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Blackley SK, Smith WC, Lee YL, Kinnard C, Williams AY, Butts CC, Mbaka MI, Haiflich A, Bright A, Simmons JD, Polite NM. Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury. Am Surg 2023:31348231174009. [PMID: 37115715 DOI: 10.1177/00031348231174009] [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: 04/29/2023]
Abstract
BACKGROUND Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI. METHODS Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention. RESULTS 1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention. CONCLUSION In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.
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Affiliation(s)
- Shem K Blackley
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - William C Smith
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Yann-Leei Lee
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | | | | | - Charles C Butts
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Maryann I Mbaka
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Andrew Haiflich
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Andrew Bright
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Jon D Simmons
- Department of Surgery, University of South Alabama, Mobile, AL, USA
| | - Nathan M Polite
- Department of Surgery, University of South Alabama, Mobile, AL, USA
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Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Behdin S, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Nahmias J. Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography. JAMA Surg 2022; 157:771-778. [PMID: 35830194 DOI: 10.1001/jamasurg.2022.2770] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures Presence of HVI diagnosed at the time of operative intervention. Results A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.
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Affiliation(s)
- Patrick T Delaplain
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Erika Tay-Lasso
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Samar Behdin
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Emily Switzer
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Morgan Schellenberg
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California, Irvine
| | - Jeffry Nahmias
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
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Diagnostic Accuracy of Computed Tomography for the Prediction of the Need for Laparotomy for Traumatic Hollow Viscus Injury: Systematic Review and Meta-Analysis. J Pers Med 2021; 11:jpm11121269. [PMID: 34945741 PMCID: PMC8708608 DOI: 10.3390/jpm11121269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI. METHOD A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models. RESULTS Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501-0.809) and 0.969 (95% CI: 0.920-0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011-0.071). CONCLUSION In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.
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Keller N, Zingg T, Agri F, Denys A, Knebel JF, Schmidt S. Significant blunt bowel and mesenteric injury - Comparison of two CT scoring systems in a trauma registry cohort. Eur J Radiol Open 2021; 8:100380. [PMID: 34646913 PMCID: PMC8496098 DOI: 10.1016/j.ejro.2021.100380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study evaluated and compared two imaging-based scoring systems for the detection of significant blunt bowel and mesenteric injury (sBBMI) by emergency computed tomography (CT). METHODS AND MATERIALS We included all consecutive adult polytrauma patients admitted to our emergency department following a road traffic accident from January 2008 to June 2015, provided that intravenously contrast-enhanced whole-body CT examination was performed immediately after hospital admission. Two radiologists, blinded to patients' outcome, reviewed the CT examinations for distinctive direct intestinal or mesenteric vascular injury and indirect signs of abdominal injury. These findings were correlated with the patients' surgical or interventional radiology findings, autopsy, or clinical follow-up (>24 h). Two previously validated imaging-based bowel-injury scoring systems, the CT-based Faget score and the clinically and radiologically based Mc Nutt score (BIPS), were compared by applying each to our trauma cohort. Student t-test, chi-squared, and logistic regression were used in analyses. RESULTS Twenty-one of 752 analysed patients (2.8 %) had confirmed sBBMI. Active mesenteric bleeding, mesenteric and free pneumoperitoneum, small haemoperitoneum, non-focal bowel wall thickening, mesenteric/pericolic fat stranding, and anterior abdominal wall injury were significantly correlated with sBBMI, as did the two evaluated scoring systems (p < 0.001). However, multivariate logistic regression revealed the superiority of the Faget score to the McNutt score. CONCLUSION The prevalence of sBBMI among polytrauma patients is low. Early diagnosis is necessary to avoid increased mortality. Certain CT features are pathognomic of sBBMI and must not be overlooked. Scoring systems are helpful, especially when they are based on radiological signs.
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Key Words
- AAWI, Anterior abdominal wall injury
- AMB, Active mesenteric bleeding
- ATMV, Abrupt termination of mesenteric vessels
- BIPS, Bowel Injury Prediction Score
- BWD, Bowel wall discontinuity
- BWT, Bowel wall thickening
- CT, Multidetector computed tomography
- DBWE, Decreased bowel wall enhancement
- FF, (Non-haematic) free fluid
- FPP, Free pneumoperitoneum
- HP, Haemoperitoneum
- IBMV, Irregular beading of mesenteric vessels
- Intestine, large
- Intestine, small
- MFS, Mesenteric (pericolic) fat stranding
- MPP, Mesenteric pneumoperitoneum
- Mesentery
- Multidetector computed tomography
- Polytrauma
- SB, Small bowel
- WBC, White blood cell
- sBBMI, Significant blunt bowel and mesenteric injury
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Affiliation(s)
- Nathalie Keller
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Francois Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic-therapeutic algorithm. Updates Surg 2020; 73:703-710. [PMID: 33340338 PMCID: PMC8005390 DOI: 10.1007/s13304-020-00929-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/11/2020] [Indexed: 11/23/2022]
Abstract
Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.
