Abdominal trauma: a disease in evolution

Operative and non-operative treatment of injury to solid abdominal organs in adult patients: a single center experience

BACKGROUND

In major trauma, lesions of the parenchymatous organs are subject of a controversy as regards the choice between an operative management (OM) in the operating room and a non-operative management (NOM) associated or not with angiography/angioembolization (AG/AE).

METHODS

Retrospective study of all consecutive data of patients coded as "traumatic pathology" in the period between 2011 and 2021. Were enrolled 13740 entries of adult patients with abdominal injuries, including at least: either hepatic or splenic or renal injury of AAST-OIS I. The primary outcome was to establish the rate of efficacy, respectively of OM and NOM. The secondary outcome is to analyze General (CG) and Specific (CS) complications, mean ward and intensive care unit (ICU) hospital stays.

RESULTS

One hundred sixty-two patients were included with 89 splenic injuries, 70 hepatic and 50 renal lesions; 35 treated with OM and 127 with NOM±AG/AE. The CGs registered in OM patients are seven (20%); seven SCs (20%); four GCs+SCs (11.4%). The average hospital stay was 24.91 days; mean ICU hospital stay of 10.74; five deaths. The CGs registered are 22 (17%); 12 SCs (9.4%); three GCs+SCs (2.3%). Average hospital stays 18 days; mean ICU hospital stay of 3.15; 6 deaths. Failure of the NOM strategy was recorded in nine patients with a success rate of 92.91%.

CONCLUSIONS

In OM the presence of numerous high-grade lesions leads to a rapid stabilization. The NOM has reduced the hospital stay and UTI hospitalization in a feasible and safe way in selected CT.

An evaluation of the "Obesity Paradox" in isolated blunt abdominal trauma in the United States

BACKGROUND

The obesity paradox theorizes a survival benefit in trauma patients secondary to the cushioning effect of adiposity. We aim to evaluate the impact of body mass index (BMI) on abdominal injury severity, morbidity, and mortality in adults with isolated, blunt abdominal trauma in the United States.

METHODS

We reviewed the National Trauma Data Bank (2013-2021) for adults sustaining isolated, blunt abdominal trauma stratified by BMI. We performed a doubly robust, augmented inverse-propensity weighted multivariable logistic regression to estimate the average treatment effect (ATE) of BMI on mortality and the presence of abdominal organ injury.

RESULTS

36,350 patients met the inclusion criteria. In our study, 41.4 % of patients were normal-weight (BMI 18.5-24.9), 20.6 % were obese (BMI 30-39.9), and 4.7 % were severely obese (BMI≥40). In these cohorts, the abdominal abbreviated injury scale (AIS) was 2 (2 -3). Obese and severely obese patients had significantly reduced presence of pancreas, spleen, liver, kidney, and small bowel injuries. The predicted probability of abdominal AIS severity decreased significantly with increasing BMI. Crude mortality was significantly higher in obese (1.3 %) and severely obese patients (1.3 %) compared to normal-weight patients (0.7 %). Obese and severely obese patients demonstrated non-statistically significant changes in the mortality of +26.4 % (ATE 0.264, 95 %CI -0.108-0.637, p = 0.164) and +55.5 % (ATE 0.555, 95 %CI -0.284-1.394, p = 0.195) respectively, compared to normal weight patients.

CONCLUSION

BMI may protect against abdominal injury in adults with isolated, blunt abdominal trauma. Mortality did not decrease in association with increasing BMI, as this may be offset by the increase in co-morbidities in this population.

Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management

BACKGROUND

Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging.

OBJECTIVE

We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM.

MATERIALS AND METHODS

This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications.

RESULTS

Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05).

CONCLUSION

Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.

Evaluation of management of CT scan proved solid organ injury in blunt injury abdomen-a prospective study

BACKGROUND

Trauma especially road traffic injury is one of the major health-related issues throughout the world, especially in developing countries like India (Mattox 2022). Solid organ injury is the most common cause of morbidity and mortality in patients with blunt abdominal trauma. The non-operative management (NOM) is being consistently followed for hemodynamically stable patients with respect to solid organ injuries. This study aims to provide an evidence base for management modalities of solid organ injuries in blunt abdominal trauma.

AIM

The aim of this study is to evaluate the effectiveness of various treatment modalities for solid organ injury in blunt abdominal trauma.

OBJECTIVES

Evaluating the characteristics of blunt abdominal injury with respect to age and gender; distribution, mode of injury, most common organ injured, and severity of injury; effect of delay in getting treatment on the management outcome for patients with solid organ injury; evaluating the various modalities of treatment of CT-proven solid organ injury; incidence of complications in different modes of treatment.

METHODS

All patients aged more than 18 years and suffering from CT-proven solid organ injury secondary to blunt abdominal trauma between February 2021 and September 2022 were included in this prospective observational study. Sixty-five patients were enrolled in the study after meeting the inclusion criteria. Details such as age, gender, mechanism of injury, the time between injury to first hospital contact, presenting complaints, organ and grade of injury, Revised Trauma Score (RTS), Trauma Score and Injury Severity Score (TRISS), management, and outcomes were collected using self-designed pro forma and analyzed. Different modalities of treatment were evaluated and patients undergoing operative and non-operative management were compared. Patients in whom non-operative management failed were compared with patients with successful non-operative management.

RESULTS

The mean age of patients involved were 36.8 years with a male:female ratio of 7.125:1 and the most common age group affected being between 21 and 30 years. The most common mode of injury was noted to be road traffic accidents (72.3%). The most common presenting complaints were abdominal pain (64.6%) followed by chest pain (29.2%) and vomiting (13.8%). There was no significant relationship between latent period and type of intervention or failure of non-operative management. FAST positivity rate was noted to be 92.3%. Chronic alcoholism and bronchial asthma were significant predictors for patients undergoing upfront surgery (p = 0.003 and 0.006 respectively). The presence of pelvic and spine injury was statistically significant for predicting mortality in polytrauma patients (p = 0.003). Concurrent adrenal injury was found in 24.6% of patients but was not related to failure of non-operative management or mortality. RTS significantly predicts the multitude of organ involvement (p = 0.015). The liver was the most common organ injured (60%) followed by the spleen (52.3%) and the kidney (20%). The liver and the spleen (9.2%) were noted to be the most common organ combination involved. No specific organ or organ injury combination was noted to predict failure of non-operative management or mortality. But the multitude of organ involvement was statistically significant for predicting patients undergoing upfront surgery (p = 0.011). Out of 65 patients enrolled in the study, 7 patients (10.8%) underwent immediate surgery, and 58 patients (89.2%) underwent non-operative management. Among the 68 chosen for non-operative management, 6 patients (9.2%) failed non-operative management and 52 patients (80%) had success of non-operative management. A significant drop in hemoglobin (83.3%) on day 1 (66.6%) was seen to be the commonest reason for failure of non-operative management. The spleen was noted to be the most commonly involved organ intra-operatively (61.5%) followed by the liver (30.8%). Concordance between pre-operative and intra-operative grading of organ injuries was highest for liver and kidney injuries (100%) and lowest for pancreatic injuries (0%). Requirement of blood transfusion and liver injuries were significant factors for failure of non-operative management (p = 0.012 and 0.045 respectively). The presence of pancreatic leak was significant between the non-operated patients and patients operated upfront (p = 0.003). Mortality was noted to be 10.8% (7 patients) in our study.

