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Santos J, Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, 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, Grigorian A, Nahmias J. Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study. J Am Coll Surg 2023; 237:826-833. [PMID: 37703489 DOI: 10.1097/xcs.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.
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Affiliation(s)
- Jeffrey Santos
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Patrick T Delaplain
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
- Department of Surgery, Boston Children's Hospital/Harvard Medical System, Boston, MA (Delaplain)
| | - Erika Tay-Lasso
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Emily Switzer
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Caitlin K Robinson
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California Irvine, Irvine, CA (Kirby)
| | - Areg Grigorian
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Jeffry Nahmias
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
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Lansier A, Bourillon C, Cuénod CA, Ragot E, Follin A, Hamada S, Clément O, Soyer P, Jannot AS. CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma. Eur Radiol 2023; 33:1918-1927. [PMID: 36305900 DOI: 10.1007/s00330-022-09200-9] [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: 08/06/2022] [Revised: 08/06/2022] [Accepted: 09/22/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma. METHODS This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort. RESULTS CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI. CONCLUSIONS An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination. KEY POINTS • A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.
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Affiliation(s)
- Alexandre Lansier
- Department of Medical Imaging, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France.
| | - Camille Bourillon
- Department of Medical Imaging, Hôpital de la Croix Saint Simon, 75020, Paris, France
| | - Charles-André Cuénod
- Department of Medical Imaging, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France
| | - Emilia Ragot
- Department of Visceral Surgery, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
| | - Arnaud Follin
- Department of Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
| | - Sophie Hamada
- Department of Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
| | - Olivier Clément
- Department of Medical Imaging, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France.,Faculté de Médecine, Université Paris Cité, 75006, Paris, France
| | - Philippe Soyer
- Faculté de Médecine, Université Paris Cité, 75006, Paris, France.,Department of Radiology, Hôpital Cochin, AP-HP, 75014, Paris, France
| | - Anne-Sophie Jannot
- Faculté de Médecine, Université Paris Cité, 75006, Paris, France.,Department of Medical Informatics and Public Health, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France
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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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Kim HW, Park BR, Hong TH. Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.
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Diagnostic Accuracy of Computed Tomography for the Prediction of the Need for Laparotomy for Traumatic Hollow Viscus Injury: Systematic Review and Meta-Analysis. J Pers Med 2021; 11:jpm11121269. [PMID: 34945741 PMCID: PMC8708608 DOI: 10.3390/jpm11121269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI. METHOD A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models. RESULTS Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501-0.809) and 0.969 (95% CI: 0.920-0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011-0.071). CONCLUSION In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.
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Chen SA, Wang CY, Hsu CP, Lin JY, Cheng CT, Ouyang CH, Huang JF, Liao CH. The Current Diagnostic Accuracy on Free Peritoneal Fluid in Computed Tomography to Determinate the Necessity of Surgery in Blunt Bowel and Mesenteric Trauma-Systemic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11112028. [PMID: 34829375 PMCID: PMC8620381 DOI: 10.3390/diagnostics11112028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
Traumatic bowel mesenteric injury (TBMI) is a challenge in trauma care. The presence of free peritoneal fluid (FF) in computed tomography (CT) was considered the indication for surgical intervention. However, conservative treatment should be applied for minor injuries. We conduct a systematic review to analyze how reliable the FF is to assess the TBMI. Publications were retrieved by structured searching among databases, review articles and major textbooks. For statistical analysis, summary receiver operating characteristic curves (SROCs) were computed using hierarchical models. Fourteen studies enrolling 4336 patients were eligible for final qualitative analysis. The SROC line was created by a hierarchical summary receiver operating characteristic model. The summary sensitivity of FF to predict surgical TBMI was 0.793 (95% CI: 0.635-0.894), and the summary specificity of FF to predict surgical TBMI was 0.733 (95% CI: 0.468-0.896). The diagnostic odds ratio was 10.531 (95% CI: 5.556-19.961). This study represents the most robust evidence (level 3a) to date that FF is not the absolute but an acceptable indicator for surgically important TBMI. However, there is still a need for randomized controlled trials to confirm.
