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Ishida T, Iwasaki Y, Yamamoto R, Tomita N, Shinohara K, Kawamae K, Yamauchi M. Evaluation of the Impact of a Less-Invasive Trunk and Pelvic Trauma Protocol on Mortality in Patients with Severe Injury by Interrupted Time-Series Analysis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1338. [PMID: 39202619 PMCID: PMC11356191 DOI: 10.3390/medicina60081338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/09/2024] [Accepted: 08/14/2024] [Indexed: 09/03/2024]
Abstract
Background and Objectives: Minimally invasive trauma management, including interventional radiology and non-operative approaches, has proven effective. Consequently, our hospital established a trauma IVR protocol called "Ohta Nishinouchi Hospital trauma protocol (ONH trauma protocol) in 2013, mainly for trunk trauma. However, the efficacy of the ONH trauma protocol has remained unverified. We aimed to assess the protocol's impact using interrupted time-series analysis (ITSA). Materials and Methods: This retrospective cohort study was conducted at Ohta Nishinouchi hospital, a tertiary emergency hospital, from January 2004 to December 2019. We included patients aged ≥ 18 years who presented to our institution due to severe trauma characterized by an Abbreviated Injury Scale of ≥3 in any region. The primary outcome was the incidence of in-hospital deaths per 100 transported patients with trauma. Multivariable logistic regression analysis was conducted with in-hospital mortality as the outcome, with no exposure before protocol implementation and with exposure after protocol implementation. Results: Overall, 4558 patients were included in the analysis. The ITSA showed no significant change in in-hospital deaths after protocol induction (level change -1.49, 95% confidence interval (CI) -4.82 to 1.84, p = 0.39; trend change -0.044, 95% CI -0.22 to 0.14, p = 0.63). However, the logistic regression analysis revealed a reduced mortality effect following protocol induction (odds ratio: 0.50, 95% CI: 0.37 to 0.66, p < 0.01, average marginal effects: -3.2%, 95% CI: -4.5 to -2.0, p < 0.01). Conclusions: The ITSA showed no association between the protocol and mortality. However, before-and-after testing revealed a positive impact on mortality. A comprehensive analysis, including ITSA, is recommended over before-and-after comparisons to assess the impact of the protocol.
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Affiliation(s)
- Tokiya Ishida
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, Fukushima 963-8558, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, Fukushima 963-8558, Japan
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Ryohei Yamamoto
- Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima 960-1295, Japan
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Nozomi Tomita
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, Fukushima 963-8558, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, Fukushima 963-8558, Japan
| | - Kaneyuki Kawamae
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, Fukushima 963-8558, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
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Ali SW, Salim A, Aslam U, Khalid S, Ashraf MS, Khan MAM. Multidisciplinary management of high-grade pediatric liver injuries. Eur J Trauma Emerg Surg 2024; 50:829-836. [PMID: 38240790 DOI: 10.1007/s00068-023-02439-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 12/28/2023] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To present our experience of multidisciplinary management of high-grade pediatric liver injuries. INTRODUCTION Pediatric high-grade liver injuries pose significant challenge to management due to associated morbidity and mortality. Emergency surgical intervention to control hemorrhage and biliary leak in these patients is usually suboptimal. Conservative management in selected high-grade liver injuries is now becoming standard of care. Management of hemobilia due to pseudoaneurysm formation and traumatic bile leaks requires multidisciplinary management. METHODS A retrospective review was undertaken for patients presenting with blunt liver injuries at two tertiary care centers in Karachi, Pakistan, from March 2021 to December 2022. Twenty-eight patients were identified, and four patients fulfilled the criteria for grade 4 and above blunt liver injury during this period. RESULTS One case with grade 4 liver injury developed hemobilia on 7th day of injury. He required two settings of angioembolization but had recurrent leak from pseudoaneurysm. He ultimately needed right hepatic artery ligation. Second patient presented with massive biliary peritonitis 2 days following injury. He was managed initially with tube laparostomy followed by ERCP and stent placement. The third patient developed large hemoperitoneum managed conservatively. One case with grade 5 injury expired during emergency surgery. CONCLUSION Conservative management of advanced liver injuries can result in significant morbidity and mortality due to high risk of complications. Trauma surgeons need to have multidisciplinary team for management of these patients to gain optimal outcome.