CONCLUSION

Solid organ injury in blunt abdominal trauma is an important cause of morbidity and mortality. RTS was noted to be a good predictor for solid organ injury in blunt abdominal trauma. Pancreatic injuries are notorious for being under-staged on CT findings; hence, the need arises for multimodality imaging for suspected pancreatic injuries. Non-operative management is a successful modality of treatment for majority of patients suffering from multiple solid organ injuries in blunt abdominal trauma provided serial close monitoring of patient's clinical signs and hemoglobin is instituted along with the presence of an emergency surgery team.

Abdominal versus pelvic gunshot injuries in terms of postoperative outcomes: A cohort representing the experience of 406 cases in seven years

Objectives

Gunshot injuries have become a significant problem globally. This study aimed to assess the differences between abdominal versus pelvic gunshot injuries in terms of postoperative outcomes to determine which type of injury is more lethal.

Material and Methods

This was a cohort study carried out to compare patients who had abdominal versus pelvic gunshot injuries, to analyse the differences in the impact of the anatomical site of injury on morbidity, mortality, and disabilities in all patients who had been admitted to the hospital due to torso gunshot injuries from February 2011 to December 2018.

Results

During the study period, 406 patients suffered from torso gunshot injuries. 391 were males and 15 were females; 343 (84.4%) patients had abdominal gunshot wounds, which were considered the first group, while in the second group, there were 63 (15.6%) patients who had pelvic gunshot wounds In the first group, 328 (95.6%) patients required urgent explorative laparotomy, complications were observed in 83 (24.2%) patients, while re-operations were reported in 51 (14.9%) patients and 11 (3.2%) patients had permanent functional disabilities, and 46 (13.4%) patients passed away. In the second group, all patients were treated with urgent explorative laparotomy, 17 (27%) patients suffered from complications, re-operation occurred in 13 (20.6%) patients, permeant functional disability occurred in 17 (27%) patients, and mortality was seen in 16 (25.4%) patients.

Conclusion

Our clinical experience has shown that mortality rates and long-term disability occur at a higher rate in pelvic gunshot injuries therefore early senior surgeon input is mandatory for the potential poor outcome to be minimized.

The effect of transarterial embolization and nephrectomy on acute kidney injury in patients with blunt renal trauma: An American College of Surgeons - Trauma Quality Improvement Program analysis

INTRODUCTION

Transarterial embolization (TAE) or nephrectomy for patients with blunt renal trauma might result in acute kidney injury (AKI). Thus, we analyzed the American College of Surgeons - Trauma Quality Improvement Program (TQIP) to validate this. We hypothesized that nephrectomy, and not TAE, would be a risk factor for AKI in patients with blunt renal trauma.

MATERIAL AND METHODS

Adult patients with blunt injuries from the TQIP between 2017 and 2019 were eligible for inclusion. The patients were divided into three treatment groups: conservative treatment, TAE, and nephrectomy. Multivariable logistic regression was used to clarify the AKI predictors.

RESULTS

The study included 12,843 patients, wherein 12,373 (96.3 %), 229 (1.8 %), and 241 (1.9 %) patients were in the conservative, TAE, and nephrectomy groups, respectively. A total of 269 (2.2 %), 20 (8.7 %), and 29 (12.0 %) patients had AKI in the three groups, respectively. Both TAE (odds ratio [OR], 2.367; 95 % confidence interval [CI], 1.372-3.900; p = 0.001) and Nephrectomy (OR, 2.745; 95 % CI, 1.629-4.528; p < 0.001) were a statistically significant predictor for AKI in the multivariable logistic regression.

CONCLUSIONS

TAE and nephrectomy were statistically associated with AKI in patients with blunt renal trauma. This result differs from our previous research findings that nephrectomy, but not TAE, was a risk factor for AKI in patients with blunt renal trauma. Further prospective and well-designed research may be needed.

Effects of a Laparotomy on Targeted Lipidomics Profiles in a Mouse Model of Surgical Stress During Aging

Laparotomy (EL) is one of the most common procedures performed among surgical specialties. Previous research demonstrates that surgery is associated with an increased inflammatory response. Low psoas muscle mass and quality markers are associated with increased mortality rates after emergency laparotomy. Analysis of lipid mediators in serum and muscle by using liquid chromatography-mass spectrometry (LC-MS)-based lipidomics has proven to be a sensitive and precise technique. In this chapter, we describe an LC-MS/MS protocol for the profiling and quantification of signaling lipids formed from Eicosapentaenoic Acid (EPA) and Eicosatetranoic acid (ETA) by 5, 12, or 15 lipoxynases. This protocol has been developed for and validated in serum and muscle samples in a mouse model of surgical stress caused by laparotomy.

The role of laparoscopy in closed abdominal injury

Objective

To investigate the effect of laparoscopy on the diagnosis and treatment of closed abdominal injury.

Methods

A total of 26 patients with closed abdominal injury admitted to our hospital from January 2016 to January 2019 were searched. All patients were treated by laparoscopy. All patient reports were made with the informed consent of the patients.

Results

All patients were diagnosed clearly during operation. Among them, there were 3 cases of gastric perforation, 2 cases of liver rupture, 13 cases of spleen rupture, 3 cases of small intestine rupture, 1 case of liver round ligament laceration, 2 cases of small mesenteric vascular laceration, 1 case of colon liver mesenteric laceration, and 1 case of retroperitoneal hematoma. Of the 26 patients in this group, 23 (88.5%) completed laparoscopically or laparoscopically assisted; 5 cases (19.3%) only performed laparoscopic exploration without special treatment, and 3 cases (11.5%) switched to laparotomy. The blood loss was 50-2000 ml (mean 500 ml), and the operative time was 60-180min (mean 128min). The length of hospital stay was 3-21 d (mean 9 d). There were no complications or deaths related to laparoscopy in the whole group. Conclusion Laparoscopic technique has the advantages of less trauma, high diagnosis rate and fast recovery. It can also be used for surgical treatment in the diagnosis and treatment of closed abdominal injury, so as to achieve the purpose of comprehensive diagnosis and treatment. The limitations of laparoscopy should also be noted.

