaldi
- Department of Pediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (F.G.); (K.B.); (M.G.); (A.M.)
- Correspondence:
| | - Kejd Bici
- Department of Pediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (F.G.); (K.B.); (M.G.); (A.M.)
| | - Marco Ghionzoli
- Department of Pediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (F.G.); (K.B.); (M.G.); (A.M.)
| | - Claudio Spinelli
- Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56100 Pisa, Italy;
| | - Paolo Muiesan
- Department of Hepatobiliary Surgery, Careggi University Hospital, 50134 Florence, Italy;
| | - Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (F.G.); (K.B.); (M.G.); (A.M.)
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LA-FALCE THIAGOSOUZA, MARTINI FILHO DINO, BOTTER MARCIO, SAAD JUNIOR ROBERTO. Evolução natural das feridas perfurocortantes de 30% de extensão do diafragma esquerdo e das características anatomopatológicas de sua cicatrização. Estudo Experimental. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.
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Affiliation(s)
| | | | - MARCIO BOTTER
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
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The gap in operative exposure in trauma surgery: quantifying the benefits of an international rotation. Surg Open Sci 2020; 2:46-50. [PMID: 32754707 PMCID: PMC7391879 DOI: 10.1016/j.sopen.2019.09.003] [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: 04/13/2019] [Revised: 09/16/2019] [Accepted: 09/25/2019] [Indexed: 12/04/2022] Open
Abstract
Background International rotations with hands-on experience are commonly cited as a potential supplement to the current experience of surgical trainees in trauma; however, quantification of this experience remains unclear. Methods A link to an online survey was distributed by electronic mail to physicians who rotated for any period of time at the Trauma Unit of the Groote-Shuur Hospital of the University of Cape Town from January 1, 2006, to December 2016. Results Of 160 participants, 75 (47%) completed the survey. A high proportion (45%) had performed less than 25 trauma-related surgical procedures during their previous training. Most (56%) performed ≥ 10 trauma laparotomies and sternotomies/thoracotomies during their rotation, whereas 43% performed ≥ 5 vascular procedures. The level of perceived confidence in managing trauma patients increased significantly from a median of 3/10 to 7/10 (P < .05). Conclusion Rotations at large-volume trauma centers abroad offer the opportunity for a hands-on operative experience and may enhance the confidence of surgical trainees. Further standardization of these opportunities may result in a larger-scale participation of graduate residents and fellows. This is a survey of physicians who participated in an international rotation at the Groote Schuur Hospital of the University of Cape Town. With this survey, we found that most participants performed in excess of 10 trauma laparotomies and thoracotomies/sternotomies. A large proportion performed 5 or more peripheral vascular procedures. These findings are combined with a significantly increased confidence in managing trauma patients. This report may serve in the planning of sponsored international rotations to increase the operative exposure in trauma surgery.
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Gascho D, Zoelch N, Deininger-Czermak E, Tappero C, Richter H, Thali MJ, Schaerli S. In situ identification of Action 4, SECA and QD-PEP bullets from special police ammunitions by computed tomography. MEDICINE, SCIENCE, AND THE LAW 2020; 60:188-195. [PMID: 32233731 DOI: 10.1177/0025802420911555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Special deformation bullets were developed for police forces to achieve a defined penetration depth (avoiding over-penetration) and a controlled energy transfer (avoiding collateral damage). This article focuses on Action 4, SECA and QD-PEP bullets. These 9 mm bullets were specially designed for controlled deformation. The characteristic slight mushrooming with a front cross-section of approximately 11.5 mm after entering a ballistic simulant was verified in ballistic tests. To achieve such slight mushrooming, the projectile's core is hollowed. The purpose of this study was to investigate the feasibility of visualising the hollowed cores of Action 4, SECA and QD-PEP bullets using a standard clinical computed tomography (CT) scanner for non-invasive identification of these special bullets from police ammunitions. METHODS First, undeformed specimens were scanned to reveal the shape of the hollowed core of each type of special bullet. Second, Action 4, SECA and QD-PEP bullets were fired towards animal cadaver models to visualise their hollow core after deformation inside biological tissue. Third, two reviewers were tasked with identifying special bullets from police ammunition (Action 4 bullets: n = 3) among 10 CT examinations of humans with lodged projectiles who were selected by the supervisor of the study. RESULTS The CT scans of the undeformed specimens revealed the special design of the bullets' metal core. All special bullets from police ammunitions that were fired towards an animal cadaver model demonstrated the characteristic slight mushrooming. In accordance with the CT scans of the undeformed bullets, visualisation of the individual internal cavities of the special bullets allowed the Action 4, SECA and QD-PEP bullets to be clearly distinguished. With regard to the real forensic cases, both reviewers clearly identified each of the three Action 4 bullets among all other lodged projectiles. CONCLUSIONS This study demonstrates the feasibility of identifying Action 4, SECA and QD-PEP bullets from special police ammunitions by CT. The individual shapes of the cavity inside the bullets were clearly visible on CT. In situ identification of these bullets can aid in the assessment of injuries, and since these bullets are fabricated from non-ferromagnetic metals, their clear identification allows for magnetic resonance imaging (MRI) without the risk of bullet movement inside the body due to the magnetic pull of the MRI unit. Furthermore, this approach could be of great interest to forensic investigators if patients who received gunshot wounds underwent non-operative treatments and the projectile remains in the body. Since the use of CT is also increasing for medico-legal post-mortem examinations, the identification of lodged projectiles is of interest for a virtual autopsy or 'Virtopsy'.