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Durrant E, Abu Mughli R, O’Neill SB, Jiminez-Juan L, Berger FH, Ezra O’Keeffe M. Evaluation of Bowel and Mesentery in Abdominal Trauma. Can Assoc Radiol J 2020; 71:362-370. [DOI: 10.1177/0846537120908132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Since the advent of multidetecter computed tomography (CT), radiologist sensitivity in detection of traumatic bowel and mesenteric abnormalities has significantly improved. Although several CT signs have been described to identify intestinal injury, accurate interpretation of these findings can remain challenging. Early detection of bowel and mesenteric injury is important as it alters patient management, disposition, and follow-up. This article reviews the common imaging findings of traumatic small bowel and mesenteric injury.
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Affiliation(s)
- Eric Durrant
- Department of Emergency and Trauma Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rawan Abu Mughli
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Siobhán B. O’Neill
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Laura Jiminez-Juan
- Department of Cardiothoracic Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ferco H. Berger
- Department of Emergency and Trauma Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael Ezra O’Keeffe
- Department of Emergency and Trauma Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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7
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Cohan CM, Beattie G, Tang A, Mazzolini K, Farzaneh N, Senekjian L, Victorino GP. Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis. J Surg Res 2020; 255:619-626. [PMID: 32653694 DOI: 10.1016/j.jss.2020.05.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.
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Affiliation(s)
- Caitlin M Cohan
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California.
| | - Genna Beattie
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Kirea Mazzolini
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | | | - Lara Senekjian
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
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Goedecke M, Kühn F, Stratos I, Vasan R, Pertschy A, Klar E. No need for surgery? Patterns and outcomes of blunt abdominal trauma. Innov Surg Sci 2019; 4:100-107. [PMID: 31709301 PMCID: PMC6817729 DOI: 10.1515/iss-2018-0004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 09/03/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction The management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM). Materials and methods Analysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury. Results Patients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001). Conclusion NOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.
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Affiliation(s)
- Maximilian Goedecke
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany.,Department of Oral and Maxillofacial Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universitätzu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Munich, Munich, Germany
| | - Ioannis Stratos
- Department of Trauma, Hand and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Robin Vasan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Annette Pertschy
- Department of General, Visceral, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Ernst Klar
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany
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Manson WC, Kirksey M, Boublik J, Wu CL, Haskins SC. Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist. Reg Anesth Pain Med 2019; 44:540-548. [DOI: 10.1136/rapm-2018-100312] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/10/2019] [Accepted: 02/20/2019] [Indexed: 11/04/2022]
Abstract
This article in our point-of-care ultrasound (PoCUS) series is dedicated to the role the focused assessment with sonography in trauma (FAST) exam plays for the regional anesthesiologist and pain specialists in the perioperative setting. The FAST exam is a well-established and extensively studied PoCUS exam in both surgical and emergency medicine literature with over 20 years demonstrating its benefit in identifying the presence of free fluid in the abdomen following trauma. However, only recently has the FAST exam been shown to be beneficial to the anesthesiologist in the perioperative setting as a means to identify the extravasation of free fluid into the abdomen from the hip joint following hip arthroscopy. In this article, we will describe how to obtain the basic FAST views (subcostal four-chamber view, perihepatic right upper quadrant view, perisplenic left upper quadrant view, and pelvic view in the longitudinal and short axis) as well as cover the relevant sonoanatomy. We will describe pathological findings seen with the FAST exam, primarily free fluid in the peritoneal space as well as in the pericardial sac. As is the case with any PoCUS skill, the application evolves with understanding and utilization by new clinical specialties. Although this article will provide clinical examples of where the FAST exam is beneficial to the regional anesthesiologist and pain specialist, it also serves as an introduction to this powerful PoCUS skill in order to encourage clinical practitioners to expand the application of the FAST exam within the scope of regional anesthesia and pain management practice.