Assessment of Frequency, Patterns, and Causes of Blunt Abdominal Trauma in a North Indian Cohort: An Autopsy-Based Study

Introduction The abdomen is one of the most frequently damaged areas in trauma patients and is commonly encountered in road traffic accidents (RTAs). The present study evaluates the frequency, etiology, causation, and form of injury in blunt abdominal trauma (BAT) cases who had autopsies. Method An autopsy-based observational prospective study was conducted at the Department of Forensic Medicine and Toxicology, Nalanda Medical College and Hospital Patna, India, during the period from October 2018 to September 2020, which included a total of 940 autopsy cases showing blunt abdominal injuries. A predesigned proforma for the postmortem evaluation of BAT victims was used to collect the required information on the cases. Descriptive statistics were performed, and the data were presented as frequency (%) and mean±SD. Chi-square tests were performed to compare categorical variables between groups. Results BAT accounted for 120 (12.76%) cases of all autopsies performed. The majority of victims were male (92.48%). Victims aged 21-30 years (31, 25.83%) were the ones most usually engaged in BAT cases. Among the mechanisms accountable for BAT, RTAs were the most common (99, 82.50%), followed by assault (16, 13.30%). In most of the cases, the liver was injured (107, 89.16%), followed by the spleen (60, 50.00%) and kidney (24, 20.00%). The majority of blunt abdominal injury-related deaths were accidental (100, 83.33%), followed by homicidal (15, 12.5%) and suicidal cases (5, 4.17%). Hemorrhage and neurogenic shock were the most prevalent causes of mortality, particularly if the individual died within a few hours. Conclusion RTAs are the most frequent cause of BAT in autopsy cases, and the liver is the most affected organ. The majority of deaths occur within the first 24 hours of injury. Since blunt abdominal injuries have the propensity to increase morbidity and mortality, appropriate emphasis on their precise diagnosis and satisfactory therapy is mandated.

Negative laparotomy rates and outcomes following blunt traumatic injury in the United States

INTRODUCTION

Exploratory laparotomy remains the mainstay of treatment following blunt abdominal trauma. However, the decision to operate can be difficult in hemodynamically stable patients with unreliable physical exams or equivocal imaging findings. The risk of a negative laparotomy and the subsequent complications must be weighed against the potential morbidity and mortality of a missed abdominal injury. Our study aims to evaluate trends and the effect of negative laparotomies on morbidity and mortality in adults with blunt traumatic injuries in the United States.

METHODS

We reviewed the National Trauma Data Bank (2007-2019) for adults with blunt traumatic injuries who underwent an exploratory laparotomy. Positive or negative laparotomy of abdominal injury was compared. We performed bivariate analysis and a modified Poisson regression to estimate the effect of negative laparotomy on mortality. A sub-analysis of patients who underwent computed tomography (CT) of the abdomen and pelvis was performed.

RESULTS

92,800 patients met the inclusion criteria of the primary analysis. Negative laparotomy rates were 12.0% in this population, down-trending throughout the study. Negative laparotomy patients had a significantly higher crude mortality (31.1% vs. 20.5%, p < 0.001), despite lower injury severity scores (20 (10-29) vs. 25 (16-35), p < 0.001) than positive laparotomy patients. Patients that underwent negative laparotomy had a 33% higher risk for mortality (RR1.33, 95% CI 1.28-1.37, P < 0.001) than positive laparotomy patients after adjusting for pertinent covariates. Patients that underwent CT abdomen/pelvis imaging (n = 45,654) had a lower rate of negative laparotomy (11.1%) and decreased difference in crude mortality (22.6% vs. 14.1%, p < 0.001) compared to positive laparotomy patients. However, the relative risk for mortality remained high at 37% (RR 1.37, 95% CI 1.29 - 1.46, p < 0.001) for this sub-cohort.

CONCLUSION

Negative laparotomy rates in adults with blunt traumatic injuries are trending down in the United States but remains substantial and may show improvement with increased use of diagnostic imaging. Negative laparotomy has a relative risk for mortality of 33% despite lower injury severity. Thus, surgical exploration in this population should be thoughtfully undertaken with appropriate evaluation via physical exam and diagnostic imaging to prevent unnecessary morbidity and mortality.

Multifaceted Analysis of the Environmental Factors in Severely Injured Trauma: A 30-Day Survival Analysis

(1) Background: Most factors that predict the in-hospital survival rate in patients with severe trauma are patient-related factors; environmental factors are not currently considered important. Predicting the severity of trauma using environmental factors could be a reliable and easy-to-use method. Therefore, the purpose of this study was to determine whether environmental factors affect the survival in patients with severe trauma. (2) Methods: Medical records of patients who activated trauma team in the single regional trauma center, from 2016 to 2020, were retrospectively analyzed. After exclusion of young patients (<19 years old), cases of mild trauma (ISS < 16), and non-preventable deaths (trauma and injury severity score <25%), a total of 1706 patients were included in the study. (3) Results: In the Cox proportional hazard regression analysis, older age, night compared with day, and high rainfall were identified as statistically significant environmental predictors of mortality due to severe trauma. The relationship between mortality and precipitation showed a linear relationship, while that between mortality and temperature showed an inverted U-shaped relationship. (4) Conclusions: Various environmental factors of trauma affect mortality in patients with severe trauma. In predicting the survival of patients with severe trauma, environmental factors are considered relatively less important, though they can be used effectively.

Introduction of Laparoscopy in an Urban High-Volume Sub-Saharan Trauma Centre

INTRODUCTION

Trauma is a major disease burden in low and middle-income countries like South Africa. Abdominal trauma is one of the leading reasons for emergency surgery. The standard of care for these patients is a laparotomy. In selected trauma patients, laparoscopy has both diagnostic and therapeutic usage. The trauma burden and the number of cases seen in a busy trauma unit make laparoscopy challenging.

AIM

We wanted to describe our journey with laparoscopy in the management of abdominal trauma in a busy urban trauma unit in Johannesburg, South Africa.

METHODS

We reviewed all trauma patients who underwent diagnostic laparoscopy (DL) or therapeutic laparoscopy (TL) between 01 January 2017 and 31 October 2020 for blunt and penetrating abdominal trauma. The demographic data, indications for laparoscopy, injuries identified, procedures performed, intraoperative laparoscopic complications, conversion to laparotomy, morbidity, and mortality were evaluated.

RESULTS

A total of 54 patients who had laparoscopy were included in the study. The median age was 29 years (IQR 25-25). Most injuries were penetrating 85.2% (n = 46/54) and 14.8% blunt trauma. Most patients were males, 94.4% (n = 51/54). Indications for laparoscopy included diaphragm evaluation (40.7%), pneumoperitoneum for evaluation of potential bowel injury (16.7%), free fluid with no evidence of solid organ injury (12.9%) and colostomy (5.5%). There were 8 (14.8%) cases converted to laparotomy. There were no missed injuries or mortality in the study group.

CONCLUSION

Laparoscopy in selected trauma patients is safe even in a busy trauma unit. It is associated with less morbidity and shortened hospital length of stay.

Severe left kidney laceration after minor fall in a patient with lumbar spine scoliosis

Background

The kidneys are one of the organs most commonly affected by blunt trauma; however, the anatomical variations that predispose kidney injury are poorly understood.

Case Presentation

An 80-year-old Japanese woman with lumber scoliosis was brought to our hospital because of severe flank pain after a minor fall at home. Contrast-enhanced computed tomography showed a severe left kidney laceration at the level of an acute angle in the vertebral column caused by scoliosis. Extravasation of contrast medium from the left renal artery branches was also noted. Selective arterial embolization achieved hemostasis. The patient was transferred to a rehabilitation facility without sequelae.