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Affiliation(s)
- Dominic Gascho
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
| | - Niklaus Zoelch
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Switzerland
| | - Eva Deininger-Czermak
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland
| | - Carlo Tappero
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
- Department of Radiology, Hôpital Fribourgeois, Switzerland
| | - Henning Richter
- Diagnostic Imaging Research Unit (DIRU), Clinic for Diagnostic Imaging, Vetsuisse Faculty, University of Switzerland
| | - Michael J Thali
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
| | - Sarah Schaerli
- Institute of Forensic Medicine, Health Department Basel, University of Basel, Switzerland
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13
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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Hamid S, Nicolaou S, Khosa F, Andrews G, Murray N, Abdellatif W, Qamar SR. Dual-Energy CT: A Paradigm Shift in Acute Traumatic Abdomen. Can Assoc Radiol J 2020; 71:371-387. [DOI: 10.1177/0846537120905301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abdominal trauma, one of the leading causes of death under the age of 45, can be broadly classified into blunt and penetrating trauma, based on the mechanism of injury. Blunt abdominal trauma usually results from motor vehicle collisions, fall from heights, assaults, and sports and is more common than penetrating abdominal trauma, which is usually seen in firearm injuries and stab wounds. In both blunt and penetrating abdominal trauma, an optimized imaging approach is mandatory to exclude life-threatening injuries. Easy availability of the portable ultrasound in the emergency department and trauma bay makes it one of the most commonly used screening imaging modalities in the abdominal trauma, especially to exclude hemoperitoneum. Evaluation of the visceral and vascular injuries in a hemodynamically stable patient, however, warrants intravenous contrast-enhanced multidetector computed tomography scan. Dual-energy computed tomography with its postprocessing applications such as iodine selective imaging and virtual monoenergetic imaging can reliably depict the conspicuity of traumatic solid and hollow visceral and vascular injuries.
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Affiliation(s)
- Saira Hamid
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Faisal Khosa
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gordon Andrews
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Murray
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Waleed Abdellatif
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sadia Raheez Qamar
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Elshaer AR, Abdelsalam AA, Elgeyoushi FA, Allam AR. Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report. J Taibah Univ Med Sci 2019; 14:193-198. [PMID: 31555071 PMCID: PMC6708075 DOI: 10.1016/j.jtumed.2019.02.006] [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: 01/24/2019] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 11/14/2022] Open
Abstract
We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.
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Affiliation(s)
- Anas R Elshaer
- Department of Diagnostic and Interventional Radiology, King Fahad Hospital Madinah, KSA
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16
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Al Rawahi AN, Al Hinai FA, Boyd JM, Doig CJ, Ball CG, Velmahos GC, Kirkpatrick AW, Navsaria PH, Roberts DJ. Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis. World J Emerg Surg 2018; 13:55. [PMID: 30505340 PMCID: PMC6260713 DOI: 10.1186/s13017-018-0215-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/05/2018] [Indexed: 01/05/2023] Open
Abstract
Background Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs. Methods We searched electronic databases (March 1966-April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I2 statistics and conducting tests of homogeneity. Results Of 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9-10.1%; I2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2-0.6%; I2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3-77.7%; I2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0-7.0%; I2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9-10.1%), and back (3.1%; 95% CI = 0-6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3-20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication. Conclusions SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.