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Affiliation(s)
- Syed Waqas Ali
- Department of Pediatric Surgery, Dow University of Health Sciences, Karachi, Pakistan
| | - Areej Salim
- Department of Pediatric Surgery, Aga Khan University, Karachi, Pakistan
| | - Uzair Aslam
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Saad Khalid
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Muhammad Arif Mateen Khan
- Department of Pediatric Surgery, Dow University of Health Sciences, Karachi, Pakistan.
- Pediatric Surgery, Aga Khan University of Health Sciences, Karachi, Pakistan.
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Campbell B, Meyer CH, Novack JC, Kokabi N, Sciarretta J, Nguyen J. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta Aids in the Successful Non-Operative Management of a Life-Threatening Penetrating Liver Injury. Am Surg 2024; 90:1736-1739. [PMID: 38198603 DOI: 10.1177/00031348241227187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
In recent years, isolated non-operative management of penetrating liver injuries has become the standard of care for the hemodynamically stable patient. However, when the patient becomes hemodynamically unstable, adjuncts such as resuscitative endovascular balloon occlusion of the aorta (REBOA) deployed in Zone 1 can be used to achieve complete aortic occlusion from the celiac axis down. Unfortunately, hemorrhage control through REBOA comes at the risk of deadly intra-abdominal ischemia. Partial REBOA (pREBOA) introduces the opportunity to make targeted changes in volume and thus titrate the amount of aortic occlusion in real-time to adequately manage hemorrhage while allowing some distal blood flow. This is a novel approach and one which may give providers more time to gain definitive hemorrhage control while minimizing the morbidity of ischemia. Here, we present a case of life-threatening penetrating liver injury that was successfully managed non-operatively with the assistance of p-REBOA.
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Affiliation(s)
- Brandi Campbell
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - Courtney H Meyer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph C Novack
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Nima Kokabi
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jason Sciarretta
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan Nguyen
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
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Sarquis LM, Collaço IA, Toderke EL, Fontes HS, Nassif AT, Freitas ACTDE. Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality. Rev Col Bras Cir 2024; 51:e20243734. [PMID: 38808820 PMCID: PMC11185065 DOI: 10.1590/0100-6991e-20243734-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/18/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients. METHODS This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention. RESULTS A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention. CONCLUSION The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.
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Affiliation(s)
- Lucas Mansano Sarquis
- - Universidade Federal do Paraná, Clínica Cirúrgica - Curitiba - PR - Brasil
- - Complexo Hospitalar do Trabalhador, Cirurgia Geral e Cirurgia do Trauma - Curitiba - PR - Brasil
| | - Iwan Augusto Collaço
- - Complexo Hospitalar do Trabalhador, Cirurgia Geral e Cirurgia do Trauma - Curitiba - PR - Brasil
| | | | | | - André Tha Nassif
- - Universidade Federal do Paraná, Clínica Cirúrgica - Curitiba - PR - Brasil
| | - Alexandre Coutinho Teixeira DE Freitas
- - Universidade Federal do Paraná, Clínica Cirúrgica - Curitiba - PR - Brasil
- - Complexo Hospitalar do Trabalhador, Cirurgia Geral e Cirurgia do Trauma - Curitiba - PR - Brasil
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Orozco G, Gupta M, Ancheta A, Shah MB, Warriner Z, Marti F, Mei X, Desai S, Bernard A, Gedaly R. Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set. J Trauma Acute Care Surg 2024; 96:763-768. [PMID: 37994467 DOI: 10.1097/ta.0000000000004220] [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: 11/24/2023]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma. METHODS We used the UNOS data set to identify patients who underwent OLT for trauma from 1987 to 2022 and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival. RESULTS Seventy-two patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pretransplant portal vein thrombosis (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pretransplant portal vein thrombosis and prolonged length of stay. Trauma was associated with decreased overall graft survival (hazards ratio, 1.42; 95% confidence interval, 1.01-1.98), and increased length of stay ( p = 0.048). There were no significant differences in long-term patient survival. CONCLUSION Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Gabriel Orozco
