Liver trauma: WSES 2020 guidelines

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study

BACKGROUND

High-grade liver injuries with extravasation (HGLI ​+ ​Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI ​+ ​Extrav. Therefore, we evaluated the management of HGLI ​+ ​Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality.

METHODS

HGLI ​+ ​Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality.

RESULTS

From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p ​= ​0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p ​> ​0.05).

CONCLUSION

Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI ​+ ​Extrav patients.

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.

Perineal laceration treated with negative pressure wound therapy following colostomy

A male in his early 30s was transported to the emergency room after being hit by a vehicle while inebriated and lying in the street. His general condition was stable; however, he had a perineal laceration that extended to the coccyx. Due to the proximity of the wound margin to the anus, we were concerned regarding the potential contamination and opted not to suture it. Therefore, we refrained from suturing the wound and kept the wound open after irrigation and debridement. Additionally, we performed a transverse colostomy. On day 4, we initiated negative pressure wound therapy for 40 days, during which sufficient wound granulation occurred. The patient was discharged, and the colostomy was closed approximately 4 months after the injury. Our case illustrates the effectiveness of negative pressure wound therapy in managing perineal lacerations.

Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Bioactive compound schaftoside from Clinacanthus nutans attenuates acute liver injury by inhibiting ferroptosis through activation the Nrf2/GPX4 pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Clinacanthus nutans (Burm. f.) Lindau, a traditional herb renowned for its anti-tumor, antioxidant, and anti-inflammatory properties, has garnered considerable attention. Although its hepatoprotective effects have been described, there is still limited knowledge of its treatment of acute liver injury (ALI), and its mechanisms remain unclear.

AIM OF THE STUDY

To assess the efficacy of Clinacanthus nutans in ALI and to identify the most effective fractions and their underlying mechanism of action.

METHODS

Bioinformatics was employed to explore the underlying anti-hepatic injury mechanisms and active compounds of Clinacanthus nutans. The binding ability of schaftoside, a potential active ingredient in Clinacanthus nutans, to the core target nuclear factor E2-related factor 2 (Nrf2) was further determined by molecular docking. The role of schaftoside in improving histological abnormalities in the liver was observed by H&E and Masson's staining in an ALI model induced by CCl4. Serum and liver biochemical parameters were measured using AST, ALT and hydroxyproline kits. An Fe2+ kit, transmission electron microscopy, western blotting, RT-qPCR, and DCFH-DA were used to measure whether schaftoside reduces ferroptosis-induced ALI. Subsequently, specific siRNA knockdown of Nrf2 in AML12 cells was performed to further elucidate the mechanism by which schaftoside attenuates ferroptosis-induced ALI.

RESULTS

Bioinformatics analysis and molecular docking showed that schaftoside is the principal compound from Clinacanthus nutans. Schaftoside was shown to diminish oxidative stress levels, attenuate liver fibrosis, and forestall ferroptosis. Deeper investigations revealed that schaftoside amplified Nrf2 expression and triggered the Nrf2/GPX4 pathway, thereby reversing mitochondrial aberrations triggered by lipid peroxidation, GPX4 depletion, and ferroptosis.

CONCLUSION

The lead compound schaftoside counters ferroptosis through the Nrf2/GPX4 axis, providing insights into a novel molecular mechanism for treating ALI, thereby presenting an innovative therapeutic strategy for ferroptosis-induced ALI.

The role of big data management, data registries, and machine learning algorithms for optimizing safe definitive surgery in trauma: a review

Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer.

Assessing associated factors for failure of nonoperative management in pediatric blunt liver and spleen injuries: a secondary analysis of the SHIPPs study

PURPOSE

The purpose of this study was to describe the characteristics of pediatric patients who underwent nonoperative management (NOM) for blunt splenic and hepatic injuries and to explore factors associated with NOM failure.

METHODS

This was a secondary analysis of a multicenter cohort study of pediatric patients with blunt liver and spleen injuries in Japan. Participants included pediatric trauma patients aged 16 years or younger between 2008 and 2019 with NOM, which was defined as no surgery provided within 6 h of hospital arrival. NOM failure, defined as abdominal surgery performed after 6 h of hospital arrival, was the primary outcome. Descriptive statistics were provided and exploratory analysis to assess the associations with outcome using logistic regression.