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Affiliation(s)
| | - Fatma A. Al Hinai
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Jamie M. Boyd
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Christopher J. Doig
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Chad G. Ball
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Regional Trauma Program, University of Calgary and the Foothills Medical Centre, Calgary, Alberta Canada
| | - George C. Velmahos
- Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Andrew W. Kirkpatrick
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
- Regional Trauma Program, University of Calgary and the Foothills Medical Centre, Calgary, Alberta Canada
| | - Pradeep H. Navsaria
- Department of Surgery, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
- Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Room A280, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9 Canada
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17
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Choi AY, Bodanapally UK, Shapiro B, Patlas MN, Katz DS. Recent Advances in Abdominal Trauma Computed Tomography. Semin Roentgenol 2018; 53:178-186. [PMID: 29861009 DOI: 10.1053/j.ro.2018.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andrew Y Choi
- Department of Radiology, NYU Winthrop Hospital, Mineola, NY.
| | - Uttam K Bodanapally
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, R. Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Boris Shapiro
- Department of Radiology, NYU Winthrop Hospital, Mineola, NY
| | - Michael N Patlas
- Division of Emergency Radiology, Department of Radiology, McMaster University, Hamilton, ON, Canada
| | - Douglas S Katz
- Department of Radiology, NYU Winthrop Hospital, Mineola, NY
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18
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Navsaria P, Nicol A, Krige J, Edu S, Chowdhury S. Selective nonoperative management of liver gunshot injuries. Eur J Trauma Emerg Surg 2018; 45:323-328. [PMID: 29368085 DOI: 10.1007/s00068-018-0913-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 01/20/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. METHODS A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. RESULTS During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. CONCLUSION The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.
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Affiliation(s)
- Pradeep Navsaria
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
| | - Andrew Nicol
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology, University of Cape Town , Cape Town, South Africa
| | - Sorin Edu
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Sharfuddin Chowdhury
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Peponis T, Kasotakis G, Yu J, Alouidor R, Burkott B, Maung AA, Johnson DC, Saillant N, Walden H, Salim A, Bryant E, Dorfman JD, Klein EN, Elefant R, Tabrizi MB, Bugaev N, Arabian SS, Velmahos GC. Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT). J Am Coll Surg 2017; 224:1036-1045. [DOI: 10.1016/j.jamcollsurg.2016.12.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/30/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
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20
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Lee KF, Chong CCN, Yeung JHH, Cheung NK, Siu EYY, Cheung YS, Wong J, Lai PBS. Factors affecting outcomes in traumatic liver injury: A retrospective study. SURGICAL PRACTICE 2017; 21:63-69. [DOI: 10.1111/1744-1633.12237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kit-Fai Lee
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | | | | | - Nai-Kwong Cheung
- Department of Trauma and Emergency Centre; Prince of Wales Hospital; Hong Kong
| | - Eva Yin-Yu Siu
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | - Yue-Sun Cheung
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | - John Wong
- Department of Surgery; Prince of Wales Hospital; Hong Kong
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21
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Kaptanoglu L, Kurt N, Sikar HE. Current approach to liver traumas. Int J Surg 2017; 39:255-259. [PMID: 28193544 DOI: 10.1016/j.ijsu.2017.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/06/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Liver injuries remain major obstacle for successful treatment, due to size and location of the liver. Requirement for surgery should be determined by clinical factors, most notably hemodynamical state. In this present study we tried to declare our approach to liver traumas. We also tried to emphasize the importance of conservative treatment, since surgeries for liver traumas carry high mortality rates. PRESENTATION OF CASE Patients admitted to the Department of Emergency Surgery at Kartal Research and Education Hospital, due to liver trauma were retrospectively analyzed between 2003 and 2013. Patient demographics, hepatic panel, APTT (activated partial thromboplastin time), PT (prothrombin time), INR (international normalized ratio), fibrinogen, biochemistry panel were recorded. Hemodynamic instability was the most prominent factor for surgery decision, in the lead of current Advanced Trauma Life Support (ATLS) protocols. Operation records and imaging modalities revealed liver injuries according to the Organ Injury Scale of the American Association for the Surgery of Trauma. 300 patients admitted to emergency department were included in our study (187 males and 113 females). Mean age was 47 years (range, 12-87). The overall mortality rate was 13% (40 out of 300). Major factor responsible for mortality rates and outcome was stability of cases on admission. 188 (% 63) patients were counted as stable, whereas 112 (% 37) cases were found unstable (blood pressure ≤ 90, after massive resuscitation). 192 patients were observed conservatively, whereas 108 cases received abdominal surgery. High levels of AST, ALT, LDH, INR, creatinine and low levels of fibrinogen and low platelet counts on admission were found to be associated with mortality and these cases also had Grade 4 and 5 injuries. Hemodynamic instability on admission and the type and grade of injury played major role in mortality rates). Packing was performed in 35 patients, with Grade 4 and 5 injuries. Mortality rate was %13 (40 out of 300). CONCLUSION A multidisciplinary approach to the management of hepatic injuries has evolved over the last few decades, but the basic principles of trauma continue to be observed. Diagnostic and therapeutic endeavors are chosen based mainly on the stability of the patient. Stable patients with reliable examinations and available resources can be managed nonoperatively. Unstable patients require surgery. Our current approach to liver traumas is non operative technique, if possible.