Conclusion

Patients with scoliosis could be at higher risk of severe kidney laceration because of intrusion of the vertebral column into the retroperitoneal space. Therefore, even after low-impact trauma, active exploration for kidney injury could be warranted in patients with spinal curvature disorders.

The Predictive Role of Systemic Inflammatory Markers in the Development of Acute Kidney Failure and Mortality in Patients with Abdominal Trauma

Background: Abdominal trauma is defined as a variety of injuries to the abdominal wall, solid or hollow intra-abdominal organs, and various intra-abdominal vessels. Recently, there has been a significant amount of interest in the establishment of a reliable biomarker that can predict the outcome in patients with an abdominal injury. The purpose of this study is to confirm the predictive role of inflammatory biomarkers and underlying risk factors and the risk of acute kidney insufficiency (AKI) developing and mortality in abdominal trauma patients; Materials and methods: The current study was intended as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with a diagnosis of abdominal trauma confirmed through a CT scan admitted to the County Emergency Clinical Hospital of Targu-Mureș, Romania between January 2017, and December 2021; Results: Non-survivor patients had a greater age (p = 0.02), as well as a higher prevalence of ischemic heart disease (IHD) (p = 0.007), history of myocardial infarction (MI) (p = 0.002), peripheral arterial disease (PAD) (p = 0.01), chronic kidney disease (CKD) (p = 0.01), and all risk factors (p = 0.0004 and p < 0.0001). In terms of injured organs, we have in the second group a higher incidence of kidney injury (p = 0.003) and hemoperitoneum (p = 0.008). Multivariate analysis showed a high baseline value for all inflammatory biomarkers that are independent predictors of adverse outcomes for all recruited patients. Furthermore, for all hospitalized patients, the history of MI (p = 0.03; p = 0.001; and p = 0.003), PAD (p = 0.01; p = 0.01; and p = 0.002), obesity (for all p < 0.0001), CKD (p < 0.001; p = 0.01; and p = 0.001), and kidney injury (p = 0.02; p = 0.004; and p = 0.01) were independent predictors of all outcomes. Moreover, IHD (p = 0.008 and p = 0.02), tobacco (p < 0.0001 and p = 0.02), and hemoperitoneum (p = 0.009 and p = 0.01) were predictors of mortality and composite endpoint, but not for AKI risk, as well as atrial fibrillation [AF] (p = 0.04) as predictors of the composite endpoint Conclusions: Higher monocyte to lymphocyte ratio (MLR), platelets to lymphocyte ratio (PLR), systemic inflammatory index (SII), neutrophil to lymphocyte ratios (NLR), aggregate inflammatory systemic index (AISI), and systemic inflammatory response index (SIRI) levels at admission, according to our data, highly predict AKI risk and death.

An unusual case of a traumatic splenic rupture masquerading as myocardial ischemia: a case report

Background

The spleen is one of the most frequently injured abdominal organs during trauma, which can result in intraperitoneal bleeding of life-threatening magnitude. Although splenic injury secondary to trivial trauma comprises a minor fraction of abdominal injuries, undiagnosed or delayed diagnosis may result in a complicated clinical course.

Case presentation

One such event is presented here, wherein a late diagnosis of an advanced grade splenic injury following a trivial trauma initially presented in disguise as acute myocardial ischaemia in a previously healthy South Asian woman in her late 30s. Emergency laparotomy and splenectomy were performed with simultaneous massive transfusion for a 3.5-L blood loss. She subsequently had an uncomplicated clinical course with regular surgical follow-up.

Conclusion

Splenic injuries might present with ambiguous symptoms such as atypical chest pain and shoulder pain, necessitating attending clinicians to have a high degree of suspicion, especially in busy units such as the emergency department (ED).

Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality patterns

PURPOSE

Abdominal injuries may occur in up to one-third of all patients who suffer severe trauma, but little is known about epidemiological trends and characteristics in a Northern European setting. This study investigated injury demographics, and epidemiological trends in trauma patients admitted with abdominal injuries.

METHODS

This was an observational cohort study of all consecutive patients admitted to Stavanger University Hospital (SUH) with a documented abdominal injury between January 2004 and December 2018. Injury demographics, age- and sex-adjusted incidence, and mortality patterns are analyzed across three time periods.

RESULTS

Among 7202 admitted trauma patients, 449 (6.2%) suffered abdominal injuries. The median age was 31 years, and the age increased significantly over time (from a median of 25 years to a median of 38.5 years; p = 0.020). Patients with ASA 2 and 3 increased significantly over time. Men accounted for 70% (316/449). The injury mechanism was blunt in 91% (409/449). Transport-related accidents were the most frequent cause of injury in 57% (257/449). The median Injury Severity Score (ISS) was 21, and the median New Injury Severity Score (NISS) was 25. The annual adjusted incidence of all abdominal injuries was 7.2 per 100,000. Solid-organ injuries showed an annual adjusted incidence of 5.7 per 100,000. The most frequent organ injury was liver injury, found in 38% (169/449). Multiple abdominal injuries were recorded in 44% (197/449) and polytrauma in 51% (231/449) of the patients. Overall 30-day mortality was 12.5% (56/449) and 90-day mortality 13.6% (61/449).

CONCLUSION

The overall adjusted incidence rate of abdominal injuries remained stable. Age at presentation increased by over a decade, more often presenting with pre-existing comorbidities (ASA 2 and 3). The proportion of polytrauma patients was significantly reduced over time. Mortality rates were declining, although not statistically significant.

Non-operative management of solid organ injuries in a middle-income country, how does it stack up?

INTRODUCTION

The first trauma surgery unit in Malaysia was established in 2011. After 10 years, we examine our experience in the management, and outcomes of blunt liver, spleen, and kidney injuries.

METHODS

This is a cross-sectional study of patients with blunt liver, spleen, and kidney injuries in a level 1 trauma centre in Malaysia between January 2018 to June 2021. Patients' characteristics, new injury severity score, organ-specific AAST injury score, type of primary management (operative management [OM], non-operative management [NOM]), causes of failed NOM, management of failed NOM, and outcome of treatment were recorded and analysed.

RESULTS

Among 448 patients, 83.9% were male and in the working-age range of 15-64 years old (93.5%). Road traffic crashes made up 92.0% of blunt trauma resulting in 65.5% of isolated organ injuries and 34.5% combined injuries. An overwhelming 84.2% of the patients had major trauma (NISS>15). Three hundred and thirty-four patients (74.6%) underwent initial non-operative management. Patients in the OM group showed lower mean GCS scores (p = 0.022) and higher NISS scores (p < 0.001). High-grade liver and kidney injuries were mostly treated with NOM (p < 0.001). In contradistinction, patients with high-grade spleen injuries had more OM performed (p < 0.001). NOM had been successful in 325 patients (97.3%) with 9 failures. Underlying causes for NOM failure were hemodynamic instability due to secondary bleeding and infectious complications. Overall mortality was 11.2%, which was significantly higher in the OM group (23.7%) than in the NOM group (6.9%).

CONCLUSION

This study represents one of the largest single centre experiences on the blunt liver, spleen, and kidney injuries in Malaysia and South-East Asia. With good selection and adequate resources, non-operative management of blunt liver, spleen, and kidney injuries is a safe and effective therapeutic approach with a high success rate of 97.3%, avoiding the morbidity of unnecessary laparotomies.

Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections

BACKGROUND

Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods.

PURPOSE

To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP.

MATERIAL AND METHODS

In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed.

RESULTS

A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections.

CONCLUSION

Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.

Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience

BACKGROUND

Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM.

METHODS

A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates.

RESULTS

Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001).

CONCLUSION

ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

Validity of the scoring system for traumatic liver injury: a generalized estimating equation analysis

Purpose: The scoring system for traumatic liver injury (SSTLI) was developed in 2015 to predict mortality in patients with polytraumatic liver injury. This study aimed to validate the SSTLI as a prognostic factor in patients with polytrauma and liver injury through a generalized estimating equation analysis. Methods: The medical records of 521 patients with traumatic liver injury from January 2015 to December 2019 were reviewed. The primary outcome variable was in-hospital mortality. All the risk factors were analyzed using multivariate logistic regression analysis. The SSTLI has five clinical measures (age, Injury Severity Score, serum total bilirubin level, prothrombin time, and creatinine level) chosen based on their predictive power. Each measure is scored as 0–1 (age and Injury Severity Score) or 0–3 (serum total bilirubin level, prothrombin time, and creatinine level). The SSTLI score corresponds to the total points for each item (0–11 points). Results: The areas under the curve of the SSTLI to predict mortality on post-traumatic days 0, 1, 3, and 5 were 0.736, 0.783, 0.830, and 0.824, respectively. A very good to excellent positive correlation was observed between the probability of mortality and the SSTLI score (γ=0.997, P<0.001). A value of 5 points was used as the threshold to distinguish low-risk (<5) from high-risk (≥5) patients. Multivariate analysis using the generalized estimating equation in the logistic regression model indicated that the SSTLI score was an independent predictor of mortality (odds ratio, 1.027; 95% confidence interval, 1.018–1.036; P<0.001). Conclusions: The SSTLI was verified to predict mortality in patients with polytrauma and liver injury. A score of ≥5 on the SSTLI indicated a high-risk of post-traumatic mortality.

Laparoscopy vs. Laparotomy for the Management of Abdominal Trauma: A Systematic Review and Meta-Analysis

Background

There is still no consensus regarding the role of laparoscopy in trauma cases. The purpose of this paper is to assess the value of diagnostic and therapeutic laparoscopy for patients with blunt or penetrating abdominal trauma by performing a systematic review and meta-analysis.

Methods

PubMed, Embase, and the Cochrane library were systemically searched for the randomized controlled trials (RCTs) and non-RCT comparative studies on effectiveness and safety of laparoscopy vs. laparotomy for the two authors independently performed the search, data extraction, and quality assessment.

Results

A total of 5,517 patients were enrolled in 23 eligible studies that were published in English. Meta-analysis results suggest that there is no significant difference in the incidence of missed injury and mortality between abdominal trauma patients receiving laparoscopy and those receiving laparotomy. Concerning postoperative complications, compared with patients in the open surgery group, those in the laparoscopy group are at a similar risk of intra-abdominal abscesses, thromboembolism, and ileus, while there is a decreased incidence of wound infection and pneumonia. Besides, patients in the laparoscopy group experience shorter hospitalization times and procedure times. For most outcomes, the sensitivity analysis yielded similar results to the primary analysis.

Conclusion

Laparoscopic surgery is a practical alternative to laparotomy for appropriate patients. The decision to perform laparoscopy should be based on the experience of the surgeon and the resources available.

Interventional radiology in renal emergencies: a pictorial essay

Renal emergencies necessitate prompt diagnosis and management to stop active bleeding and retain kidney function. Causes of renal emergencies can be classified into traumatic, atraumatic, iatrogenic, and obstructive etiologies. Interventional radiology (IR) has emerged as an acceptable alternative to surgical treatment in the management of renal emergencies due to its minimally invasive nature. With the rise of interventional procedures, there is a need for further discussion of angiographic and fluoroscopic imaging in the setting of renal emergencies.

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.

[Diagnosis and treatment of kidney damage following stab and blunt abdominal injuries]

OBJECTIVE

To improve treatment outcomes in victims with kidney damage following blunt and stab abdominal trauma by using of minimally invasive methods of diagnosis and treatment.

MATERIAL AND METHODS

About 1.2-3.5% of all victims arrived to the Dzhanelidze St. Petersburg Research Institute for Emergency Care have kidney injuries. We analyzed the results of treatment of 117 patients with isolated and combined blunt and stab abdominal injuries. The retrospective (2014-2017) group included 62 victims, and the prospective (2018-2021) group enrolled 55 patients who were treated according to the new algorithm. This algorithm included non-surgical and minimally invasive management for patients with systolic blood pressure >90 mm Hg after contrast-enhanced CT. Angiography with selective embolization was required for ongoing bleeding. We analyzed incidence of open interventions, organ-sparing procedures, complications, duration of treatment and mortality. Between-group differences were assessed using the χ² test and Student's test.

RESULTS

In both groups, kidney damage in most victims with abdominal trauma was due to road accident and catatrauma. Most patients had combined abdominal injuries, mainly in combination with head and chest lesions. Severity of injuries and clinical condition were similar in both groups. In the retrospective group, there were 9 laparotomies with nephrectomy. Nephrorraphy was performed in 8 cases, kidney vessel suture - in 4 patietns. In the prospective group, nephrectomy was performed in 3 patients with unstable hemodynamics and injuries AAST grade V. Nephrorraphy was performed in 4 victims. In one case, vascular suture was applied for tangential vein damage. All laparoscopies in both groups were diagnostic without nephrectomy. We used non-surgical treatment in 34 patients of the prospective group. One patient underwent angiography and selective embolization of renal artery branches. There were no significant between-group differences in the incidence of infectious and non-infectious complications. Mortality rate was 30.6% (n=19) and 27.3% (n=15) in the retrospective and prospective groups, respectively.

CONCLUSION

The proposed algorithm for kidney injury made it possible to reduce the incidence of laparoscopies and laparotomies by 2 times, preserve the damaged kidney in 94.5% of cases and avoid invasive treatment in 62% of victims.

Cost-effectiveness of splenic artery embolization versus splenectomy after trauma in the Netherlands

PURPOSE

To investigate the cost-effectiveness of SAE versus splenectomy from a societal perspective in the Netherlands.

MATERIALS AND METHODS

Patient-level data obtained from the XXX study were used to populate a health economic model and supplemented with expert opinion when necessary. Propensity score matching was used to correct for baseline differences in injury severity scores. The health economic model consisted of three health states (complications after intervention, SAE failure, and recovery) and a dead state. Model outcomes were incremental quality adjusted life years (QALYs) and incremental costs of SAE over splenectomy. Dutch health economic guidelines were followed. The model used a lifetime time horizon. Uncertainty was assessed using probabilistic sensitivity analysis and scenario analyses.