RESULTS

During the study period, 1339 met our eligibility criteria. The median age was 9 years, with a majority being male. The median Injury Severity Score (ISS) was 10. About 14.0% required transfusion within 24 h, and 22.3% underwent interventional radiology procedures. NOM failure occurred in 1.0% of patients and the in-hospital mortality was 0.7%. Factors associated with NOM failure included age, positive focused assessment with sonography for trauma (FAST), contrast extravasation on computed tomography (CT), severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and ISS.

CONCLUSIONS

In our study, NOM failure were rare. Older age, positive FAST, contrast extravasation on CT, severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and higher ISS were suggested as possible risk factors for NOM failure.

Deep Learning for Automated Detection and Localization of Traumatic Abdominal Solid Organ Injuries on CT Scans

Computed tomography (CT) is the most commonly used diagnostic modality for blunt abdominal trauma (BAT), significantly influencing management approaches. Deep learning models (DLMs) have shown great promise in enhancing various aspects of clinical practice. There is limited literature available on the use of DLMs specifically for trauma image evaluation. In this study, we developed a DLM aimed at detecting solid organ injuries to assist medical professionals in rapidly identifying life-threatening injuries. The study enrolled patients from a single trauma center who received abdominal CT scans between 2008 and 2017. Patients with spleen, liver, or kidney injury were categorized as the solid organ injury group, while others were considered negative cases. Only images acquired from the trauma center were enrolled. A subset of images acquired in the last year was designated as the test set, and the remaining images were utilized to train and validate the detection models. The performance of each model was assessed using metrics such as the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, and negative predictive value based on the best Youden index operating point. The study developed the models using 1302 (87%) scans for training and tested them on 194 (13%) scans. The spleen injury model demonstrated an accuracy of 0.938 and a specificity of 0.952. The accuracy and specificity of the liver injury model were reported as 0.820 and 0.847, respectively. The kidney injury model showed an accuracy of 0.959 and a specificity of 0.989. We developed a DLM that can automate the detection of solid organ injuries by abdominal CT scans with acceptable diagnostic accuracy. It cannot replace the role of clinicians, but we can expect it to be a potential tool to accelerate the process of therapeutic decisions for trauma care.

Multidisciplinary management of high-grade pediatric liver injuries

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.

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.

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Future Perspectives on Radiomics in Acute Liver Injury and Liver Trauma

Background: Acute liver injury occurs most frequently due to trauma, but it can also occur because of sepsis or drug-induced injury. This review aims to analyze artificial intelligence (AI)'s ability to detect and quantify liver injured areas in adults and pediatric patients. Methods: A literature analysis was performed on the PubMed Dataset. We selected original articles published from 2018 to 2023 and cohorts with ≥10 adults or pediatric patients. Results: Six studies counting 564 patients were collected, including 170 (30%) children and 394 adults. Four (66%) articles reported AI application after liver trauma, one (17%) after sepsis, and one (17%) due to chemotherapy. In five (83%) studies, Computed Tomography was performed, while in one (17%), FAST-UltraSound was performed. The studies reported a high diagnostic performance; in particular, three studies reported a specificity rate > 80%. Conclusions: Radiomics models seem reliable and applicable to clinical practice in patients affected by acute liver injury. Further studies are required to achieve larger validation cohorts.

Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality

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.

National Analysis of Clinical Outcomes Associated With Cirrhotic Blunt Trauma Patients Undergoing Emergency Laparotomy Versus Non-operative Management: A Propensity Case-Matched Analysis

INTRODUCTION

This study aims to evaluate clinical outcomes among severely injured trauma patients presenting with isolated blunt abdominal solid organ injuries with a pre-diagnosis of liver cirrhosis (LC) undergoing emergency laparotomy vs nonoperative management (NOM).