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Affiliation(s)
| | - Necmi Kurt
- Kartal Research and Education Hospital, Turkey
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22
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Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Ceresoli M, Montori G, Sartelli M, Weber D, Fraga G, Naidoo N, Moore FA, Zanini N, Ansaloni L. WSES classification and guidelines for liver trauma. World J Emerg Surg 2016; 11:50. [PMID: 27766112 PMCID: PMC5057434 DOI: 10.1186/s13017-016-0105-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Gustavo Fraga
- Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas, SP Brazil
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nicola Zanini
- General Surgery Department, Infermi Hospital, Rimini, Italy
| | - Luca Ansaloni
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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23
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Sardiwalla I, Govender M, Matsevych O, Koto MZ. Indirect ballistic injury to the liver: Case report and review of literature. INTERNATIONAL JOURNAL OF SURGERY OPEN 2016. [DOI: 10.1016/j.ijso.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pyogenic liver abscess after gunshot injury: 10 years' experience at a single level 1 trauma center. Ir J Med Sci 2015; 185:797-804. [PMID: 26377603 DOI: 10.1007/s11845-015-1358-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/05/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Liver abscesses are approximately 50 % of all visceral abscesses, and trauma presents as a rare cause of the liver abscess. Otherwise, hepatic abscess is an uncommon complication of gunshot wound (GSW) to the liver among all trauma cases. Here we reviewed their experience in detail. METHOD From January 1, 2004 to September 30, 2013, there were 2143 patients admitted to Ryder Trauma Center at Jackson Memorial Hospital/University of Miami with severe abdominal trauma: 1227 penetrating and 866 blunt. Among the patients who had penetrating trauma, 637 had GSWs and 551 had stab wounds. Thirty-nine patients had other kinds of penetrating traumas. Eleven patients were identified as having liver abscess, with 8 of them belonging to the GSW group, and 3 to the blunt injury group. The diagnosis and management of the 8 patients with a hepatic abscess after GSW to the liver were demonstrated. RESULT There were seven males and one female with a mean age of 29 ± 10 years. There were one grade 2, four grade 3, two grade 4 and one grade 5 injuries. The mean abscess size was 10 ± 2 cm. The abscesses were usually caused by infection from mixed organisms. These abscesses were treated with antibiotics and drainage. No mortality and long-term morbidity were seen. CONCLUSION Hepatic abscess after GSW to the liver is a rare condition, with an incidence of 1.2 %. It is usually seen in severe liver injury (grade 3 and above), but our patients were all treated successfully, with no mortality.
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Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, Peitzman AB, Rizoli S, Tugnoli G, Sartelli M, Manfredi R, Ansaloni L. Liver trauma: WSES position paper. World J Emerg Surg 2015; 10:39. [PMID: 26309445 PMCID: PMC4548919 DOI: 10.1186/s13017-015-0030-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/24/2015] [Indexed: 01/13/2023] Open
Abstract
The liver is the most injured organ in abdominal trauma. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries. The present position paper represents the position of the World Society of Emergency Surgery (WSES) about the management of liver injuries.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | | | | | | | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Gregorio Tugnoli
- General, Emergency and Trauma Surgery, Maggiore Hospital, Bologna, Italy
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Roberto Manfredi
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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STARLING SIZENANDOVIEIRA, AZEVEDO CAMILAISSADE, SANTANA ALINEVALENTE, RODRIGUES BRUNODELIMA, DRUMOND DOMINGOSANDRÉFERNANDES. Isolated liver gunshot injuries: nonoperative management is feasible? Rev Col Bras Cir 2015; 42:238-43. [DOI: 10.1590/0100-69912015004008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/08/2015] [Indexed: 11/22/2022] Open
Abstract
ABSTRACTObjective:to evaluate the safety and effectiveness of non-operative management (NOM) of liver injury, being the only abdominal injury, from gunshot wounds to the abdomen.Methods:patients who had liver damage diagnosed as single abdominal injury caused by PAF in the right thoracoabdominal region, hemodynamically stable were studied. All underwent examination with computed tomography. Were analyzed: age, gender, levels of trauma, hemodynamic condition and the abdominal examination on admission, the results of the CT scan, the extra-abdominal lesions found, the serum levels of hemoglobin, clinical course, complications, length of hospital stay, outpatient treatment and death.Results:during the study period 169 patients, treated non-operatively, presented liver gunshot wounds. Of these, only 28 patients (16.6%) had liver injury as the only abdominal injury and consequently met the inclusion criteria for this study. The average age was 27.7 years and 25 patients (89.2%) were male. The overall average of verified trauma scores were: RTS 7.45, ISS 10.9, and TRISS 98.7%. The most frequent injuries were grade II and grade III (85.7%). Complications occurred in only one patient who presented a progressive decline in hemoglobin. He underwent a CT scan which showed blush in the liver parenchyma. An arteriography was performed, which showed a successfully embolized arteriovenous fistula. There were no deaths in the patient sample. The average hospital stay was 5.3 days.Conclusion:isolated hepatic injury in gunshot abdominal trauma is uncommon. However, the NOM protocol for this type of injury is safe and has low morbidity. This approach should only be followed in institutions with adequate infrastructure, where an experienced and cohesive team is able to follow a specific protocol, with rigorous periodic evaluation of its results.