- From the Division of Transplantation, Department of Surgery (G.O., M.G., A.A., M.B.S., F.M., X.M., S.D., R.G.), and Division of Acute Care Surgery, Trauma & Surgical Critical Care, Department of Surgery (Z.W., A.B.), University of Kentucky, Lexington, Kentucky
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Cheng CT, Ooyang CH, Kang SC, Liao CH. Applications of Deep Learning in Trauma Radiology: A Narrative Review. Biomed J 2024:100743. [PMID: 38679199 DOI: 10.1016/j.bj.2024.100743] [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: 11/13/2023] [Revised: 03/26/2024] [Accepted: 04/24/2024] [Indexed: 05/01/2024] Open
Abstract
Diagnostic imaging is essential in modern trauma care for initial evaluation and identifying injuries requiring intervention. Deep learning (DL) has become mainstream in medical image analysis and has shown promising efficacy for classification, segmentation, and lesion detection. This narrative review provides the fundamental concepts for developing DL algorithms in trauma imaging and presents an overview of current progress in each modality. DL has been applied to detect free fluid on Focused Assessment with Sonography for Trauma (FAST), traumatic findings on chest and pelvic X-rays, and computed tomography (CT) scans, identify intracranial hemorrhage on head CT, detect vertebral fractures, and identify injuries to organs like the spleen, liver, and lungs on abdominal and chest CT. Future directions involve expanding dataset size and diversity through federated learning, enhancing model explainability and transparency to build clinician trust, and integrating multimodal data to provide more meaningful insights into traumatic injuries. Though some commercial artificial intelligence products are Food and Drug Administration-approved for clinical use in the trauma field, adoption remains limited, highlighting the need for multi-disciplinary teams to engineer practical, real-world solutions. Overall, DL shows immense potential to improve the efficiency and accuracy of trauma imaging, but thoughtful development and validation are critical to ensure these technologies positively impact patient care.
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Affiliation(s)
- Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan Taiwan
| | - Chun-Hsiang Ooyang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan Taiwan
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan Taiwan.
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan Taiwan
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Beltzer C, Imach S, Wafaisade A, Lefering R, Kölbel B. Use of angioembolization, treatment modalities and mortality in association with blunt liver trauma in Germany - a data analysis of the TraumaRegister DGU®. Langenbecks Arch Surg 2023; 409:6. [PMID: 38093037 PMCID: PMC10719148 DOI: 10.1007/s00423-023-03196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Angioembolization (ANGIO) is highly valued in national and international guideline recommendations as a treatment adjunct with blunt liver trauma (BLT). The literature on BLT shows that treatment, regardless of the severity of liver injury, can be accomplished with a high success rate using nonoperative management (NOM). An indication for surgical therapy (SURG) is only seen in hemodynamically instable patients. For Germany, it is unclear how frequently NOM ± ANGIO is actually used, and what mortality is associated with BLT. METHODS A retrospective systematic data analysis of patients with BLT from the TraumaRegister DGU® was performed. All patients with liver injury AIS ≥ 2 between 2015 and 2020 were included. The focus was to evaluate the use ANGIO as well as treatment selection (NOM vs. SURG) and mortality in relation to liver injury severity. Furthermore, independent risk factors influencing mortality were identified, using multivariate logistic regression. RESULTS A total of 2353 patients with BLT were included in the analysis. ANGIO was used in 18 cases (0.8%). NOM was performed in 70.9% of all cases, but mainly in less severe liver trauma (AIS ≤ 2, abbreviated injury scale). Liver injuries AIS ≥ 3 were predominantly treated surgically (64.6%). Overall mortality associated with BLT was 16%. Severity of liver injury ≥ AIS 3, age > 60 years, hemodynamic instability (INSTBL), and mass transfusion (≥ 10 packed red blood cells/pRBC) were identified as independent risk factors contributing to mortality in BLT. CONCLUSION ANGIO is rarely used in BLT, contrary to national and international guideline recommendations. In Germany, liver injuries AIS ≥ 3 are still predominantly treated surgically. BLT is associated with considerable mortality, depending on the presence of specific contributing risk factors.
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Affiliation(s)
- Christian Beltzer
- Department of General, Abdominal and Thoracic Surgery, German Armed Forces Hospital Ulm, Ulm, Germany.