METHODS

This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) dataset from 2017 to 2021. Adults (≥18 years) with a pre-existing diagnosis of LC who presented with severe blunt (ISS ≥ 16) isolated solid organ abdominal injuries and underwent laparotomy or NOM were included. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and in-hospital complications such as acute renal failure and deep vein thrombosis.

RESULTS

929 patients were included in this analysis, with 355 undergoing laparotomy and 574 managed nonoperatively. Laparotomy patients suffered greater in-hospital mortality (n = 186, 52.3% vs n = 115, 20.0%; P < .01), required significantly more blood within 4 hours (8.9 units vs 4.3 units, P < .01), and had a significantly longer ICU-LOS (10.2 days vs 6.7 days, P < .01). In the 1:1 propensity score matched analysis of 556 matched patients, in-hospital mortality was greater for laparotomy patients (52.3% vs 20.0%, P < .01).

CONCLUSION

Laparotomy was associated with significantly higher in-hospital mortality in propensity-matched trauma patients, longer ICU-LOS, and more blood products given at 4 hours compared to NOM. These findings illustrate that NOM may be a safe approach in managing severely injured trauma patients with isolated blunt abdominal solid organ injuries and a pre-diagnosis of LC.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set

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.

[Management of Injuries to the Parenchymal Abdominal Organs]

The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.

Survival benefits of interventional radiology and surgical teams collaboration during primary trauma surveys: a single-centre retrospective cohort study

BACKGROUND

A team approach is essential for effective trauma management. Close collaboration between interventional radiologists and surgeons during the initial management of trauma patients is important for prompt and accurate trauma care. This study aimed to determine whether trauma patients benefit from close collaboration between interventional radiology (IR) and surgical teams during the primary trauma survey.

METHODS

A retrospective observational study was conducted between 2014 and 2021 at a single institution. Patients were assigned to an embolization group (EG), a surgery group (SG), or a combination group (CG) according to their treatment. The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course of treatment.

RESULTS

The analysis included 197 patients, consisting of 135 men and 62 women, with a median age of 56 [IQR, 38-72] years and an injury severity score of 20 [10-29]. The EG, SG, and CG included 114, 48, and 35 patients, respectively. Differences in organ injury patterns were observed between the three groups. In-hospital survival rates in all three groups were higher than the Ps. In particular, the survival rate in the CG was 15.5% higher than the Ps (95% CI: 7.5-23.6%; p < 0.001). In the CG, the median time for starting the initial procedure was 53 [37-79] min and the procedure times for IR and surgery were 48 [29-72] min and 63 [35-94] min, respectively. Those times were significantly shorter among three groups.

CONCLUSION

Close collaboration between IR and surgical teams, including the primary survey, improves the survival of severe trauma patients who require both IR procedures and surgeries by improving appropriate treatment selection and reducing the time process.

Evolution in liver trauma management: a single centre experience

OBJECTIVES

Liver trauma is common and can be treated non-operatively, through radiological embolisation, or surgically. Non-operative management (NOM) is preferred when possible, but specific criteria remain unclear. This retrospective study at a level I trauma centre assessed the evolution and outcomes of liver injury management over more than 20 years.

METHODS

Data from January 1996 to June 2020 were analysed for liver trauma cases. Variables were evaluated, including the type of injury, diagnostic modalities, liver injury grade, transfer from other hospitals, treatment type, and length of hospital stay. Outcomes were assessed using soft (hospitalisation time and intensive care unit stay) and hard (mortality) endpoints.

RESULTS

In total 406 patients were analysed, of which 375 (92.4%) had a blunt and 31 (7.6%) a penetrating liver trauma. Approximately one-third (31.2%) were hemodynamically unstable, although 78.8% had low-grade liver lesions. The initial treatment was non-operative in 72.9% of the patients (68.5% conservative, 4.4% interventional radiology). Blunt trauma was treated by surgery in 23.2% of the patients, while 74.2% in case of penetrating trauma. Overall mortality was 11.1% including death caused by associated lesions. The 24-h mortality was 5.7%. Indication for surgical treatment was determined by hemodynamic instability, high grade liver lesion, penetrating trauma, and associated lesions.

