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Khdhir M, Ghosn Y, Jabbour Y, Abbas N, Tarcha Z, Kayali M, Khouzami R, Natout M, Muallem N. Does delayed phase imaging in CT angiography provide additional information in patients with suspected active bleeding? Emerg Radiol 2024; 31:439-446. [PMID: 38760647 DOI: 10.1007/s10140-024-02239-9] [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: 02/22/2024] [Accepted: 05/01/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE We hypothesize that delayed phase imaging does not provide additional diagnostic information in patients who undergo multi-phasic CTA for suspected active bleeding. METHODS Data on patients who underwent multiphasic CTA (pre-contrast, arterial, porto-venous, and delayed phases) for suspected acute bleed were retrospectively collected between January 2019 and November 2021. CTA images were reviewed by a general radiologist, an interventional radiologist, and a body imaging radiologist independently. Each reader evaluated if delayed phase images provided additional information that would change the final impression of the CTA report. Additional information regarding bleeding location, time needed for delayed image acquisition, and radiation exposure were also obtained. RESULTS A total of 104 patients with CTAs were analyzed with an average age of 58 years ± 22. Studies rated with absent additional findings on delayed images were 102 (98.1%) by the interventional radiologist, 101 (97.1%) by the body imaging radiologist, and 100 (96.1%) by the general radiologist with percent agreement of 96.15% (kappa 0.54, p < 0.001). All the findings were characterized as unlikely to be clinically significant. Mean time added to complete a delayed phase images was 3.61 ± 3.4 min. The average CT dose length product (DLP) for the total exam was 3621.78 ± 2129.57 mGy.cm with delayed acquisition adding a mean DLP of 847.75 ± 508.8 mGy.cm. CONCLUSION Delayed phase imaging does not provide significant additional diagnostic information in evaluating patients with suspected active bleeding but is associated with increased examination time and radiation exposure.
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Affiliation(s)
- Mihran Khdhir
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, USA
| | - Youssef Ghosn
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O. Box 11-0236, Bierut, 1107 2020, Lebanon
| | - Yara Jabbour
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O. Box 11-0236, Bierut, 1107 2020, Lebanon
| | - Nada Abbas
- American University of Beirut, Bierut, Lebanon
| | - Ziad Tarcha
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, USA
| | - Mohamad Kayali
- Department of Radiology, University of Iowa Hospital and Clinics, Lowa, USA
| | - Riad Khouzami
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O. Box 11-0236, Bierut, 1107 2020, Lebanon
| | - Mustafa Natout
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O. Box 11-0236, Bierut, 1107 2020, Lebanon
| | - Nadim Muallem
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O. Box 11-0236, Bierut, 1107 2020, Lebanon.
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Cheng CT, Lin HS, Hsu CP, Chen HW, Huang JF, Fu CY, Hsieh CH, Yeh CN, Chung IF, Liao CH. The three-dimensional weakly supervised deep learning algorithm for traumatic splenic injury detection and sequential localization: an experimental study. Int J Surg 2023; 109:1115-1124. [PMID: 36999810 PMCID: PMC10389597 DOI: 10.1097/js9.0000000000000380] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/23/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Splenic injury is the most common solid visceral injury in blunt abdominal trauma, and high-resolution abdominal computed tomography (CT) can adequately detect the injury. However, these lethal injuries sometimes have been overlooked in current practice. Deep learning (DL) algorithms have proven their capabilities in detecting abnormal findings in medical images. The aim of this study is to develop a three-dimensional, weakly supervised DL algorithm for detecting splenic injury on abdominal CT using a sequential localization and classification approach. MATERIAL AND METHODS The dataset was collected in a tertiary trauma center on 600 patients who underwent abdominal CT between 2008 and 2018, half of whom had splenic injuries. The images were split into development and test datasets at a 4 : 1 ratio. A two-step DL algorithm, including localization and classification models, was constructed to identify the splenic injury. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Grad-CAM (Gradient-weighted Class Activation Mapping) heatmaps from the test set were visually assessed. To validate the algorithm, we also collected images from another hospital to serve as external validation data. RESULTS A total of 480 patients, 50% of whom had spleen injuries, were included in the development dataset, and the rest were included in the test dataset. All patients underwent contrast-enhanced abdominal CT in the emergency room. The automatic two-step EfficientNet model detected splenic injury with an AUROC of 0.901 (95% CI: 0.836-0.953). At the maximum Youden index, the accuracy, sensitivity, specificity, PPV, and NPV were 0.88, 0.81, 0.92, 0.91, and 0.83, respectively. The heatmap identified 96.3% of splenic injury sites in true positive cases. The algorithm achieved a sensitivity of 0.92 for detecting trauma in the external validation cohort, with an acceptable accuracy of 0.80. CONCLUSIONS The DL model can identify splenic injury on CT, and further application in trauma scenarios is possible.