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Benny Kölbel
- Department of General, Abdominal and Thoracic Surgery, German Armed Forces Hospital Ulm, Ulm, Germany
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Di Serafino M, Iacobellis F, Ronza R, Martino A, Grimaldi D, Rinaldo C, Caruso M, Dell’Aversano Orabona G, Barbuto L, Verde F, Sabatino V, Schillirò ML, Brillantino A, Romano L. Hepatobiliary-specific magnetic resonance contrast agents: role in biliary trauma. Gland Surg 2023; 12:1425-1433. [PMID: 38021201 PMCID: PMC10660186 DOI: 10.21037/gs-23-29] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Non-iatrogenic traumatic bile duct injuries (NI-TBIs) are a rare complication after abdominal trauma, with an estimated prevalence of 2.8-7.4% in patients underwent blunt liver injuries. They may be overlooked in patients with extensive multi-organ trauma, particularly hepatic, splenic and duodenal injuries, which have a prevalence of 91%, 54% and 54%, respectively. Whole body contrast-enhanced computed tomography (CE-CT) represents the examination of choice in polytraumatized hemodynamically stable patients, as it allows a comprehensive evaluation of vascular, parenchymal, bone and soft tissues injuries, but the diagnosis of any biliary leaks is limited to the evaluation of nonspecific imaging findings and on findings evolution in the follow-up, such as the progressive growth of fluid collections. Furthermore, biliary complications, such as the occurrence of biloma or biliary peritonitis, may become manifest several days after the initial trauma, often with unspecific progressive signs and symptoms. Although CT and ultrasonography can suggest bile leaks based on several nonspecific imaging findings (e.g., fluid collections), magnetic resonance imaging (MRI) using hepatobiliary contrast agents helps to identify the site and entity of post-traumatic biliary disruption. Indeed, MRI allows to obtain cholangiographic sequences that may show post-traumatic active bile leakage and cysto-biliary communications by direct visualisation of contrast material extravasation into fluid collections, increasing the preoperative accuracy of NI-TBIs. Few data are available about MRI use in the follow-up of trauma with NI-TBI management. So, in the present mini review, its role is reviewed and our preliminary experience in this field is reported.
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Affiliation(s)
- Marco Di Serafino
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Roberto Ronza
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Dario Grimaldi
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Chiara Rinaldo
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Martina Caruso
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | | | - Luigi Barbuto
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Francesco Verde
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Vittorio Sabatino
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | - Maria Laura Schillirò
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
| | | | - Luigia Romano
- Department of General and Emergency Radiology, “Antonio Cardarelli” Hospital, Naples, Italy
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D'Souza K, Norman M, Rebchuk AD, Samarasinghe N, Hounjet CD, Griesdale DE, Joos E, Field TS. Efficacy of Antithrombotic Therapy and Risk of Hemorrhagic Complication in Blunt Cerebrovascular Injury Patients with Concomitant Injury: A Systematic Review. J Am Coll Surg 2023; 237:663-672. [PMID: 37222430 DOI: 10.1097/xcs.0000000000000771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The risk-benefit balance of antithrombotic therapy administration for blunt cerebrovascular injuries (BCVI) patients with concomitant injuries at high risk for bleeding is an ongoing therapeutic conundrum for trauma clinicians. We performed a systematic review to assess the reported efficacy and safety of treatment in this population with respect to prevention of ischemic stroke and risk of hemorrhagic complications. STUDY DESIGN A systematic electronic literature search of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was performed from January 1, 1996 to December 31, 2021. Studies were included if they reported treatment-stratified clinical outcomes after antithrombotic therapy in BCVI patients with concomitant injuries at high risk of bleeding into a critical site. Data were extracted from selected studies by two independent reviewers, including the main outcomes of interest were BCVI-related ischemic stroke rates and rates of hemorrhagic complications. RESULTS Of the 5,999 studies reviewed, 10 reported on the effects of treating BCVI patients with concurrent traumatic injuries and were included for review. In the pooled data, among patients with BCVI and concomitant injury who received any form of antithrombotic therapy, the BCVI-related stroke rate was 7.6%. The subgroup of patients who did not receive therapy had an overall BCVI-related stroke rate of 34%. The total rate of hemorrhagic complications in the treated population was 3.4%. CONCLUSIONS In BCVI patients with concomitant injuries at high risk for bleeding, antithrombotic use reduces the risk of ischemic strokes with a low reported risk of serious hemorrhagic complications.