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Affiliation(s)
- Szu-An Chen
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chen-Yu Wang
- Department of Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan;
| | - Chih-Po Hsu
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Jia-Yen Lin
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chi-Tung Cheng
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Jen-Fu Huang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
| | - Chien-Hung Liao
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33328, Taiwan; (S.-A.C.); (C.-P.H.); (J.-Y.L.); (C.-T.C.); (C.-H.O.); (J.-F.H.)
- Correspondence: ; Tel.: +886-3281200 (ext. 3651)
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Tominaga GT, Crandall M, Cribari C, Zarzaur BL, Bernstein M, Kozar RA. Organ Injury Scaling 2020 update: Bowel and mesentery. J Trauma Acute Care Surg 2021; 91:e73-e77. [PMID: 34137742 DOI: 10.1097/ta.0000000000003319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gail T Tominaga
- From the Department of Surgery (G.T.T.), Scripps Memorial Hospital La Jolla, La Jolla, California; Department of Surgery (M.C.), University of Florida College of Medicine Jacksonville, Jacksonville, Florida; Department of Surgery (C.C.), University of Colorado, Denver, Colorado; Department of Surgery (B.L.Z.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Trauma & Emergency Radiology (M.B.), NYU Lagone Health Medical Centers/Bellvue Hospital, New York, New York; and Shock Trauma (R.A.K.), University of Maryland School of Medicine, Baltimore, Maryland
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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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Traumatic abdominal wall injuries-a primer for radiologists. Emerg Radiol 2020; 28:361-371. [PMID: 32827286 DOI: 10.1007/s10140-020-01842-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022]
Abstract
Traumatic abdominal wall injuries encompass a broad clinical and radiological spectrum and are identified in approximately 9% of blunt trauma patients. The most severe form of abdominal wall injury-a traumatic abdominal wall hernia-is seen in less than 1.5% of blunt abdominal trauma patients. However, the incidence of concurrent intra-abdominal injuries in these patients is high and can result in significant morbidity and mortality. Although the diagnosis of abdominal wall injuries is typically straight forward on CT, associated injuries may distract the interpreting radiologist in more subtle cases. Thus, it is important for the radiologist to identify abdominal wall injuries and their associated injuries on admission CT, as these injuries typically require surgical correction early in the course of their management. Untreated abdominal wall injuries subject the patient to increased risk of delayed bowel incarceration and strangulation. Therefore, it is important for the radiologist to be knowledgeable of injuries to the abdominal wall and commonly associated injuries to provide optimal patient triage and expedite management.
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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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11
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Filiberto DM, Afzal MO, Sharpe JP, Seger C, Shankar S, Croce MA, Fabian TC, Magnotti LJ. Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score. Eur J Trauma Emerg Surg 2020; 47:1813-1817. [PMID: 32300849 DOI: 10.1007/s00068-020-01371-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/06/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma. METHODS All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score. RESULTS 151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91). CONCLUSIONS CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.
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Affiliation(s)
- Dina M Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Muhammad O Afzal
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - John P Sharpe
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Catherine Seger
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sridhar Shankar
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Timothy C Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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12
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Zarrintan S. A commentary on "Findings requiring immediate surgery in blunt abdominal trauma patients with isolated free fluid without solid organ injury on abdominal computed tomography: Retrospective laboratory, clinical and radiologic analysis. A case control study" (Int. J. Surg. 2020; Epub ahead of print). Int J Surg 2020; 77:132-133. [PMID: 32247848 DOI: 10.1016/j.ijsu.2020.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sina Zarrintan
- Division of Vascular & Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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13
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Ghumman Z, Monteiro S, Mellnick V, Coates A, Engels P, Patlas M. Accuracy of Preoperative MDCT in Patients With Penetrating Abdominal and Pelvic Trauma. Can Assoc Radiol J 2020; 71:231-237. [DOI: 10.1177/0846537119888375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI). Method and Materials: We used our hospitals’ trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted. Results: Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system ( F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge. Conclusion: The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.