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Molinelli V, Iosca S, Duka E, De Marchi G, Lucchina N, Bracchi E, Carcano G, Novario R, Fugazzola C. Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries. Radiol Med 2018; 123:891-903. [PMID: 30039378 DOI: 10.1007/s11547-018-0923-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 07/12/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine the accuracy of MDCT in the evaluation of blunt surgically relevant bowel and/or mesenteric injuries (BMIs) using single specific CT signs together with specific pairs of nonspecific signs. METHODS Fifty-four patients examined with MDCT were divided into two groups: a 'surgical' group of 20 patients-which underwent surgery for blunt BMIs-and a control group of 34 'nonsurgical' trauma patients. Two radiologists with different experience performed a double-blind retrospective evaluation of the images, classifying the patients in the two groups by using only single specific signs; then, the images were reviewed in consensus with a third radiologist and sensitivity and specificity were calculated. Subsequently, the frequency of every single sign and of every possible combination of nonspecific signs in the two groups was registered, to find combinations present only in the surgical group; sensitivity and specificity were calculated by using even those specific combinations. RESULTS At the first consensual evaluation, sensitivity and specificity were 75 and 100%, respectively. Two combinations of nonspecific signs (focal wall thickening + extraluminal air; focal wall thickening + seat belt sign) were found only in surgical patients that did not present any single specific sign: Sensitivity calculated adding those two combinations was 95%, without a decrease in specificity. CONCLUSIONS MDCT is an accurate technique in the evaluation of blunt surgically relevant BMIs. The single specific CT signs were sufficient for the diagnosis in only 75% of the cases; adding the two specific combinations allowed an increase in sensitivity of 20%.
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Affiliation(s)
- Valeria Molinelli
- Department of Radiology, University Hospital, Viale Borri 57, Varese, Italy.
| | - Simona Iosca
- Department of Radiology, University Hospital, Viale Borri 57, Varese, Italy
| | - Ejona Duka
- Department of Radiology, University Hospital, Viale Borri 57, Varese, Italy
| | - Giuseppe De Marchi
- Department of Radiology, University Hospital, Viale Borri 57, Varese, Italy
| | - Natalie Lucchina
- Department of Radiology, University Hospital Maggiore, Largo Nigrisoli 2, Bologna, Italy
| | - Elena Bracchi
- Department of Radiology, University Hospital, Luigi Sacco, Via Grassi 74, Milan, Italy
| | - Giulio Carcano
- Department of Surgery, University Hospital, Viale Borri 57, Varese, Italy
| | - Raffaele Novario
- Department of Medical Physics, University Hospital, Viale Borri 57, Varese, Italy
| | - Carlo Fugazzola
- Department of Radiology, University Hospital, Viale Borri 57, Varese, Italy
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Firetto MC, Sala F, Petrini M, Lemos AA, Canini T, Magnone S, Fornoni G, Cortinovis I, Sironi S, Biondetti PR. Blunt bowel and mesenteric trauma: role of clinical signs along with CT findings in patients’ management. Emerg Radiol 2018; 25:461-467. [PMID: 29700647 DOI: 10.1007/s10140-018-1608-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/18/2018] [Indexed: 01/09/2023]
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Park HC, Kim JW, Kim MJ, Lee BH. Outcomes of selective surgery in patients with suspected small bowel injury from blunt trauma. Ann Surg Treat Res 2018; 94:44-48. [PMID: 29333425 PMCID: PMC5765277 DOI: 10.4174/astr.2018.94.1.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/07/2017] [Accepted: 06/13/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose The role of initial conservative therapy with selective surgery for patients with suspected blunt bowel injury by radiologic evaluation is less clear. The aim of the study is to assess the outcomes of patients who received initial conservative therapy with selective delayed surgery, compared to emergency surgery. Methods During this 8-year study, a total of 77 patients who were hemodynamically stable were enrolled, in which computed tomography verified suspected bowel injury from blunt trauma (mesenteric hematoma, mesenteric fat infiltration, bowel wall thickening, and free fluid without solid organ injury) was managed with either initial conservative therapy with selective delayed surgery (group A; n = 42) or emergency surgery (group B; n = 35). The clinical outcomes including the rate of negative or nontherapeutic exploration and postoperative complications, between the groups were compared. Results The enrolled patients had a mean age of 41 years including 51 men and 26 women. No difference in the clinical characteristics was found between the groups. In group A, 18 patients underwent delayed surgery and 24 recovered without surgery. Among patients who underwent surgery, 3 (17%) underwent negative or nontherapeutic explorations. In group B, 13 (37%) underwent negative or nontherapeutic explorations. Postoperative complications occurred in 21 patients and there was no difference between the groups. Conclusion Initial conservative therapy with selective delayed surgery did not increased severe postoperative complications and had a low rate of negative or nontherapeutic surgical explorations in hemodynamically stable patients with suspected blunt bowel injury.