CONCLUSIONS

Although the role of surgery in liver trauma management has strongly diminished over recent decades, hemodynamically unstable patients, high-grade lesions, penetrating trauma, and severe associated lesions are the main indications for surgery. In other situations, NOM by full conservative therapy or radiological embolisation seems effective.

Is it possible to predict mortality in patients with high-grade blunt liver injury? A single trauma center study

BACKGROUND

Blunt abdominal trauma constitutes a significant portion of trauma cases and is often associated with liver injury. Given that high-grade liver injuries remain life-threatening, identifying patients who will likely require more vigilant attention and care is crucial. This study aims to determine the parameters that increase mortality in patients with high-grade liver trauma.

METHODS

This study enrolled 38 patients with Grade III or higher liver injuries, treated by the general surgery department between 2008 and 2023. Eleven patients who died were categorized into Group 1, and 27 survivors were placed in Group 2. We evaluated their respective mechanisms of injury, imaging results, Glasgow Coma Scale scores, Base Excess, Lactate levels, pH, and Injury Severity Score findings. Receiver Operating Characteristics (ROC) analysis was performed for parameters with significant differences, and certain cutoff values were determined.

RESULTS

The grade of liver injury and additional abdominal organ injuries were significantly higher in Group 1 (p<0.05). The difference in extra-abdominal injury sites was statistically insignificant between the groups (p>0.05). Erythrocyte suspension requirements were significantly higher in Group 1 (p<0.05). Average lactate and base deficit values were also significantly higher in Group 1 (p<0.05), while leukocyte counts were significantly lower in Group 1 (p<0.05).

CONCLUSION

Base deficit, hemoglobin (Hb), lactate levels, injury severity, liver injury grade, accompanying abdominal injuries at admission, and erythrocyte suspension demands were found to be associated with increased mortality rates. Certain cutoff values for the aforementioned parameters could be established. However, further data are required to confirm these findings.

Therapeutic Dilemma: Acute Myocardial Infarction in a Patient with Traumatic Hepatic and Mesenteric Injuries: A Case Report

ST-elevation myocardial infarction (STEMI) in a trauma patient with solid abdominal organ or vascular injuries can present complex diagnostic and therapeutic challenges. Evidence for managing such demanding cases is scarce, and isolated case reports remain the source of information in treating these patients. We present a patient with traumatic mesenteric and hepatic injuries who developed acute STEMI in the immediate postoperative period.

Damage Control Interventional Radiology in Liver Trauma: A Comprehensive Review

The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients.

MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma

INTRODUCTION

One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma.

METHODS

A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed.

RESULTS

Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA.

CONCLUSIONS

Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.

Liver cirrhosis requiring transplantation in the context of hepaticojejunostomy stricture after a traumatic bile duct injury

Biliary injury secondary to trauma is frequently associated with long-term complications. Liver transplantation is rarely indicated but might be the best therapeutic option in severe or intractable cases. We report the case of a 19-year-old male referred for liver transplantation due to biliary injury after abdominal trauma. A Roux-en-Y hepaticojejunostomy was initially performed without immediate complications. Anastomotic stricture developed requiring several trials of biliary dilatation and stenting through a percutaneous approach. The presence of liver cirrhosis and the intractability of this complication culminated in the decision of liver transplantation. The authors present clinical course, complications and interventional procedures that were used in a judicious step-up approach.

[Total saponins of Panax japonicus alleviates CCl4-induced acute liver injury in rats by regulating the PI3K/AktNF-κB signaling pathway]

OBJECTIVE

To investigate the protective effect of total saponins of Panax japonicus (TSPJ) against CCl4-induced acute liver injury (ALI) in rats and explore the underlying pharmacological mechanisms.