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Affiliation(s)
- Zonia Ghumman
- Department of Diagnostic Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Vincent Mellnick
- Department of Diagnostic Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angela Coates
- Department of Trauma and Surgery, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Paul Engels
- Department of Trauma and Surgery, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Michael Patlas
- Department of Diagnostic and Emergency Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
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14
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Delaplain PT, Barrios C, Spencer D, Lekawa M, Schubl S, Dosch A, Grigorian A, Smith M, Pejcinovska M, Nahmias J. The use of computed tomography imaging for abdominal seatbelt sign: A single-center, prospective evaluation. Injury 2020; 51:26-31. [PMID: 31706587 DOI: 10.1016/j.injury.2019.10.089] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/11/2019] [Accepted: 10/30/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Guidelines surrounding abdominal seat belt sign (SBS) were made prior to the use of modern computed tomography (CT) imaging. We sought to prospectively determine whether a negative CT scan is associated with the absence of hollow viscus injury (HVI), and we hypothesized that trauma patients with an abdominal SBS without CT imaging findings would not have a hollow viscus injury (HVI). METHODS A prospective cohort of patients with SBS was compiled over one year. Subjects were divided into those with and without HVI. Covariate distributions were summarized by group. Bivariate tests and logistic regression were used to investigate associations between covariates and HVI. RESULTS Of 220 patients with SBS, the incidence of HVI was 7% (n = 15). Radiographic findings were strongly associated with HVI and no patients with a negative CT scan had HVI. Free fluid was seen in 80% (12) of patients with HVI, whereas it was found in only 11% (23) without injury. A composite variable for negative CT scan was found to be associated with the absence of HVI: (Fisher's exact 1-tailed p, doubled = 0.014). CONCLUSION In this study, the incidence of HVI with SBS is lower than previously reported, and no patients with negative CT imaging required an operation for HVI-suggesting there is a population of patients with SBS who could be discharged from the emergency room. A prospective multicenter study is needed to confirm these findings.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, United States.
| | - Cristobal Barrios
- Division of Trauma, Burns and Critical Care, University of California, Irvine Medical Center, United States
| | - Dean Spencer
- Department of Surgery, University of California, Irvine Medical Center, United States
| | - Michael Lekawa
- Division of Trauma, Burns and Critical Care, University of California, Irvine Medical Center, United States
| | - Sebastian Schubl
- Division of Trauma, Burns and Critical Care, University of California, Irvine Medical Center, United States
| | - Austin Dosch
- Department of Surgery, University of California, Irvine Medical Center, United States
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine Medical Center, United States
| | - Megan Smith
- Center for Statistical Consulting, University of California, Irvine, United States
| | - Marija Pejcinovska
- Center for Statistical Consulting, University of California, Irvine, United States
| | - Jeffry Nahmias
- Division of Trauma, Burns and Critical Care, University of California, Irvine Medical Center, United States
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15
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Liao CH, Hsieh FJ, Chen CC, Cheng CT, Ooyang CH, Hsieh CH, Yang SJ, Fu CY. The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey. J Clin Med 2019; 8:jcm8091300. [PMID: 31450573 PMCID: PMC6780049 DOI: 10.3390/jcm8091300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/01/2019] [Accepted: 08/22/2019] [Indexed: 11/28/2022] Open
Abstract
Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.
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Affiliation(s)
- Chien-Hung Liao
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Feng-Jen Hsieh
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chun-Hsiang Ooyang
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Shang-Ju Yang
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and emergency surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan.
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16
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Stefanou CK, Stefanou SK, Tepelenis K, Flindris S, Tsiantis T, Spyrou S. A big mesenteric rupture after blunt abdominal trauma: A case report and literature review. Int J Surg Case Rep 2019; 61:56-59. [PMID: 31336242 PMCID: PMC6656956 DOI: 10.1016/j.ijscr.2019.06.041] [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: 03/21/2019] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION A blunt abdominal trauma especially in organs less commonly injured (such as small bowel and mesentery injury), are difficult to diagnose. PRESENTATION OF CASE We report a case of a blunt abdominal trauma, in a 43 year old male presented in the Emergency Department after a truck vehicle accident. He sustained a chest injury, a pelvic fracture and diffuse abdominal tenderness. The patient had tachycardia (120 pulses/min) and normal blood pressure (120/90mmHg). The computed tomography (CT) showed only free fluid. We placed two chest tubes (due to pneumothorax and hemothorax at both sides) and the patient went to the operating room (OP). An external pelvic osteosynthesis was performed first and then we did an exploratory laparotomy, which revealed a big mesenteric rupture. Finally, an enterectomy (circa 2m) with a fist stage side to side anastomosis was performed. DISCUSSION Mesentery and bowel injury constitutes 3-5% of blunt abdominal injuries. The main diagnostic challenge is to identify lesions that require surgery. Diagnostic delay over 8h can lead to high morbidity and mortality rates. Laparotomy is the standard of care in hemodynamically unstable patients. CONCLUSION In polytrauma cases with abdominal pain and unclear CT findings the decision to proceed with exploratory laparotomy is better than a conservative treatment, because any surgical delay can lead to severe complications.