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Abstract
BACKGROUND Bile leaks occur in 4% to 23% of patients after major liver injuries. The role of conservative management versus internal biliary drainage has not been clearly defined. The safety and efficacy of nonoperative management of bile leaks were studied. METHODS Four hundred twelve patients with liver injuries were assessed in a prospective study between 2008 and 2013. All patients with clinically significant injuries to the intrahepatic biliary tract were evaluated. Bile leaks were classified as minor or major (>400 mL/d or persistent drainage >14 days). Minor leaks were managed conservatively, and major leaks underwent endoscopic retrograde cholangiogram and endoscopic biliary stenting. RESULTS Fifty-one patients (12%) developed a bile leak after liver trauma. Eleven patients (22%) with an extrahepatic duct injury underwent open surgery. Forty patients (78%) had an intrahepatic bile leak. Twenty-six patients (65%) with minor bile leaks were treated conservatively, and 14 patients (35%) with major leaks underwent endoscopic retrograde cholangiogram and internal drainage. All bile leaks resolved. There was no significant difference in the two groups with respect to septic complications (p = 0.125), intensive care unit stay (p = 0.534), hospital stay (p = 0.164), or mortality (p = 1.000). CONCLUSION Sixty-five percent of the intrahepatic bile leaks following trauma are minor and easily managed conservatively. Endoscopic retrograde cholangiogram and internal drainage should be reserved for major leaks. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Abstract
Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.
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Selective non operative management of gunshot wounds to the abdomen: a collective review. Int Emerg Nurs 2014; 23:22-31. [PMID: 25023337 DOI: 10.1016/j.ienj.2014.06.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/19/2014] [Accepted: 06/19/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Over the past four decades there has been a shift from operative to selective conservatism in trauma. Selective nonoperative management (SNOM) of stab wounds to the abdomen is widely accepted in trauma centres. However, selective conservatism with gunshot wounds to the abdomen is controversial. This collective review assesses the evidence of SNOM of gunshot wounds to the abdomen. METHODS A Medline search between 1 January 1960 and 31 July 2013 was conducted identifying studies that investigated SNOM of gunshot wounds to the abdomen. Case reports, review articles and editorials were excluded. All other studies that investigated SNOM of gunshot wounds to the abdomen and its outcomes were included. RESULTS A total of 37 studies were included of which 22 were prospective, 14 were retrospective and 1 case series. A total of 21330 patients with gunshot wounds to the abdomen were included, of which 6468 (30.3%) were managed nonoperatively. Successful SNOM was possible in 5510 (85.18%) patients and 958 (14.8%) failed SNOM and underwent delayed laparotomies. SNOM reduces rates of non-therapeutic laparotomies and the associated morbidity. Special aspects reviewed include the prehospital and nursing involvement in this modality of care. CONCLUSIONS Current evidence supports SNOM of gunshot wounds to the abdomen. It is associated with a decreased rate of non therapeutic laparotomy. Careful patient selection and specially designed protocols should be established and adhered to.
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Ball CG. Current management of penetrating torso trauma: nontherapeutic is not good enough anymore. Can J Surg 2014; 57:E36-43. [PMID: 24666458 DOI: 10.1503/cjs.026012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.