METHODS

Male SD rat models of CCl4-induced ALI were given intraperitoneal injections of distilled water, 100 mg/kg biphenyl bisabololol, or 50, 100, and 200 mg/kg TSPJ during modeling (n=8). Liver functions (AST, ALT, TBil and ALP) of the rats were assessed and liver pathologies were observed with HE staining. Immunohistochemistry was used to detect the expressions of PI3K/Akt/NF-κB signaling pathway molecules in liver tissue; ELISA was used to determine the levels of T-SOD, GSH-Px, and MDA. Western blotting was performed to detect the expression levels of PI3K-Akt and SIRT6-NF-κB pathways in the liver tissue.

RESULTS

Network pharmacological analysis indicated that the key pathways including PI3K/Akt mediated the therapeutic effect of TSPJ on ALI. In the rat models of ALI, treatments with biphenyl bisabololol and TSPJ significantly ameliorated CCl4-induced increase of serum levels AST, ALT, ALP, TBil and MDA and decrease of T-SOD and GSH-Px levels (all P < 0.01). The rat models of ALI showed significantly increased expression of p-NF-κB (P < 0.01), decreased expressions of PI3K, p-Akt and SIRT6 proteins, and elevated expression levels of p-NF-κB, TNF-α and IL-6 proteins in the liver, which were all significantly improved in the treatment groups (P < 0.05 or 0.01).

CONCLUSION

TSPJ can effectively alleviate CCl4-induced ALI in rats by suppressing inflammatory responses and oxidative stress in the liver via regulating the PI3K/Akt and SIRT6/NF-κB pathways.

Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis

BACKGROUND

Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing.

METHODS

This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18 years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3).

RESULTS

Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01).

CONCLUSION

Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.

Management and Outcomes of Traumatic Liver Injury: A Retrospective Analysis from a Tertiary Care Center Experience

BACKGROUND

although liver injuries are one of the most critical complications of abdominal trauma, choosing when to operate on these injuries is challenging for surgeons worldwide.

METHODS

We conducted a retrospective analysis of liver injury cases at our institution from 2016 to 2022 to describe the operative and nonoperative management (NOM) outcomes in patients with traumatic liver injuries. Baseline patient characteristics, liver injury details, treatments, and outcomes were analyzed.

RESULTS

Data from 45 patients (male, 77.8%) were analyzed. The mean age was 29.3 years. Blunt trauma was the most common injury mechanism (86.7%), whereas penetrating injuries were 8.9% of cases. Conservative management was associated with 18.9% of complications. The overall complication rate was 26.7%; delirium and sepsis were the most common (13.3%), followed by acute renal failure (4.4%), pneumonia, biliary leaks, and meningitis/seizures.

CONCLUSIONS

Notwithstanding its limitations, this retrospective analysis demonstrated that NOM can serve as a safe and effective strategy for hemodynamically stable patients with liver trauma, irrespective of the patient's injury grade. Nevertheless, careful patient selection and monitoring are crucial. Further investigations are necessary to thoroughly evaluate the management of traumatic liver injuries, particularly in the context of multiorgan injuries.

Portal vein embolization following arterial portography for the management of an active portal bleeding after blunt liver trauma in a cirrhotic patient

BACKGROUND

The management of blunt liver trauma in cirrhotic patients is challenging, because while bleeding is most often of arterial origin, the increased pressure in the portal system associated with cirrhosis can increase the risk of portal bleeding, which is sometimes difficult to confirm on contrast-enhanced abdominal computed tomography.

CASE PRESENTATION

We managed a 54-year-old cirrhotic patient who presented with blunt liver trauma. Computed Tomography showed active intraperitoneal bleeding presumed to be of hepatic origin. Given the patient's hemodynamic stability, the decision was made to manage the patient non-surgically. The patient underwent hepatic arteriography to rule out an arterial origin to the bleeding. A superior mesenteric arterial portography confirmed the portal venous origin of the bleeding. To stop the bleeding, a distal portal vein embolization using coils and glue was performed by approaching a large paraumbilical vein.

CONCLUSIONS

Our case study shows the value of arterial portography in the management of these patients, when they are clinically stable enough to benefit from non-surgical management; This allows arterial bleeding to be excluded on hepatic arteriography, portal bleeding to be confirmed on portography following arteriography in the superior mesenteric artery, and guidance of portal vein embolization.