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Affiliation(s)
- Hyoung-Chul Park
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jong Whan Kim
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Min Jeong Kim
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Bong Hwa Lee
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Johnston LR, Wind G, Bradley MJ. Duodenal trauma. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408616684866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Duodenal trauma represents a unique challenge to the surgeon due to its relative rarity, anatomic location, and often the difficulty in diagnosing and managing these injuries. Despite these challenges, significant advances have been made over the previous century, and mortality has fallen to as low as 17%. The CT scan is the primary modality for diagnosis in the blunt trauma patient, and thorough surgical exploration at laparotomy is the mainstay for penetrating injuries. Management is guided by the grade of injury, with low-grade hematomas managed by observation, intermediate grade injuries by primary repair, and high-grade injuries with a damage control surgery approach. While pyloric exclusion remains the most common technique to augment primary repair in intermediate and higher grade injuries, the utility of this procedure has come into question in current literature, and an overall ‘less-is-more’ surgical approach has been advocated in recent publications. Complications following duodenal trauma are common and include fistulae, duodenal obstruction, and infectious complications. However, the overall morbidity and mortality have improved with these injuries. Future investigation is needed to determine the optimal management approach for these challenging patients.
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Affiliation(s)
- Luke R Johnston
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
| | - Gary Wind
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Matthew J Bradley
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
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Patlas MN. Invited Commentary on “Multidetector CT of Surgically Proven Blunt Bowel and Mesenteric Injury”. Radiographics 2017; 37:625-627. [DOI: 10.1148/rg.2017160183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael N. Patlas
- Department of Radiology, Hamilton General Hospital Hamilton, Ontario, Canada
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Peritoneal fluid of low CT Hounsfield units as a screening criterion for traumatic bowel perforation. Jpn J Radiol 2017; 35:145-150. [PMID: 28091837 DOI: 10.1007/s11604-017-0613-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate whether peritoneal fluid of low CT Hounsfield units is an important screening criterion for traumatic bowel perforation. MATERIALS AND METHODS We performed a retrospective study on two cohorts of blunt trauma patients who had peritoneal fluid. Intravenous and oral contrast was used for the first cohort (61 patients) as opposed to intravenous contrast only for the second cohort (60 patients). We compared the CT Hounsfield units of peritoneal fluid with bowel perforation. The optimal cutoff value of CT Hounsfield units was determined, and its diagnostic values for bowel perforation were calculated. RESULTS The mean CT Hounsfield units (HU) of peritoneal fluid with bowel perforation were significantly lower (30.3 ± 9.0 versus 44.1 ± 13.6 HU, p = 0.008) in the second cohort. The optimal cutoff value was 43 HU, and its sensitivity, specificity, accuracy and positive likelihood ratio were 100.0, 69.2, 73.3% and 3.3, respectively, for bowel perforation. Comparisons of CT HUs of peritoneal fluid with bowel perforation in the first cohort that used additional oral contrast for CT did not show statistically significant differences. CONCLUSION Peritoneal fluid of low CT HU is a sensitive and important CT screening criterion for traumatic bowel perforation.
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16
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Are We Missing Traumatic Bowel and Mesenteric Injuries? Can Assoc Radiol J 2016; 67:420-425. [DOI: 10.1016/j.carj.2015.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/27/2015] [Accepted: 11/10/2015] [Indexed: 11/22/2022] Open
Abstract
Purpose Traumatic bowel and mesenteric injury (TBMI), although an uncommon entity, can be lethal if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the detection of TBMI in patients at our level 1 trauma centre. Methods We used our hospital's trauma registry to identify patients with a diagnosis of TBMI from January 1, 2006, to June 30, 2013. Only patients who had a 64-slice MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in the study cohort. Using the surgical findings as the gold standard, the accuracy of prospective radiology reports was analyzed. Results Of the 4781 trauma patients who presented to our institution, 44 (0.92%) had surgically proven TBMI. Twenty-two of 44 were excluded as they did not have MDCT before surgery. The study cohort consisted of 14 males and 8 females with a median age of 41.5 years and a median injury severity score of 27. In total 17 of 22 had blunt trauma and 5 of 22 had penetrating injury. A correct preoperative imaging diagnosis of TBMI was made in 14 of 22 of patients. The overall sensitivity of the radiology reports was 63.6% (95% confidence interval [CI]: 41%-82%), specificity was 79.6% (95% CI: 67%-89%), PPV was 53.9% (95% CI: 33%-73%), and the NPV was 85.5% (95% CI: 73%-94%). Accuracy was calculated at 75.3%. However, only 59% (10 of 17) of patients with blunt injury had a correct preoperative diagnosis. Review of the findings demonstrated that majority of patients with missed blunt TBMI (5 of 7) demonstrated only indirect signs of injury. Conclusion The detection of TBMI in trauma patients on 64-slice MDCT can be improved, especially in patients presenting with blunt injury. Missed cases in this population occurred because the possibility of TBMI was not considered despite the presence of indirect imaging signs. The prospective diagnosis of TBMI remains challenging despite advances in CT technology and widespread use of 64-slice MDCT.