RESULTS

Patients receiving SAE had a higher life expectancy compared to patients receiving splenectomy. Incremental QALYs were 3.1 (mostly explained by difference in life expectancy) and incremental costs were €34,135 (explained by costs related to medical consumption and lost productivity in additional life years), leading to an incremental cost-effectiveness ratio of €11,010 per QALY. SAE was considered cost-effective in over 95% of iterations using a threshold of €20,000 per QALY.

CONCLUSION

SAE results in more QALYs than splenectomy. Intervention costs for SAE are lower than for splenectomy, but medical consumption and productivity costs in later years are higher for SAE due to better survival. SAE was found to be cost-effective compared to splenectomy under appropriate Dutch cost-effectiveness thresholds.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®

INTRODUCTION

Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma.

METHODS

Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene.

RESULTS

The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004).

CONCLUSION

DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

Lessons learned from blunt trauma abdomen: Surgical experience in level I trauma centre

Objective: The number of accident cases is increasing day by day, so as the challenges. With an emphasis on trauma care, the government started a 120 bedded level I trauma centre in northern India catering to a population of 2.8 million in June 2018. Through this article, we aimed to share our experience of blunt abdominal trauma management from a new level I trauma centre.

Material and Methods: In this retrospective observational study, historical analysis of all available records from July 2018 to March 2020 was done. Inclusion criteria included blunt trauma abdomen with or without associated injuries. Data regarding age, sex, mechanism of injury, time taken to reach the hospital, the pattern of solid organs and hollow viscus injuries, associated extra abdominal injuries, mode of treatment, complications, length of ICU and hospital stay, and mortality were reviewed.

Results: Overall, 154 cases sustained abdominal injuries during the study period. Seventy-five percent were male. The most common cause of blunt trauma abdomen was road traffic crashes. Operative management was required in 57 (37.01%) cases while 97(62.98%) were managed non-operatively (NOM). Mean ICU stay was 05.73 days, while the average hospital stay was 12 days (range 10-60 days). Procedures performed included splenectomy, liver repair, primary closure of bowel injury, and stoma formation. Complications occured in 16.88% cases and the overall mortality rate was 11.68%.

Conclusion: The study revealed that among 154 cases of fatal blunt abdominal trauma, road traffic crash was the most common cause of blunt abdominal trauma, predominantly affecting males. The visceral and peritoneal injury frequently perceived was liver in 40 cases (25.9%), spleen 66 (43%), intestine 21(13.6%) and kidney 13 cases (09%). Abdominal injury was associated with other injuries like head, chest and extremity injuries in 52.5% cases. Duration of injury, presence of associated injury and preoperative ventilation requirement were independent predictors of mortality apart from contributary factors such as clinical presentation, organ involved and presence of complications.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of active abdominopelvic bleeding in the polytraumatized patient

PURPOSE

An increasing number of polytraumatized patient presenting with active abdominal pelvic bleeding (APB) have been treated by endovascular selective embolization. However, reports on evaluate the efficacy, safety and complications caused by this technique have been limited. The aim of this study was to assess the safety and efficacy of embolization of APB using N-butyl cyanoacrylate glue (NBCA).

MATERIALS AND METHODS

Single center retrospective study, that included consecutive 47 patients presenting with traumatic APB treated by embolization with NBCA between January 2013 and June 2019. The efficacy endpoint was defined as the absence of contrast extravasation immediately after procedure and clinical stabilization in the following 24 h after procedure. Clinical stabilization was defined as no rebleeding after embolization or the need for a surgical approach until the patient is discharged. Safety endpoint were any technical or clinical complications related to the embolization procedure.

RESULTS

The mean age of patients was 38.6 years (3-81), with a predominance of males (87.2%). The major causal factor of APB being involvement in a car accident, accounting for 68% of cases. Of the 47 cases, 29.8% presented pelvic trauma and the remaining (70.2%) presented abdominal trauma. The efficacy rate was 100%, while no complications related to the procedure were observed. The mortality rate was 14.8% (7/47) due to neurologic decompensation and other clinical causes.

CONCLUSION

Endovascular embolization of traumatic abdominopelvic bleedings appear to be a highly safe and effective treatment, while avoiding emergent exploratory open surgeries.

Interventional Radiology in Renal Trauma

Traumatic injuries to the kidney and collecting system can range widely from small lacerations to significant bleeding and its sequelae. Urinary obstruction can occur in the renal pelvis, ureters, or urethra. Interventional radiology plays a significant role in treatment and management, in many cases requiring emergent action. Endovascular embolization is frequently the first-line approach to treating hemorrhage. Percutaneous interventions for urinary obstruction include nephrostomy and suprapubic catheter placement. In this article, we outline the clinical approach and interventional methods used in the evaluation and treatment of renal trauma. Several case presentations demonstrate the role of interventional radiology in renal trauma.

Performance validation of different trauma scoring systems among polytrauma patients having predominantly blunt abdominal trauma

Introduction

Blunt abdominal trauma substantially contributes to mortality and morbidity in patients with polytrauma. Appropriate clinical assessment is important in setups lacking facilities of advanced diagnostics (abdominal computed tomography scans and ultrasonography) to decide if the patients' needs exceed the facilities available. This study aimed to assess the utility of the commonly used trauma scores in predicting the outcome (favorable or unfavorable) in patients with predominantly blunt abdominal trauma.

Study Design and Methods

In this prospective observational study of 12-month duration, we calculated three scores (Glasgow Coma Scale [GCS], Revised Trauma Score [RTS], and Injury Severity Score [ISS]) in patients brought to emergency department and fulfilling the inclusion criteria. These patients were categorized into two categories (favorable and unfavorable) depending on their treatment outcome. The difference in the mean scores for both outcomes in each score was calculated and further inferences were obtained by using the unpaired t test. A receiver-operating characteristic curve for each score was drawn to understand the trade-off between sensitivity and specificity at each cutoff value and for determining area under curve (AUC) for all three scores.

Result

A total of 103 patients were recruited in the study (88 men and 15 women) with the mean age of 31.03 (±13.40) years and 34.47 (±18.04) years, respectively. The difference in the scores was maximum for ISS and minimal for RTS. The visual impression, as well as AUC values, shows that ISS performed well to discriminate between the favorable and unfavorable outcomes in each cutoff values (AUC -0.806, lower bound 0.678 to upper bound 0.934) compared to GCS and RTS scores. The Youden's J statistic for ISS value of 42 was maximum (0.298) and corresponding sensitivity and specificity were 0.651 and 0.647.

Conclusion

ISS is superior as compared to GCS and RTS in predicting outcome in polytrauma patients with a blunt abdominal injury. ISS value of <42 predicts a favorable outcome.

Trends and outcomes of blunt renal trauma management: a nationwide cohort study in Japan

Background

There is a paucity of information for predicting patient outcomes other than the American Association for the Surgery of Trauma (AAST) renal injury scale. The aim of this study was to evaluate the association between the patient characteristics and outcomes of patients with blunt renal trauma using a nationwide database in Japan.

Methods

We performed a retrospective analysis of the Japan Trauma Data Bank (JTDB) from 2004 to 2018. We identified patients with blunt renal trauma by AIS codes converted to AAST grades. We evaluated trends in patient characteristics and management and assessed factors associated with mortality and nephrectomy using a multivariable logistic regression analysis.