Use of angioembolization, treatment modalities and mortality in association with blunt liver trauma in Germany - a data analysis of the TraumaRegister DGU®

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.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy

INTRODUCTION

We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL).

METHODS

This is a 4-year (2017-2020) analysis of the ACS-TQIP. Adult trauma patients with severe liver injuries (AAST-OIS grade ​≥ ​III) who underwent DCL and hepatic resection were included. We excluded patients with early mortality (<24 ​h). Patients were stratified into those who received hepatic resection within the initial operation (Early) and take-back operation (Delayed).

RESULTS

Of 914 patients identified, 29% had a delayed hepatic resection. On multivariable regression analyses, although delayed resection was not associated with mortality (aOR:1.060,95%CI[0.57-1.97],p ​= ​0.854), it was associated with higher complications (aOR:1.842,95%CI[1.38-2.46],p ​< ​0.001), and longer hospital (β: +0.129, 95%CI[0.04-0.22],p ​= ​0.005) and ICU (β:+0.198,95%CI[0.14-0.25],p ​< ​0.001) LOS, compared to the early resection.

CONCLUSION

Delayed hepatic resection was associated with higher adjusted odds of major complications and longer hospital and ICU LOS, however, no difference in mortality, compared to early resection.

Construction and validation of a novel and severe hepatic injury model in swine focuses on research and training. Observational study

Some hepatic wound models have been developed in pigs with the aim of reproducing liver injury; however, the wound shape, severity, and outcome differ among them. The novel injury profile employed in this study differed from that used elsewhere for standardized, repeatable, reproducible, incising-penetrating, vascular, and severe injury in swine. It is made with a cutting object that penetrates deep into the hepatic parenchyma, always affecting the two suprahepatic veins at the point where they merge into the common trunk. The primary outcome was reproducibility and replicability of the surgical method. The secondary outcome was the analysis of some variables (blood loss, survival, and flow) to validate the model. •This novel method of liver injury provides a liver injury with the following characteristics: standardized, incise-penetrated, deep, bloody, and severe.•This model can be used for research (trauma, hepato-bilio-pancreatic, pharmaceutical) and training (damage control surgery).•Method name: Incising-Penetrating, Vascular and Severe Liver Injury Model in Swine.

Gastric Artery Injury Due to Blunt Abdominal Trauma

Gastric artery injury resulting from blunt abdominal trauma is rare, with only eight previous cases documented in the published literature. Our report describes a case involving an injury to the right gastric artery with concomitant injuries to the liver and spleen, for which arterial embolization targeting the right gastric artery was performed. The patient, a 66-year-old woman without any remarkable medical history, was involved in a motor vehicle accident. She was brought to the hospital in a state of shock and complaining of upper abdominal pain. Contrast-enhanced CT indicated hepatic and splenic injuries, intra-abdominal hemorrhaging, and effusion of contrast medium, suggesting involvement of the right gastric artery. Subsequent angiography confirmed irregularities in the diameter of the right gastric artery, prompting coil embolization. A conservative therapeutic approach was selected due to the absence of evidence regarding active hemorrhage or vascular injury within the hepatic or splenic regions. The patient remained clinically stable following the embolization, without any sequelae. Arterial embolization is warranted if preoperative contrast CT indicates signs of hemorrhage, even if hemostasis is ostensibly attained during angiography. Our findings allude to the feasibility of non-operative management (NOM) rather than laparotomy for cases of gastric artery injury.