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Verma N, Pham JD, Linnau KF. Core curriculum illustration: blunt trauma to the bowel. Emerg Radiol 2016; 24:109-111. [PMID: 27757729 DOI: 10.1007/s10140-016-1455-5] [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: 10/04/2016] [Accepted: 10/11/2016] [Indexed: 12/01/2022]
Abstract
This is the 22nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .
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Affiliation(s)
- Nupur Verma
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, FL, 32610-0374, USA.
| | - John D Pham
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, FL, 32610-0374, USA
| | - Ken F Linnau
- Department of Radiology, University of Washington, Seattle, WA, USA
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de Araújo ROMB, de Matos MP, Penachim TJ, Pereira BMT, Mantovani MEDF, Rizoli S, Fraga GP. Jejunum and ileum blunt trauma: what has changed with the implementation of multislice computed tomography? Rev Col Bras Cir 2016; 41:278-84. [PMID: 25295990 DOI: 10.1590/0100-699120140040010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/15/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate the impact of the new technology of multidetector computed tomography (MDCT) in improving the accuracy and early diagnosis of BSBI. METHODS patients with blunt small bowel injuries (BSBI) grade> I were identified retrospectively and their CT scans reviewed by an experienced radiologist. Clinical and tomographic findings were analyzed and patients grouped as "pre-MDCT" and "post-MDCT", according to the time of implementation of a 64-slice MDCT. RESULTS of the 26 patients with BSBI 16 had CT scans. Motor vehicle collision (62.5%) was the most frequent mechanism of injury. In the pre-MDCT period, five of the 13 patients (38.5%) had abdominal CT, and in the post-MDCT, 11 of 13 patients (84.6%) had the exam. During pre-MDCT, all CT scans were abnormal with findings of pneumoperitoneum (60%), free fluid (40%) and bowel wall enhancement (20%). In the post-MDCT group, all exams but one were abnormal and the most frequent findings were free fluid (90.9%), bowel wall enhancement (72.7%), and pneumoperitoneum (54.5%). However, the rate of delayed laparotomy did not change. The mortality rate in both groups were similar, with 20% during pre-MDCT and 18.2% during post-MDCT. CONCLUSION the use of MDCT in abdominal trauma in our service has increased the sensibility of the diagnosis, but has had no impact on outcome so far.
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Affiliation(s)
| | | | - Thiago José Penachim
- Department of Radiology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | | | - Sandro Rizoli
- Department of Surgery and Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Gustavo Pereira Fraga
- Departmentof Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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Abstract
Mesenteric hematomas may present as a radiologic finding after blunt abdominal trauma that may be associated with surgically significant mesenteric and/or bowel injury. The question of whether to operate or not to operate on patients with mesenteric hematoma remains a topic of debate, especially with the improved imaging technology. This study sought to identify clinical and radiological characteristics for patient selection for operative management (OM) of mesenteric hematoma. A retrospective review of 33 adults with blunt abdominal trauma and mesenteric hematoma on CT scan (2009–2012) was performed. Patients with other intra-abdominal injuries, penetrating trauma, isolated gastric hematoma, contrast extravasation, extraluminal air, and Glasgow Coma Scale < 14 were excluded. Patients requiring surgical treatment within 24 hours of admission were compared with those who did not using chi-squared test, Fisher's exact test, and t test. Parameters included age, gender, race, Glasgow Coma Scale, vital signs, pain, tenderness, ecchymosis, Injury Severity Score, length of stay, and inhospital mortality. Logistic regression was used to determine positive associations with OM. Of the 33 patients, 19 underwent OM and 14 did not. Both groups were similar at baseline. Regression analysis revealed association for pain [odds ratio (OR) = 9.6, confidence interval (CI) = 1.8–49.9, P < 0.01], tenderness (OR = 32, CI = 4.6–222.2, P < 0.01), and free fluid (OR = 10.3, CI = 1.8–60, P < 0.01) with need for operative intervention. Nonoperative management patients had 100 per cent success rate. Of the OM patients, 100 per cent underwent therapeutic laparotomies. Findings of mesenteric hematoma on CT scan in examinable patients with no abdominal pain, tenderness, or free fluid predict successful nonoperative management.