Results

We identified 3550 patients with blunt renal trauma. Their median age was 43 years and 74.2% were male. Nephrectomy was performed in 3.8%, and the overall mortality rate was 9.5%. We found increasing trends in age and emergency abdominal angiography and decreasing trends in nephrectomy and mortality over the 15-year period. The following factors were associated with mortality: age ≥ 65 years (adjusted OR 3.36); pedestrian accident (adjusted OR 1.94); fall from height (adjusted OR 1.91); shock on arrival (adjusted OR 4.02); concomitant injuries to the head/neck (adjusted OR 3.14), pelvis/lower-extremity (adjusted OR 1.59), liver (adjusted OR 1.68), spleen (adjusted OR 1.45), and gastrointestinal tract (adjusted OR 1.90); AAST grades III–V (adjusted ORs 1.42, 2.16, and 5.55); and emergency abdominal angiography (adjusted OR 0.70). The following factors were associated with nephrectomy: shock on arrival (adjusted OR 1.98), concomitant injuries to the thorax (adjusted OR 0.46) and spleen (adjusted OR 2.07), AAST grades III, IV, and V (adjusted ORs 18.40, 113.89, and 468.17), and emergency abdominal angiography (adjusted OR 0.28).

Conclusions

We demonstrated that the AAST grade and emergency angiography were associated with mortality and nephrectomy in blunt renal trauma in the Japanese population.

The Approach to the Patient with Hematuria

Hematuria is common; whether gross or microscopic, it is incumbent on emergency providers to consider life-threatening and benign processes when evaluating these patients. Most workup is driven by a focused history and physical, including laboratory studies and diagnostic imaging. The cause originates in the genitourinary tract and, as long as the patient remains stable, they can be discharged with close outpatient follow-up. The importance of this cannot be stressed enough because hematuria, especially in the elderly, frequently signals the presence of urologic malignancy. In addition, the workup occasionally yields a nongenitourinary tract cause, and these patients often require emergent management.

Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia

Background

Abdominal injury is among the major causes of trauma admissions. The aim was to determine etiology, commonly injured organs, indication and outcome of patients with abdominal injuries requiring laparotomy.

Methods

A retrospective study of all adult patients who underwent laparotomy for abdominal injury at St. Paul's Hospital Millennium Medical College was conducted from January 2014 to December 2016. The factors associated with outcome were identified with bivariate and multivariate logistic regressions.

Results

Laparotomy for abdominal injury was performed for 145 patients. Of these, 129 (89%) case records were retrieved. The male to female ratio was 6.2:1. The mean age was 29 years, and most of them were unemployed. Penetrating trauma was the commonest injury, stab (46, 35.7%) and Road Traffic Accidents (RTA) (27, 20.9%) being the leading causes. Extra-abdominal injuries were seen in 33.3% (46) of the cases. Hollow organs were commonly injured than solid organs. Small intestine (35, 43.8%) and Spleen (17, 34.7%) were the leading injured organs in penetrating and blunt respectively. The main procedure performed was repair of hollow and solid organ laceration/perforation (70,54.3%). The negative laparotomy rate was 4.6% (6). Complications were seen in 23(17.8%) patients, the commonest being irreversible shock (7,30.4%). The mortality rate was 8.5 % (11), and it was significantly associated with blunt abdominal injury (AOR=7.25; 95% CI 1.09–48.37; p=0.041) and systolic blood pressure<90mmHg (AOR=8.66; 95% CI 1.1–68.41; p=0.041).

Conclusion

Stab and RTA were the commonest indications of laparotomy. The mortality was significantly associated with blunt abdominal injury and hypotension (SBP<90mmHg).

The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience

This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in "Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona" and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.

Non-Operative Management of Blunt Liver Trauma: Safety, Efficacy and Complications of a Standardized Treatment Protocol

Objective:

To evaluate the safety and effectiveness of NOM (non-operative management) in the treatment of blunt liver trauma, following a standardized treatment protocol.

Methods:

All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS.

Results:

181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results.

Conclusion:

Non-operative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Autosomal dominant polycystic kidney disease and minimal trauma: medical review and case report

Background

Blunt abdominal trauma in the setting of polycystic kidney disease is still scantly described in the literature and management guidelines of such patients are not well-established.

Case presentation

The authors herein present a case of hypovolemic shock secondary to segmental renal artery bleed in a 75-year-old man with polycystic kidney disease after minimal blunt abdominal trauma, who underwent successful selective arterial embolization, and provide a thorough review of similar cases in the literature, while shedding the light on important considerations when dealing with such patients.

Conclusions

It is important to suspect renal injury in patients with pre-existing renal lesions irrespective of the mechanism of injury; and, vice-versa to suspect an underlying abnormality in patients with a clinical deterioration that’s out of proportion to the mechanism of injury.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0192-3) contains supplementary material, which is available to authorized users.

Abdominopelvic injuries due to road traffic accidents: Characteristics in a registry of 162,695 victims

OBJECTIVE

Road traffic accidents (RTAs) are the first cause of abdominopelvic injuries (APIs). The objective of this study was to describe the characteristics and severity of APIs due to traffic accidents in a large French trauma registry and to identify risk factors for API.

METHODS

All victims from the French Rhône registry of victims of RTAs were analyzed from 1996 to 2013. This registry contained data that were issued over a 20-year period from 245 medical departments, from prehospital care until re-adaptation, and forensic medicine departments. All APIs, defined as an injury between the diaphragm and the pelvic bone, were extracted and studied.

RESULTS

Among 162,695 victims, 10,165 had an API (6.7%). Accidents frequently involved young men and 2 cars. Mean Injury Severity Score (ISS) was 8.7. Mortality rate was 5.6%. Soft tissue injuries largely predominated (n = 6,388; 54.4% of patients). Overall, 2,322 victims had a pelvic bone injury. Internal abdominal organs were involved in 2,425 patients; the most frequent were the spleen, liver, and kidney. Wearing of the seat belt appeared to be a significant protective factor in API, including serious injuries. A partial analysis over the past 2 years among the most severe patients hospitalized in the intensive care unit indicated that nonoperative management was carried out in two thirds of the wounded. In uni- or multivariate analysis, sex, age, type of user, antagonist, time of occurrence, associated severe lesions, or wearing of the seat belt were statistically associated with the occurrence of API, highlighting a more dangerous user profile.

CONCLUSIONS

Abdominopelvic injuries concern a minority of road traffic injuries, but they are responsible for significant mortality. Large solid organs are the most frequently affected. Women drivers wearing a seat belt and driving in town during the day appear to be more protected against API.

An assessment of repeat computed tomography utilization in the emergency department in the setting of blunt trauma

PURPOSE

Computed tomography (CT) is a standard imaging modality utilized during the evaluation of trauma patients in the emergency department (ED). However, while it is common to utilize intravenous (IV) contrast as an adjunct, the use of multiple CT scans and how it impacts patient flow can lead to changes in patient management. Our objectives are to assess length of stay (LOS) and rates of acute kidney injury (AKI), when two CT scans of the abdomen/pelvis are performed compared to one CT scan.