Hepatic artery pseudoaneurysm rupture: A case report

Hepatic artery pseudoaneurysms are an uncommon complication of blunt hepatic trauma typically presenting in a delayed fashion. A 40-year-old male presented to a trauma centre after a 6-metre fall from a construction site with multiple injuries including a grade IV liver laceration centred around the porta hepatis. This liver injury was managed non-operatively. On day sixteen of admission, he had a sudden cardiac arrest from haemorrhagic shock with a subsequent CT demonstrating a ruptured extrahepatic proper hepatic artery pseudoaneurysm. Despite laparotomy and vessel repair, he died from pulmonary complications of aspiration pneumonia and acute lung injury associated with massive transfusion. The literature demonstrates conflicting views regarding the utility of repeat CT to detect a pseudoaneurysm in asymptomatic, non-operatively managed patients with blunt hepatic trauma. In particular, the literature does not distinguish the utility of repeat routine CT for intrahepatic and extrahepatic hepatic artery pseudoaneurysm, the latter if which is rarer. Current guidelines recommend against it, but there are observational studies suggesting utility, particularly in high grade (≥IV) liver injury. In patients with a high-grade injury extending to the porta hepatis, repeat imaging should be considered to detect possible pseudoaneurysm.

Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries

INTRODUCTION

Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries.

METHODS

Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS.

RESULTS

From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years.

CONCLUSIONS

AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.

Blunt abdominal trauma: watch and wait

PURPOSE OF REVIEW

This review examines recent advancements in nonoperative management (NOM) of hemodynamically stable blunt abdominal trauma, focusing on expanding patient selection for observation-first strategies, particularly for high-grade solid organ injuries.

RECENT FINDINGS

Advances include a more deliberate nonoperative approach, allowing for broader patient inclusion in diagnostic and interventional angiography. Strict clinical monitoring and appropriate follow-up strategies are crucial to identify early signs of clinical progression and complications. Repeated contrast-enhanced CT (CECT) scan can be used for close observation of high-risk injuries, while the repetition of CECTs may be avoided for lower-risk cases, such as specific high-grade kidney injuries. The role of contrast-enhanced ultrasound (CEUS) in detecting sequelae of nonoperative approaches is still debated and has lot of potential, with ongoing trials exploring possible advantages.

SUMMARY

Multidisciplinary trauma teams play a crucial role in nonoperative management, particularly for high-grade injuries. A careful selection of patients is essential to minimize failure rates. Complications of nonoperative and angiographic approaches should be managed according to local expertise.

PANoptosis: Emerging mechanisms and disease implications

PANoptosis, a unique new form of programmed cell death (PCD), is characterized by pyroptosis, apoptosis, and necroptosis, but it cannot be explained by pyroptosis, apoptosis or necroptosis alone. Assembly of the PANoptosome complex is a key feature of PANoptosis. To date, four kinds of PANoptosomes with distinct sensors and regulators have been defined, namely Z-DNA binding protein 1 (ZBP1) PANoptosome, absent in melanoma 2 (AIM2) PANoptosome, receptor-interacting protein kinase 1 (RIPK1) PANoptosome, and nucleotide-binding leucine-rich repeat-containing receptor 12 (NLRP12). Each PANoptosome contains three components: sensors for pathogen-associated molecular patterns (PAMPs) or damage-associated molecular patterns (DAMPs), adaptors as connected bridges, and catalytic effectors or executioners. Mechanistically, different PAMPs or DAMPs are recognized by the sensors in a context-dependent manner, which initiates PANoptosome assembly through adaptors, and ultimately engages synchronous activation of pyroptosis, apoptosis, and necroptosis via different catalytic effectors. Resultantly, PANoptosis is emerged as a prospective and promising therapeutic target for various diseases. This review covers the accumulating evidence about the roles and mechanisms of PANoptosis in innate immunity and discusses the attractive prospect of manipulating PANoptosis as a new treatment for diseases.

Blunt Trauma in Children: Efficacy and Safety of Transarterial Embolization, 10-Year Experiences in a Single Trauma Center

BACKGROUND

Transcatheter arterial embolization (TAE) is an established approach for controlling hemorrhage in adults with acute abdominal and pelvic trauma. However, its application in pediatric trauma is not well established. This study aimed to evaluate the safety and effectiveness of TAE in a population of pediatric patients with blunt trauma.

METHODS

This retrospective study was conducted in pediatric patients (<18 years) who underwent TAE for blunt trauma between February 2014 and July 2022. The patients were categorized into subgroups based on age and body weight. Patient demographics, injury severity, transfusion requirements, and clinical outcomes were analyzed.