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CT imaging signs of surgically proven bowel trauma. Emerg Radiol 2016; 23:213-9. [DOI: 10.1007/s10140-016-1380-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 01/26/2016] [Indexed: 11/25/2022]
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Faget C, Taourel P, Charbit J, Ruyer A, Alili C, Molinari N, Millet I. Value of CT to predict surgically important bowel and/or mesenteric injury in blunt trauma: performance of a preliminary scoring system. Eur Radiol 2015; 25:3620-8. [DOI: 10.1007/s00330-015-3771-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 03/24/2015] [Accepted: 04/03/2015] [Indexed: 11/28/2022]
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Steenburg SD, Petersen MJ, Shen C, Lin H. Multi-detector CT of blunt mesenteric injuries: usefulness of imaging findings for predicting surgically significant bowel injuries. ACTA ACUST UNITED AC 2014; 40:1026-33. [DOI: 10.1007/s00261-014-0262-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Swaid F, Peleg K, Alfici R, Matter I, Olsha O, Ashkenazi I, Givon A, Kessel B. Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database. Injury 2014; 45:1409-12. [PMID: 24656303 DOI: 10.1016/j.injury.2014.02.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 02/12/2014] [Accepted: 02/20/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. METHODS A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. RESULTS Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. CONCLUSIONS The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.
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Affiliation(s)
- Forat Swaid
- General Surgery Department, Bnai-Zion Medical Center, Haifa, Israel.
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Ricardo Alfici
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ibrahim Matter
- General Surgery Department, Bnai-Zion Medical Center, Haifa, Israel
| | - Oded Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | | | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel
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A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients. Int J Surg 2014; 12:340-5. [PMID: 24486932 DOI: 10.1016/j.ijsu.2014.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 12/04/2013] [Accepted: 01/16/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To develop a scoring tool based on clinical and radiological findings for early diagnosis and intervention in hemodynamically stable patients with traumatic bowel and mesenteric injury (TBMI) without obvious solid organ injury (SOI). METHODS A retrospective analysis was conducted for all traumatic abdominal injury patients in Qatar from 2008 to 2011. Data included demographics and clinical, radiological and operative findings. Multivariate logistic regression was performed to analyze the predictors for the need of therapeutic laparotomy. RESULTS A total of 105 patients met the inclusion criteria with a mean age of 33 ± 15. Motor Vehicle Crashes (58%) and fall (21%) were the major MOI. Using Receiver operating characteristic curve, Z-score of >9 was the cutoff point (AUC = 0.98) for high probability of the presence of TBMI requiring surgical intervention. Z-Score >9 was found to have sensitivity (96.7%), specificity (97.4%), PPV (93.5%) and NPV (98.7%). Multivariate regression analysis found Z-score (>9) to be an independent predictor for the need of exploratory laparotomy (OR7.0; 95% CI: 2.46-19.78, p = 0.001). CONCLUSION This novel tool for early diagnosis of TBMI is found to be simple and helpful in selecting stable patients with free intra-abdominal fluid without SOI for exploratory Laparotomy. However, further prospective studies are warranted.