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Affiliation(s)
- Chad G Ball
- From the University of Calgary, Calgary, Alta
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Selective non-operative management of civilian gunshot wounds to the abdomen: a systematic review of the evidence. Injury 2014; 45:659-66. [PMID: 23895795 DOI: 10.1016/j.injury.2013.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 07/05/2013] [Accepted: 07/06/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds. METHODS A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed. RESULTS Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n=6072) of patients were initially managed non-operatively and 15.5% (n=943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay. CONCLUSIONS SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.
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Petersen K, Waterman P. Prophylaxis and treatment of infections associated with penetrating traumatic injury. Expert Rev Anti Infect Ther 2014; 9:81-96. [DOI: 10.1586/eri.10.155] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Khan MS, Khan BM, Naz S, Pirzada MT. Is estimated bullet trajectory a reliable predictor of severe injury? Case report of a thoraco-abdominal gunshot with a protracted trajectory managed nonoperatively. BMC Res Notes 2013; 6:63. [PMID: 23414905 PMCID: PMC3598892 DOI: 10.1186/1756-0500-6-63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 02/12/2013] [Indexed: 11/30/2022] Open
Abstract
Background Operative management of all gunshot’s traumas carries a high rate of unwarranted interventions that are known to cause serious complications. Selective nonoperative management is thus being increasingly practiced which has reduced these avoidable interventions. Physical examination and computed tomography scans are most sensitive in assessing need of laparotomy. Assessment of internal injuries on the basis of an estimated bullet trajectory is often practiced but has seldom been studied. We report a case of conservative management of a thoraco abdominal gun shot patient where an estimated bullet trajectory was indicative of serious injuries. To the best of our knowledge this is the first report of a thoraco abdominal gunshot that, despite of a protracted trajectory, had no sequelae and was thus managed nonoperatively. Case presentation A 30 year old male patient having height of 180 cm and weight of 70 kg (Body Mass Index 21.6) presented with complaint of a penetrating injury at left side of upper torso. The patient had no symptoms or obvious bleeding and was vitally stable. On examination a 1 cm × 1 cm entry wound at the left 3rd intercostal space in the mid clavicular line was identified. The chest and abdomen were otherwise unremarkable on examination. The chest radiograph displayed clear lung fields. The abdominal radiographs displayed a bullet in the upper left quadrant of the abdomen lateral to the spine. The bullets estimated trajectory from 3rd intercostal space and its lodgment in the abdomen lateral to the spine indicated severe visceral injury. The computed tomography scan showed that the bullet was lodged postero-medially to the left kidney. All thoracic, intra peritoneal and retroperitoneal visceral structures were identified to be normal. The patient remained clinically and vitally stable, hence was managed nonoperatively being discharged after 48 h of observation. Conclusion From this case we conclude that decision for managing gun shot patients should be based on objective clinical and diagnostic findings. We recommend further investigation of the predictability of estimated trajectory for visceral injuries and consequent operative intervention as we found it to be misleading in this case.
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Wohlgemut JM, Jansen JO. The principles of non-operative management of penetrating abdominal injury. TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613497161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. Recognition of the morbidity, mortality, and cost associated with non-therapeutic exploration has provided the impetus for selective management. This review describes the principles of, and evidence for, this strategy. Selective management is widely accepted for the treatment of stab wounds, but the selective management of ballistic injuries, particularly in the military setting, remains contentious. As a result, there are marked variations in the application of this practice. Computed tomography is a prerequisite for the selective management of ballistic injuries, and possibly also stab wounds. Failure of non-operative management, following stab wounds or gunshot wounds, is invariably apparent within 24 hours.
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Affiliation(s)
| | - Jan O Jansen
- Department of Surgery and Intensive Care Medicine, Aberdeen Royal Infirmary, UK
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Abstract
PURPOSE OF REVIEW Patients with penetrating abdominal trauma are at risk of harboring life-threatening injuries. Many patients are in need of emergent operative intervention. However, there are clearly patients who can be safely managed nonoperatively. This review evaluates the literature to identify management guidelines for patients with penetrating abdominal trauma. RECENT FINDINGS Accumulating evidence supports nonoperative management of patients with stab wounds to the thoracoabdominal region, the back, flank, and anterior abdomen. Furthermore, select patients with gunshot wounds can be safely managed nonoperatively. SUMMARY Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating abdominal trauma. Thoracoabdominal stab wounds should be further evaluated with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the back and flank should be imaged with CT scanning. Anterior abdominal stab wound victims can be followed with serial clinical assessments. The majority of patients with gunshot wounds are best served by laparotomy; however, select patients may be managed expectantly.