METHODS

Data of trauma hospital encounters were retrospectively collected during a 5-year period at a large, level 1 trauma center. Encounters were categorized into patients who received one or two CT scans of the abdomen/pelvis, as well as if they had received IV contrast or not. CT scan reads were extracted from chart records, and groups were compared.

RESULTS

Of 5787 patient encounters, 5335 (93.4%) received IV contrast and 75 (1.3%) received two CT scans. Lower rates of AKI were associated with IV contrast (2.5 vs 12.5%). Receiving two CT scans was associated with increased rates of AKI (20.0 vs 3.0%; p < 0.0001), ICU admissions (88.0 vs 25.1%; p < 0.0001), and hospital LOS (21.9 vs 1.4 days; p < 0.0001). Of the repeat CT scans, 59.4% demonstrated no significant difference and did not require blood products or the operating room.

CONCLUSION

Two CT scans performed during blunt trauma encounters demonstrated mixed benefit and were associated with an increased hospital LOS. Additionally, IV contrast was associated with lower rates of AKI.

Spontaneous and Traumatic Splenic Rupture: Retrospective Clinical, B-Mode and CEUS Analysis in 62 Patients

Introduction

Both B-mode ultrasound and contrast-enhanced ultrasound (CEUS) are well established procedures when diagnosing traumatic splenic ruptures (TSR). To date, there are no data about CEUS patterns in spontaneous splenic ruptures (SSR). It remains unknown whether TSR and SSR differ with respect to clinical characteristics, B-mode and CEUS characteristics.

Patients and Methods

Between 12/2003 and 2/2010, n=33 SSRs and n=29 TSRs were diagnosed in a tertiary referral center. All patients were examined with B-mode and CEUS, and clinical data and the outcome were retrospectively analyzed.

Results

Patients with SSR were significantly older than patients with TSR (62 years vs. 44 years; p=0.01). The 4-week mortality was significantly higher in SSR than in TSR (36% vs. 0%; p=0.001). No differences between the grading of TSR and SSR could be shown in B-mode or in CEUS. Notably, CEUS was significantly superior to B-mode with respect to the grading of splenic ruptures (p=0.01). Therefore, therapeutic management was influenced by CEUS.

Conclusion

There are differences between SSR and TSR, especially concerning clinical data (age, course of disease and mortality). Regarding the sonographic pattern, SSR and TSR show identical grading. When splenic rupture is suspected, CEUS should always be performed to identify patients at risk who require interventional procedures.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

PREDICTIVE FACTORS OF THE INITIAL TREATMENT FOR 207 BLUNT RENAL TRAUMA CASES BASED ON THE CLASSIFICATION FOR RENAL INJURY OF JAPANESE ASSOCIATION FOR THE SURGERY OF TRAUMA 2008's VERSION

(Objective) We retrospectively investigated the applicability of the Japanese Association for the Surgery of Trauma (JAST) classification version 2008 for renal injuries as predictive factors of the initial treatment for 207 blunt renal injury cases. (Materials and methods) We reviewed 207 patients between 1982 and 2013 who were admitted to our institution with blunt renal trauma. Patients were classified as conservative management group, immediate transcatheter arterial embolization (TAE) group, and immediate nephrectomy group by initial treatment. We retrospectively assessed several parameters including JAST criteria version 2008 type of renal injury (type), severity of hematoma (H factor) and extravasation of urine (U factor), the shock on arrival, associated abdominal injuries, serum hemoglobin levels, and macrohematuria as predicting factors of initial treatment of blunt renal trauma. (Result) TypeIII and PV injuries, H2 factor and associated non-renal abdominal injuries were predictive factors of immediate nephrectomy (p=0.001, p=0.000, p=0.003). TypeIII and PV injuries and H2 factor were predictive factors of immediate TAE. Both of H2 and U2 factors were significant predictors of immediate nephrectomy in patients with typeIII injury. H factor was a significantly predictive factor of immediate TAE in patients with typeI/II injuries (p=0.040). The rate of immediate TAE has been increasing but the rate of partial nephrectomy except for nephrectomy has been decreasing since the year 2007 when TAE was immediately available in our hospital. (Conclusion) The type category and severity of hematoma of JAST classification version 2008 would be predictive factors of initial management of blunt renal injuries. Patients with typeIII injuries and both of H2 and U2 factors, can be adapted to immediate nephrectomy. Patients with typeI/II and H2 factors can be adapted to immediate TAE.

Laparoscopy in Blunt Abdominal Trauma: for Whom? When?and Why?

The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.

The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis

BACKGROUND

Splenic artery embolization (SAE) has been an effective adjunct to the Non-operative management (NOM) for blunt splenic injury (BSI). However, the optimal embolization techniques are still inconclusive. To further understand the roles of different embolization locations and embolic materials in SAE, we conducted this system review and meta-analyses.

METHODS

Clinical studies related to SAE for adult patients were researched in electronic databases, included PubMed, Embase, ScienceDirect and Google Scholar Search (between October 1991 and March 2013), and relevant information was extracted. To eliminate the heterogeneity, a sensitivity analysis was conducted on two reduced study sets. Then, the pooled outcomes were compared and the quality assessments were performed using Newcastle-Ottawa Scale (NOS). The SAE success rate, incidences of life-threatening complications of different embolization techniques were compared by χ² test in 1st study set. Associations between different embolization techniques and clinical outcomes were evaluated by fixed-effects model in 2nd study set.

RESULTS

Twenty-three studies were included in 1st study set. And then, 13 of them were excluded, because lack of the necessary details of SAE. The remaining 10 studies comprised 2nd study set, and quality assessments were performed using NOS. In 1st set, the primary success rate is 90.1% and the incidence of life-threatening complications is 20.4%, though the cases which required surgical intervention are very few (6.4%). For different embolization locations, there was no obvious association between primary success rate and embolization location in both 1st and 2nd study sets (P > 0.05). But in 2nd study set, it indicated that proximal embolization reduced severe complications and complications needed surgical management. As for the embolic materials, the success rate between coil and gelfoam is not significant. However, coil is associated with a lower risk of life-threatening complications, as well as less complications requiring surgical management.

CONCLUSIONS

Different embolization techniques affect the clinical outcomes of SAE. The proximal embolization is the best option due to the less life-threatening complications. For commonly embolic material, coil is superior to gelfoam for fewer severe complications and less further surgery management.

Imaging Genitourinary Trauma

Contrast-enhanced multidetector computed tomography (MDCT) has become a critical tool in the evaluation of the trauma patient. MDCT can quickly and accurately assess trauma patients for renal, ureteral, and bladder injuries. Moreover, CT guides clinical management triaging patients to those requiring discharge, observation, angioembolization, and surgery. Recognition of urinary tract trauma on initial scan acquisition should prompt delayed excretory phase imaging to identify urine leaks. Urethral and testicular trauma are imaged with retrograde urethrography and sonography, respectively.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

INTRODUCTION

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France.

METHODOLOGY

Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis.

RESULTS

One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM.

CONCLUSION

Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.