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Park MH, Shin BS, Namgung H. Diagnostic performance of 64-MDCT for blunt small bowel perforation. Clin Imaging 2013; 37:884-8. [DOI: 10.1016/j.clinimag.2013.06.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/25/2013] [Accepted: 06/11/2013] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Despite the availability of more accurate imaging modalities, specifically multidetector computed tomography (MDCT), the diagnosis of non-ischemic (NI-) and ischemic (I-) blunt hollow viscus and mesenteric injury (BHVMI) remains challenging. We hypothesized that BHVMI can be still missed with newer generations of MDCT and that patients with I-BHVMI have a poorer outcome than those with NI-BHVMI. METHODS We performed an eight-year retrospective review at a level 1 trauma center. Ischemic-BHVMI was defined as devascularization confirmed at laparotomy. Non-ischemic-BHVMI included perforation, laceration, and hematoma without devascularization. The sensitivity of each generation of MDCT for BHVMI was calculated. Potential predictors and outcomes of I-BHVMI were compared to the NI-BHVMI group. RESULTS Of 7,875 blunt trauma patients, 67 patients (0.8 %) were included in the BHVMI group; 13 patients did not have any CT findings suggestive of BHVMI (sensitivity 81 %), and 11 of them underwent surgical intervention without delay (<5 h). Newer generations of MDCT were not associated with higher sensitivity. Patients with I-BHVMI had a significantly higher rate of delayed laparotomy ≥ 12 h (23 % versus 2 %; p = 0.01) and a significantly longer length of hospital stay (median 14 versus 9 days; p = 0.02) than those with NI-BHVMI. CONCLUSIONS Even using an advanced imaging technique, the diagnosis of I-BHVMI can be delayed, with significant negative impact on patient outcome.
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Bège T, Chaumoître K, Léone M, Mancini J, Berdah SV, Brunet C. Blunt bowel and mesenteric injuries detected on CT scan: who is really eligible for surgery? Eur J Trauma Emerg Surg 2013; 40:75-81. [PMID: 26815780 DOI: 10.1007/s00068-013-0318-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is no consensually accepted approach to the management of blunt bowel and mesenteric injuries. Surgery is required urgently in the case of bowel perforation or haemodynamic instability, but several patients can be treated non-operatively. This study aimed to identify the risk factors for surgery in an initial assessment. METHODS We retrospectively reviewed the medical charts and computed tomography (CT) scans of adult patients presenting with a blunt abdominal trauma to our centre between the years 2004 and 2011. We included only patients with a CT scan showing suspected injury to the mesentery or bowel. RESULTS There were 43 patients (33 males and 10 females), with a mean Injury Severity Score (ISS) of 22. The most frequently suspected injuries based on a CT scan were mesenteric infiltrations in 40 (93 %) patients and bowel wall thickening in 22 (51 %) patients. Surgical therapy was required for 23 (54 %) patients. Four factors were independently associated with surgical treatment: a free-fluid peritoneal effusion without solid organ injury [adjusted odds ratio (OR) = 14.4, 95 % confidence interval (CI) [1.9-111]; p = 0.015], a beaded appearance of the mesenteric vessels (OR = 9 [1.3-63]; p = 0.027), female gender (OR = 14.2 [1.3-159]; p = 0.031) and ISS >15 (OR = 6.9 [1.1-44]; p = 0.041). Surgery was prescribed immediately for 11 (26 %) patients and with delay, after the failure of initially conservative treatment, for 12 (28 %) patients. The presence of a free-fluid peritoneal effusion without solid organ injury was also an independent risk factor for delayed surgery (OR = 9.8 [1-95]; p = 0.048). CONCLUSIONS In blunt abdominal trauma, the association of a bowel and/or mesenteric injury with a peritoneal effusion without solid organ injury on an initial CT scan should raise the suspicion of an injury requiring surgical treatment. Additionally, this finding should lead to a clinical discussion of the benefit of explorative laparotomy to prevent delayed surgery. However, these findings need validation by larger studies.
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Affiliation(s)
- T Bège
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France. .,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France.
| | - K Chaumoître
- Department of Radiology, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - M Léone
- Department of Anesthesia and Resuscitation, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - J Mancini
- Department of Public Health and Medical Information, APHM Timone, Aix-Marseille University, 13006, Marseille, France
| | - S V Berdah
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France
| | - C Brunet
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France
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Abstract
The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention.
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Affiliation(s)
- Jorge A Soto
- Department of Radiology, Boston University Medical Center, FGH Building, 3rd Floor, 820 Harrison Ave, Boston, MA 02118, USA.