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Affiliation(s)
- Christos K Stefanou
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece.
| | - Stefanos K Stefanou
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
| | - Kostas Tepelenis
- Department of Surgery, Filiates General Hospital, Mpempi 1, 45600 Filiates, Greece
| | - Stefanos Flindris
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
| | - Thomas Tsiantis
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
| | - Spyridon Spyrou
- Department of General Surgery, General Hospital of Ioannina "G. Chatzikosta", Makriyianni Avenue 1, 45001 Ioannina, Greece
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17
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Lannes F, Scemama U, Maignan A, Boyer L, Beyer-Berjot L, Berdah SV, Chaumoître K, Leone M, Bège T. Value of early repeated abdominal CT in selective non-operative management for blunt bowel and mesenteric injury. Eur Radiol 2019; 29:5932-5940. [PMID: 31025065 DOI: 10.1007/s00330-019-06212-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI). METHODS This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test). RESULTS Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94). CONCLUSION In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment. KEY POINTS • Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. • An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.
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Affiliation(s)
- F Lannes
- Aix-Marseille University, Marseille, France. .,Department of General Surgery, APHM, CHU Nord, Marseille, France.
| | - U Scemama
- Aix-Marseille University, Marseille, France.,Department of Radiology, APHM, CHU Nordz, Marseille, France
| | - A Maignan
- Aix-Marseille University, Marseille, France.,Department of General Surgery, APHM, CHU Timone, Marseille, France
| | - L Boyer
- Aix-Marseille University, Marseille, France.,Public Health and Chronic Disease Research Unit, APHM, CHU Timone, Marseille, France
| | - L Beyer-Berjot
- Department of General Surgery, APHM, CHU Nord, Marseille, France.,LBA UMR T24, Aix-Marseille University, Marseille, France
| | - S V Berdah
- Department of General Surgery, APHM, CHU Nord, Marseille, France.,LBA UMR T24, Aix-Marseille University, Marseille, France
| | - K Chaumoître
- Aix-Marseille University, Marseille, France.,Department of Radiology, APHM, CHU Nordz, Marseille, France
| | - M Leone
- Aix-Marseille University, Marseille, France.,Department of Anesthesiology and Reanimation, APHM, CHU Nord, Marseille, France
| | - T Bège
- Department of General Surgery, APHM, CHU Nord, Marseille, France.,LBA UMR T24, Aix-Marseille University, Marseille, France
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18
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Abdel-Aziz H, Dunham CM. Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review. Am J Surg 2018; 218:201-210. [PMID: 30201138 DOI: 10.1016/j.amjsurg.2018.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/02/2018] [Accepted: 08/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial. DATA SOURCES A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI. CONCLUSIONS Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.
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Affiliation(s)
- Hiba Abdel-Aziz
- Department of Surgical Education, Northeast Ohio Medical University, 4209 State Route 44, Rootstown, OH, USA.
| | - C Michael Dunham
- Trauma/Neuroscience Research Department, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, USA.
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19
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Bennett AE, Levenson RB, Dorfman JD. Multidetector CT Imaging of Bowel and Mesenteric Injury: Review of Key Signs. Semin Ultrasound CT MR 2018; 39:363-373. [DOI: 10.1053/j.sult.2018.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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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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21
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Dattwyler M, Bodanapally UK, Shanmuganathan K. Blunt Injury of the Bowel and Mesentery. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0276-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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22
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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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Zingg T, Agri F, Bourgeat M, Yersin B, Romain B, Schmidt S, Keller N, Demartines N. Avoiding delayed diagnosis of significant blunt bowel and mesenteric injuries: Can a scoring tool make the difference? A 7-year retrospective cohort study. Injury 2018; 49:33-41. [PMID: 28899564 DOI: 10.1016/j.injury.2017.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury. PATIENTS AND METHODS Single-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed. RESULTS For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66). CONCLUSIONS Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.