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Abstract
Over the history of surgery, the management of abdominal gunshot wounds in the stable evaluable patient without peritonitis has evolved. While non-operative management has been widely accepted and employed for the management of abdominal stab wounds, recently it has been deemed a safe option for abdominal gunshot wounds as well. Selective non-operative management of penetrating abdominal trauma in the appropriate setting has been shown to decrease the rate of nontherapeutic laparotomy as well as the cost and total length of hospital stay, and potentially decrease short- and long-term morbidity. This review examines the background support for non-operative management of abdominal gunshot wounds while discussing patient evaluation, selection, and clinical management.
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Affiliation(s)
- Stephen Varga
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Scott Zakaluzny
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
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Jansen JO, Inaba K, Resnick S, Fraga GP, Starling SV, Rizoli SB, Boffard KD, Demetriades D. Selective non-operative management of abdominal gunshot wounds: survey of practise. Injury 2013; 44:639-44. [PMID: 22341771 DOI: 10.1016/j.injury.2012.01.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 01/21/2012] [Accepted: 01/23/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal gunshot wounds. However, much of the research which supports this conclusion has originated from a few centres, and the actual utilisation of SNOM by trauma surgeons is not known. We therefore conducted a survey to assess the acceptance of this strategy and evaluate variations in practise. METHODS Electronic questionnaire survey of trauma surgeons in the United States of America, Canada, Brazil, and South Africa. Responses were compared using Chi(2) and Fisher's exact tests. RESULTS 183 replies were received. 105 (57%) respondents practise SNOM of abdominal gunshot wounds, but there are marked regional variations in the acceptance of this strategy (p<0.01). Respondents who had completed trauma (p<0.01) or critical care (p<0.01) fellowships, and those who practise in a higher volume centre (defined as >50 penetrating abdominal injuries seen per year) (p<0.01) are more likely to practise SNOM of gunshot wounds. Most surgeons who practise SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient as a contraindication to attempting non-operative management. Almost all regard CT as essential. Respondents' preparedness to consider SNOM is related to injury extent. CONCLUSIONS SNOM of abdominal gunshot wounds is practised by trauma surgeons in all four countries surveyed, but is not universally accepted, and there are variations in how it is practised.
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Affiliation(s)
- Jan O Jansen
- Department of Surgery and Department of Intensive Care Medicine, University of Aberdeen, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK.
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Starling SV, Rodrigues BDL, Martins MPR, da Silva MSA, Drumond DAF. Non operative management of gunshot wounds on the right thoracoabdomen. Rev Col Bras Cir 2013; 39:286-94. [PMID: 22936227 DOI: 10.1590/s0100-69912012000400008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 03/18/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To analyze the results after the implementation of the non-operative management (NOM) of the right upper thoracoabdominal gunshot injuries protocol. METHODS Prospective study. From January 2005 to December 2011, 115 patients were included into this study. Criteria for inclusion were gunshot wound to the right thoracoabdominal region, haemodynamic stability, no signs of peritonitis, and realized CT scan. The data collected were analysed by the software EXCEL. RESULTS Among the 115 patients included in our study, the mean age was 25.8 years old (range, 14-78 years old), of whom 95.6% were male, 62.6% had thoracoabdominal injuries and 37.4% had exclusively abdominal injuries. The averages of trauma scores were RTS 7.7, ISS 14.8 and TRISS 97%. One hundred and nine patients (94.8%) had liver injury, 72 (62.6%) had diaphragm and lung injury, 28 (24.4%) had renal injury. Complications were present in 12 (10.5%) patients, 7 of these related to the thorax. The NOM failure happened in 4 (3.5%) patients, 2 of them due to bile peritonitis, 1 related to bleeding and 1 the laparotomy was unnecessary. The mean hospital stay was 9.4 days. There were 2 deaths due to associated gunshot brain injury. Sixty seven patients (58.3%) were presented in the follow-up after 2 months of trauma. The CT scan showed injury scar in 58 patients (86.5%). CONCLUSION NOM of the penetrating right thoracoabdominal injuries must be seen with caution. The NOM of right thoracoabdominal gunshot injuries is safe only in selected cases, followed by well-defined protocols and when performed in places that have adequate infrastructure.