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Multi detector computed tomography in the diagnosis of bowel injury. Indian J Surg 2012; 74:445-50. [PMID: 24293897 DOI: 10.1007/s12262-011-0405-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 12/22/2011] [Indexed: 10/14/2022] Open
Abstract
Bowel Injuries are uncommonly associated with traumatic abdominal injuries. However, they are associated with significant morbidity and mortality and require operative intervention unlike solid organ injuries. Hence, early diagnosis is of paramount importance. Computed tomographic (CT) scan is a well-established and highly accurate imaging modality for the detection of solid organ injury after blunt abdominal trauma. However, its role in diagnosing hollow viscus injury remains controversial. The aim of our study was to analyze the accuracy of multidetector CT (MDCT) in the diagnosis of bowel injury. Imaging features of surgically proven cases of bowel injury were identified over 8-year period (i.e., from January 2003 to December 2010) and were retrospectively analyzed. There were 32 patients with age range of 3-90 years. There was only one female. Sensitivity of various CT signs specific to bowel injury (i.e., extravasation of contrast and discontinuity of bowel wall) was 15.62, and 28.12%, respectively. While that of signs suggestive of bowel injury were pneumoperitoneum, 62.5%; gas in the vicinity, 40.62%; bowel wall hematoma, 21.87%; bowel wall thickening, 75%; ascites, 78.12%; mesenteric hematoma, 46.87%; and mesenteric stranding, 40.62%. Based on the major and minor signs, a diagnosis of bowel injury could be made in all patients except one. The minor signs showed a higher sensitivity than the major signs. Hence, we recommend that multidetector CT should be used as the modality of choice in case of patients with suspected bowel injury. We also suggest that the minor signs should be given as much importance as the major signs.
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Salepcioglu H, Bertin C, Riou B. Lésion non hémorragique au cours d’un traumatisme abdominal fermé. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-010-0007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Minimally invasive techniques have now become standard for the treatment of many surgical conditions in children. During the past decade, there has been increasing interest in the use of this technology for the management of injured children. Laparoscopy has become an important adjunct in the evaluation of both blunt and penetrating intra-abdominal trauma and frequently is both diagnostic and therapeutic. Laparoscopic techniques have been used to repair injuries involving the gastrointestinal tract, solid organs, and the diaphragm. These procedures have been performed successfully, and avoid the complications associated with formal laparotomy.
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Affiliation(s)
- Barbara A Gaines
- Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh/UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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Tan KK, Liu JZ, Go TS, Vijayan A, Chiu MT. Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma. Injury 2010; 41:475-8. [PMID: 19836018 DOI: 10.1016/j.injury.2009.09.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 09/18/2009] [Accepted: 09/18/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Computed tomographic (CT) scans have become invaluable in the management of patients with blunt abdominal trauma. No clear consensus exists on its role in hollow viscus injuries (HVI) and mesenteric injuries (MI). The aim of this study was to correlate operative findings of HVI and MI to findings on pre-operative CT. METHODS All patients treated for blunt abdominal trauma at Tan Tock Seng Hospital from January 2003 to January 2008 were reviewed. CT scans were only performed if the patients were haemodynamically stable and indicated. All scans were performed with intravenous contrast using a 4-slice CT scanner from 2003 to December 2004 and a 64-slice CT scanner from January 2005 onwards. All cases with documented HVI/MI that underwent both CT scans and exploratory laparotomy were analysed. RESULTS Thirty-one patients formed the study group, with median age of 40 (range, 22-65) years and a significant male (83.9%) predominance. Vehicular-related incidents accounted for 67.7% of the injuries and the median Injury Severity Score (ISS) was 13 (4-50). The 2 commonest findings on CT scans were extra-luminal gas (35.5%) and free fluid without significant solid organ injuries (93.5%). During exploratory laparotomy, perforation of hollow viscus (51.6%) occurred more frequently than suspected from the initial CT findings of extra-luminal gas. Other notable findings included haemoperitoneum (64.5%), and mesenteric tears (67.7%). None of our patients with HVI and MI had a normal pre-operative CT scan. CONCLUSION Our study suggests that patients with surgically confirmed HVI and MI found at laparotomy were very likely to have an abnormal pre-operative CT scan. Unexplained free fluid was a very common finding in blunt HVI/MI and is one major indication to consider exploratory laparotomy.
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Affiliation(s)
- Ker-Kan Tan
- TTSH-NNI Trauma Centre, Tan Tock Seng Hospital, Singapore.
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Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med 2009; 17:13. [PMID: 19267941 PMCID: PMC2663535 DOI: 10.1186/1757-7241-17-13] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 03/08/2009] [Indexed: 12/04/2022] Open
Abstract
Diagnostic peritoneal lavage (DPL) is a highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus, but is performed less frequently today due to the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT). All three of these exams have advantages and disadvantages and thus each still play unique roles in the evaluation of abdominal trauma. Since DPL is performed less frequently today, a review of its indications, technique, and interpretation is pertinent.
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Affiliation(s)
- Jill S Whitehouse
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI 53226, USA.
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