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Affiliation(s)
- Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Mylène Bourgeat
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Bertrand Yersin
- Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Benoît Romain
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Department of Digestive Surgery, Strasbourg University Hospital, 1 Avenue Molière, 67000 Strasbourg, France
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nathalie Keller
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland
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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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Bates DDB, Wasserman M, Malek A, Gorantla V, Anderson SW, Soto JA, LeBedis CA. Multidetector CT of Surgically Proven Blunt Bowel and Mesenteric Injury. Radiographics 2017; 37:613-625. [DOI: 10.1148/rg.2017160092] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- David D. B. Bates
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
| | - Michael Wasserman
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
| | - Anita Malek
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
| | - Varun Gorantla
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
| | - Stephan W. Anderson
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
| | - Jorge A. Soto
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
| | - Christina A. LeBedis
- From the Departments of Radiology (D.D.B.B., M.W., V.G., S.W.A., J.A.S., C.A.L.) and Pathology (A.M.), Boston University Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118
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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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Abstract
Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.
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Affiliation(s)
- T Bège
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - C Brunet
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - S V Berdah
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
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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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Iaselli F, Mazzei MA, Firetto C, D'Elia D, Squitieri NC, Biondetti PR, Danza FM, Scaglione M. Bowel and mesenteric injuries from blunt abdominal trauma: a review. Radiol Med 2015; 120:21-32. [PMID: 25572542 DOI: 10.1007/s11547-014-0487-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/12/2014] [Indexed: 12/01/2022]
Abstract
The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.
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Affiliation(s)
- Francesco Iaselli
- Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domitiana, Km 30, 81100, Castel Volturno, Italy,
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Barnett RE, Love KM, Sepulveda EA, Cheadle WG. Article Commentary: Small Bowel Trauma: Current Approach to Diagnosis and Management. Am Surg 2014. [DOI: 10.1177/000313481408001217] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rebecca E. Barnett
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky; and
| | - Katie M. Love
- Virginia Tech Carilion School of Medicine, Carilion Clinic, Roanoke, Virginia
| | | | - William G. Cheadle
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
- Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky; and
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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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Fu CY, Liao CA, Liao CH, Kang SC, Wang SY, Hsu YP, Lin BC, Yuan KC, Kuo IM, Ouyang CH. Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures. Am J Emerg Med 2014; 32:553-7. [PMID: 24666741 DOI: 10.1016/j.ajem.2014.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 02/05/2014] [Accepted: 02/10/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Transcatheter arterial embolization (TAE) is usually necessary in the management of hemodynamically unstable patients with concomitant pelvic fractures. Given the critical conditions of such patients, TAE is at times performed only according to the results of a primary evaluation without computed tomographic (CT) imaging. Therefore, the evaluation of associated intra-abdominal injuries (IAIs) might be insufficient. Clinically, some patients have required post-TAE laparotomy due to further deterioration. In this study, we attempted to determine a feasible protocol for post-TAE observation. MATERIALS AND METHODS This study focused on patients who received TAE to achieve hemostasis of retroperitoneal hemorrhage and who did not undergo CT imaging due to their unstable hemodynamics. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. We also analyzed the effects of the timing of post-TAE CT imaging on patients with IAIs requiring surgery. RESULTS A total of 41 patients were enrolled in the study. Of these patients, all of whom underwent primary TAE without preprocedure CT imaging; 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Comparisons between the 2 patient groups revealed no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P=.480), loss of consciousness (66.7% vs 73.1%, P=.730), or abdominal symptoms (20.0% vs 23.1%, P=1.000). CONCLUSION In the management of hemodynamically unstable patients with concomitant pelvic fractures, greater attention should be paid to associated IAIs. Early CT imaging is encouraged after the patient's hemodynamic status is stabilized with TAE.
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Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Chien-An Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Shang-Yu Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Yu-Pao Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Being-Chuan Lin
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Kuo-Ching Yuan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - I-Ming Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
| | - Chun-Hsiang Ouyang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kwei Shan Township, Taoyuan, Taiwan.
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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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