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The use of a liver with a gunshot injury as a donor for auxiliary liver transplantation: Case report. Int J Surg Case Rep 2013; 4:917-9. [DOI: 10.1016/j.ijscr.2013.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 06/23/2013] [Accepted: 07/22/2013] [Indexed: 11/22/2022] Open
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Selective non-operative management of penetrating abdominal injury in Great Britain and Ireland: survey of practice. Injury 2012; 43:1799-804. [PMID: 21529801 DOI: 10.1016/j.injury.2011.03.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/30/2011] [Accepted: 03/31/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND The selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. In Great Britain and Ireland, the management of trauma remains the responsibility of general surgeons. This study appraises the acceptance and utilisation of selective non-operative management strategies by British and Irish general surgeons, compared with trauma surgeons in the United States of America. METHODS Electronic questionnaire survey of British and Irish consultant general surgeons and trauma surgeons in the United States of America. RESULTS 139 British and Irish general surgeons and 75 US trauma surgeons completed the survey. 84.3% of British and Irish general surgeons and 94.4% of US trauma surgeons practise selective non-operative management of abdominal stab wounds, and 14.0% and 74.3% practise selective non-operative management of abdominal gunshot wounds. The management of those British and Irish surgeons who do practise selective non-operative management is broadly similar to that of US trauma surgeons, with the exception of the use of laparoscopy to examine the left hemidiaphragm following thoracoabdominal injuries, which is employed by fewer British and Irish general surgeons than US trauma surgeons. CONCLUSIONS The selective non-operative management of abdominal stab wounds is generally accepted by British and Irish general surgeons. In contrast, few British and Irish surgeons are comfortable with non-operatively managing patients with abdominal gunshot wounds, reflecting both the rarity of this type of injury, and surgeons' training and experience. This proportion is unlikely to change until the management of torso trauma is recognised as a specialty, and services are concentrated in regional centres.
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Abstract
The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.
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Affiliation(s)
- C Swift
- Department of General Surgery, Rotherham NHS Foundation Trust, Rotherham South Yorkshire S60 2UD
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Jiang H, Wang J. Emergency strategies and trends in the management of liver trauma. Front Med 2012; 6:225-33. [PMID: 22673827 DOI: 10.1007/s11684-012-0186-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 01/10/2012] [Indexed: 12/14/2022]
Abstract
The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.
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Affiliation(s)
- Hongchi Jiang
- Department of Hepatic Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Atoini F, Traibi A, Elkaoui H, Elouieriachi F, Elhammoumi M, Sair K, Kabiri EH. [Missed right post-traumatic diaphragmatic injuries: a review of six cases]. REVUE DE PNEUMOLOGIE CLINIQUE 2012; 68:185-193. [PMID: 22196082 DOI: 10.1016/j.pneumo.2011.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Revised: 06/15/2011] [Accepted: 07/17/2011] [Indexed: 05/31/2023]
Abstract
INTEREST Right posttraumatic diaphragmatic injuries are rare; literature relates mainly isolated cases or small series and most often rupture are succeeding of blunt trauma. This series is interesting because the number of cases and the existence of two injuries following a right stab wound. PATIENTS AND METHODS Retrospective study between January 2002 and September 2010. We collected the data of initial trauma, clinical, radiological, operative and follow-up for six patients supported for right posttraumatic diaphragmatic injuries. RESULTS All injuries were in late presentation. Four injuries were secondary to road traffic accident, and two after stab wound. The time to diagnosis was between 47 days and 15 years. Right posterolateral thoracotomy was the elective approach in the cases with diaphragmatic hernia (5 patients). In one case, video-assisted thoracoscopic surgery permits the diagnosis and repair of injury. Mortality was null and morbidity was present in one case from six. Follow-up ranging from 8 months and 42 months don't objectified complications. CONCLUSION Right diaphragmatic hernia is terrible sequelae after thoracoabdominal trauma. Surgery becomes more complex at this stage and can be done by thoracotomy. With strong suspicious signs at the first assessment of trauma, exploration by thoracoscopy can always avoid the occurrence of long-term sequelae.
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Affiliation(s)
- F Atoini
- Service de chirurgie thoracique, hôpital militaire d'instruction Mohammed V, Rabat, Maroc.
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Petrowsky H, Raeder S, Zuercher L, Platz A, Simmen HP, Puhan MA, Keel MJ, Clavien PA. A quarter century experience in liver trauma: a plea for early computed tomography and conservative management for all hemodynamically stable patients. World J Surg 2012; 36:247-54. [PMID: 22170476 DOI: 10.1007/s00268-011-1384-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome. METHODS A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010). RESULTS 395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P = 0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis. CONCLUSIONS Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver trauma.
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Affiliation(s)
- Henrik Petrowsky
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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Prometheus bound: evolution in the management of hepatic trauma--from myth to reality. J Trauma Acute Care Surg 2012; 72:321-9. [PMID: 22327973 DOI: 10.1097/ta.0b013e31824b15a7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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