RESULTS

Exactly 73 patients underwent TAE. Technical success was achieved in all patients (100%), and clinical success was achieved in 83.6%. The mortality and complication rates were 4.1% and 1.4%, respectively. The mean duration of hospitalization was 19.3 days. Subgroup analysis showed that age, body weight, and sex did not significantly affect clinical success. The injury severity score and transfusion requirement were predictors of clinical success, with lower values associated with better outcomes.

CONCLUSIONS

TAE is effective and safe for managing blunt pediatric trauma in younger and lighter patients. Injury severity and transfusion requirement are predictors of clinical success.

Hepatobiliary-specific magnetic resonance contrast agents: role in biliary trauma

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.

Biological function and clinical application prospect of tsRNAs in digestive system biology and pathology

tsRNAs are small non-coding RNAs originating from tRNA that play important roles in a variety of physiological activities such as RNA silencing, ribosome biogenesis, retrotransposition, and epigenetic inheritance, as well as involvement in cellular differentiation, proliferation, and apoptosis. tsRNA-related abnormalities have a significant influence on the onset, development, and progression of numerous human diseases, including malignant tumors through affecting the cell cycle and specific signaling molecules. This review introduced origins together with tsRNAs classification, providing a summary for regulatory mechanism and physiological function while dysfunctional effect of tsRNAs in digestive system diseases, focusing on the clinical prospects of tsRNAs for diagnostic and prognostic biomarkers. Video Abstract.

Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney

According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review

BACKGROUND

Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs.

METHODS

We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria.

RESULTS

We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries.

CONCLUSION

We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level III.

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

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.

Assessing the Variability of the Twelfth Rib as a Landmark for Percutaneous Nephrolithotomy Using Computed Tomography

BACKGROUND

The variability in length of the twelfth rib is mentioned in the literature but has never been formally studied. The highly variable rib length provides a challenge for urologists seeking a consistent landmark for Percutaneous Nephrolithotomy (PCNL). We set out to determine whether the twelfth rib is safe to use as a consistent landmark for surgery.

METHODS

Single centre, cross-sectional retrospective observational study and analysis of CT scans of 100 adults who had imaging between 23rd March and 12th April 2020. The distance from the mid-sagittal line to the twelfth rib tip in the axial plane was measured as was the distance from the twelfth rib tip to the kidney, spleen and liver.

RESULTS

Length from the mid-sagittal line to the right twelfth rib tip varied from 46 (percentile 95% CI 40 to 57) to 136mm (percentile 95% CI 133 to 138). On the left, the distances varied from 55 (percentile 95% CI 50 to 64) to 134mm (percentile 95% CI 131 to 135). Twenty-three percent of people had an organ lying between the tip of the twelfth rib and the kidney on the right and 11% on the left.

CONCLUSION

The twelfth rib is highly variable in length. Similar variability was recorded in the distance from the tip to intra-abdominal organs. Due to the frequency of organs lying between the tip of the rib and the kidney it should not be used as a landmark for accessing the kidney without prior knowledge of an individual patient's anatomy as seen on imaging.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

Emergency Abdominopelvic Injuries

The presentation of traumatic abdominopelvic injuries in sport can range from initially benign appearing to hemorrhagic shock. A high clinical suspicion for injury, knowledge of the red flags for emergent further evaluation, and familiarity with the initial stabilization procedures are necessary for sideline medical providers. The most important traumatic abdominopelvic topics are covered in this article. In addition, the authors outline the evaluation, management, and return-to-play considerations for the most common abdominopelvic injuries, including liver and splenic lacerations, renal contusions, rectus sheath hematomas, and several others.

[Clinical Role of Interventional Radiology in Abdominal Solid Organ Trauma]

Interventional management is commonly used for traumatic injuries to the abdominal solid organs. The American Association for the Surgery of Trauma (AAST) and the World Society of Emergency Surgery (WSES) recently published guidelines for the management and treatment of liver, spleen, and kidney injuries, emphasizing the importance of interventions. Here, we discuss the characteristics of each organ and the procedure method for each organ that interventional radiologists need to know when treating trauma patients.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].