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Affiliation(s)
- Karan D'Souza
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mathew Norman
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alexander D Rebchuk
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadeesha Samarasinghe
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Celine D Hounjet
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery (Rebchuk, Hounjet), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald Eg Griesdale
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine (Griesdale), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Emilie Joos
- From the Section of Acute Care Surgery and Trauma, Division of General Surgery (D'Souza, Samarasinghe, Joos), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- Faculty of Medicine (D'Souza, Norman, Rebchuk, Samarsinghe, Hounjet, Griesdale, Joos, Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Stroke Program, Division of Neurology (Field), Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Junior MAR, Almehrzi ASM, Jaszczak N, Albalooshi MEA, Rathinavelu B, Karajeh M, DeSoucy ES, AlSayari A, Hughes JD. A 21-Year-Old Man with Previous History of Gastrectomy, Cholecystectomy, and Biliary Stenting with Failed Non-Operative Management of Blunt Trauma to the Liver Due to Traumatic Stent Perforation. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e940984. [PMID: 37649250 PMCID: PMC10479200 DOI: 10.12659/ajcr.940984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/18/2023] [Accepted: 07/13/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Conservative management of blunt trauma to the liver is commonly used when there are no immediate signs of rupture or hemorrhage, but requires patient monitoring. The rate of failure for non-operative management ranges is 3-15%. This report is of a 21-year-old man with a previous history of gastrectomy, cholecystectomy, and biliary stenting with failed non-operative management of blunt trauma to the liver following a motor vehicle crash, due to traumatic stent perforation. CASE REPORT The patient reported abdominal pain and had positive FAST for fluid in the hepatorenal space. CT abdomen showed grade 3 hepatic injury and a common bile duct stent. He was resuscitated and admitted to the ICU. He developed escalating abdominal pain and tachycardia without hypotension. Repeat CT demonstrated a paraduodenal gas bubble. He underwent exploratory laparotomy, during which the following were found: hemoperitoneum, no active bleeding, a 3-cm blue stent exiting the left hepatic duct surrounded by a fibrous tract, and bile spilling from around the stent. The protruding portion of the stent was resected, the was tract oversewn, and the abdomen was closed. Once stabilized, the patient underwent ERCP with removal of the remaining stent segment. The postoperative course was complicated by surgical wound infection and fascial dehiscence managed operatively and with local wound care, and deep-space infections managed by interventional radiology drainage. CONCLUSIONS Blunt trauma injury of the liver can be successfully managed conservatively. However, this case highlights the importance of knowledge of the patient's medical history and the presence of biliary stents, which can result in traumatic biliary perforation with an intact liver.
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Affiliation(s)
- Marcelo A.F. Ribeiro Junior
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Ali Salim Mohamed Almehrzi
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Nicholas Jaszczak
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | - Balamurugan Rathinavelu
- Department of Radiology, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Mohammed Karajeh
- Department of Gastroenterology, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Erik S. DeSoucy
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Ahmed AlSayari
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Joy Dowden Hughes
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
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Tang WR, Wu CH, Yang TH, Yen YT, Hung KS, Wang CJ, Shan YS. Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan. Sci Rep 2023; 13:5429. [PMID: 37012308 PMCID: PMC10070483 DOI: 10.1038/s41598-023-32760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.
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Affiliation(s)
- Wen-Ruei Tang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Chih-Jung Wang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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12
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Brooks A, Joyce D, La Valle A, Reilly JJ, Blackburn L, Kitchen S, Morris L, Naumann DN. Improvements over time for patients following liver trauma: A 17-year observational study. Front Surg 2023; 10:1124682. [PMID: 36911603 PMCID: PMC9998517 DOI: 10.3389/fsurg.2023.1124682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/10/2023] [Indexed: 03/14/2023] Open
Abstract
Background Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre. Methods All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V). Results There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively). Conclusions Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.
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Affiliation(s)
- Adam Brooks
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom
| | - Danielle Joyce
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom.,Institute of Inflammation and Ageing, University of Aberdeen, Aberdeen, United Kingdom
| | - Angelo La Valle
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom
| | - John-Joe Reilly
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom
| | - Lauren Blackburn
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom
| | - Samuel Kitchen
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom
| | - Louise Morris
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom
| | - David N Naumann
- Major Trauma Department, East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, United Kingdom.,Department of Trauma and Emergency General Surgery, University of Birmingham, Birmingham, United Kingdom.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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13
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Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications. Diagnostics (Basel) 2022; 12:diagnostics12061456. [PMID: 35741266 PMCID: PMC9221646 DOI: 10.3390/diagnostics12061456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.
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14
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Henry L, Fischer N. Delayed haemorrhage and pseudoaneurysms following liver trauma. Eur J Trauma Emerg Surg 2022; 48:2823-2830. [PMID: 35190854 DOI: 10.1007/s00068-022-01889-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/17/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Delayed Haemorrhage (DH) is a potential complication following liver trauma. Hepatic artery pseudoaneurysms (HAPAs) are also a frequently considered delayed complication of liver trauma, yet their incidence is rare. Furthermore, little is known about their natural history, with some observed to resolve spontaneously. Some authors postulate that DH following liver trauma may in fact originate from HAPAs. AIM To investigate the incidence of DH and HAPA following liver trauma, review subsequent management and explore a possible association between the two. METHODS A retrospective study of liver trauma over a 14 year period at a trauma centre, including a case-control analysis comparing patients with DH and HAPA to liver injury grade matched controls. RESULTS 450 patients were admitted with liver trauma of which 10 patients had DH (2.2%) and 7 HAPA (1.6%). Both DH and HAPA patients had significantly greater blood transfusion requirements, lower haemoglobin (Hb) levels and a greater Hb decrease compared to controls. No patient with an HAPA had a large volume of haemoperitoneum on imaging, and there were no patients in the clinical DH group with previous or concurrent HAPA identified, and no deaths in either group. CONCLUSION DH and HAPA following liver trauma are rare. DH following liver trauma was not associated with HAPA on imaging. This study shows that HAPAs cause ongoing insidious bleeding and Hb decline, but we did not find evidence to support the commonly held perception of a risk of 'rupture' and catastrophic haemorrhage.
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Affiliation(s)
- Luke Henry
- Department of General Surgery, Auckland City Hospital, 2 Park Road, Grafton, Private Bag 92024, Auckland, New Zealand.
| | - Nicholas Fischer
- New Zealand Liver Transplant Unit, Auckland City Hospital, 2 Park Road, Grafton, Private Bag 92024, Auckland, New Zealand
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Salomon B, Howk A, Heidel R, McKnight CL. Impact of coronavirus disease 2019 (COVID-19) on trauma surgical education at a level I trauma center. Surgery 2021; 170:1359-1363. [PMID: 34116858 PMCID: PMC8141696 DOI: 10.1016/j.surg.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND During the coronavirus disease 2019 pandemic, trauma presentations to the emergency room decreased across the country. The goal of this study is to analyze the educational impact of coronavirus disease 2019 on trauma education and training at a level I trauma center. METHODS Trauma patient presentations were analyzed 6 months before a Tennessee executive stay-at-home order and 6 months after the state executive order. To control for the seasonal trauma volumes, an additional 6 months before the executive order was then analyzed comparing month to month. Total number of presentations, demographics, procedures, airway management, and coronavirus disease 2019 status of patients and residents were analyzed. RESULTS The number of trauma presentations were sustained after executive orders at our level I trauma center. There was no significant difference in intubations, central line placements, and chest tube placements before and during the pandemic. Blunt trauma decreased after stay-at-home orders. Of the 36 residents, no residents tested positive during the study period. CONCLUSION Trauma-focused surgical education was not affected at an academic level I trauma center. Understanding that it is region, city, and hospital specific, this study shows that quality trauma education can continue throughout the coronavirus disease 2019 pandemic while keeping trainees safe. Proper airway management, personal protective equipment, social distancing, and coronavirus disease 2019-preventative protocols seem to protect residents from potential harm while allowing them to participate and continue in quality trauma education and training.
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Affiliation(s)
- Brett Salomon
- Department of Surgery, University of Tennessee at Knoxville Graduate Medical Education, TN.
| | - Amy Howk
- Department of Surgery, University of Tennessee at Knoxville Graduate Medical Education, TN
| | - Robert Heidel
- Division of Biostatistics, Department of Surgery, University of Tennessee Medical Center at Knoxville, TN
| | - C Lindsay McKnight
- Division of Trauma and Critical Care Surgery, Department of Surgery, University of Tennessee Medical Center at Knoxville, TN
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