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Affiliation(s)
- Chi-Tung Cheng
- Department of Trauma and Emergency Surgery
- Chang Gung University, Taoyuan
| | - Hou-Shian Lin
- Department of Trauma and Emergency Surgery
- Chang Gung University, Taoyuan
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery
- Chang Gung University, Taoyuan
| | - Huan-Wu Chen
- Department of Medical Imaging and Intervention
- Chang Gung University, Taoyuan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery
- Chang Gung University, Taoyuan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery
- Chang Gung University, Taoyuan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery
- Chang Gung University, Taoyuan
| | - Chun-Nan Yeh
- Department of General Surgery
- Chang Gung University, Taoyuan
| | - I-Fang Chung
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Linkou
- Chang Gung University, Taoyuan
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Virdis F, Reccia I, Di Saverio S, Tugnoli G, Kwan SH, Kumar J, Atzeni J, Podda M. Clinical outcomes of primary arterial embolization in severe hepatic trauma: A systematic review. Diagn Interv Imaging 2018; 100:65-75. [PMID: 30555019 DOI: 10.1016/j.diii.2018.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE This purpose of this systematic review was to determine the safety and efficacy of arterial embolization as the primary treatment for grade III-V liver trauma, excluding the postoperative use of arterial embolization. MATERIAL AND METHODS A total of 24 studies published between January 2000 and June 2018 qualified for inclusion in this study. Four of them were prospective studies and 20 were retrospective. A total of 3855 patients (mean age, 33.5 years; range: 22-52.5 years) were treated non-operatively and 659 patients (659/3855; 17.09%) with hepatic hemorrhage underwent primary arterial embolization from 2000 to 2017. Indication for arterial embolization was a contrast blush visible on computed tomography in hemodynamically stable patient in all studies. RESULTS The arterial embolization success rate ranged from 80% to 97%. The most commonly reported complication was bile leak, with an incidence of 5.7%. Nineteen bilomas (2.8%) were reported in five studies with a range between 4% and 45%. Hepatic ischemia was reported in eight studies, with a mean incidence of 8.6%. CONCLUSION Primary arterial embolization has a high success rate in patients with hepatic trauma. Complications, including biloma and hepatic ischemia, have acceptable rates in the context of a minimally-invasive procedure that allows stabilization of life-threatening, complex liver injuries.
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Affiliation(s)
- F Virdis
- General Surgery Department, Hillingdon Hospital NHS Foundation Trust, Uxbridge, UB8 3NN, London, United Kingdom.
| | - I Reccia
- Haepato-Biliary-Pancreatic Unit, Hammersmith Hospital, Imperial College, Du Cane Road W120HS, London, United Kingdom
| | - S Di Saverio
- Department of Surgery, Addenbrooke's Hospital, Hills Rd, CB2 0QQ, Cambridge, United Kingdom
| | - G Tugnoli
- Trauma and Emergency Surgery Unit, Maggiore Hospital, Largo Nigrisoli, 2, 40133 Bologna BO, Italy
| | - S H Kwan
- Royal Perth Hospital, 97, Wellington St, Perth WA 6000, Australia
| | - J Kumar
- Department of Surgery & Cancer, Imperial College, Du Cane Road, W120HS London, United Kingdom
| | - J Atzeni
- General and Emergency Surgery Unit, Ns Signora di Bonaria Hospital, 09037 San Gavino, Italy
| | - M Podda
- General, Emergency and Robotic Surgery Unit, San Francesco Hospital, 08100 Nuoro NU, Italy
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4
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Kim SJ, Ahn SJ, Choi SJ, Park DH, Kim HS, Kim JH. Optimal CT protocol for the diagnosis of active bleeding in abdominal trauma patients. Am J Emerg Med 2018; 37:1331-1335. [PMID: 30340991 DOI: 10.1016/j.ajem.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 10/04/2018] [Accepted: 10/10/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The aim of this study is to compare the radiologic diagnostic performance of arterial phase, portal phase and combined phase computed tomography (CT) for traumatic abdominal injury. In addition, this study is attempted to decrease lifetime attributable risks (LARs) of cancer due to radiation exposure by using optimal CT protocol. MATERIALS AND METHODS A total of 114 consecutive patients with a traumatic abdominal injury and an abdominal hematoma on CT were enrolled at a single tertiary regional trauma center between January 2016 and March 2017. Each CT protocol set was independently reviewed by three radiologists, and the diagnostic performance of all three CT phases were compared with regard to the capability to detect active bleeding, contained vascular injuries, and organ injuries. Additionally, LARs for cancer incidence and mortality were calculated using dose-length product values, for each phase of CT. RESULTS The pooled area under the receiver operating characteristic curves for the diagnosis of active bleeding, contained vascular injuries, and organ injuries ranged from 0.910 to 0.922, 0.643 to 0.723, and 0.948 to 0.915 for arterial, portal, and combined phase CT, respectively. There was no statistically significant difference in the diagnosis of active bleeding and organ injuries for any combination of two phase sets. The mean LARs for cancer incidence was 0.059%, 0.062% and 0.121% during arterial, portal and combined phase CT, respectively. CONCLUSION Single phase CT could be a potential protocol for abdominal trauma patients. Use of single phase CT could significantly decrease the incidence of radiation-associated cancer in the future.
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Affiliation(s)
- Se Jong Kim
- Gachon University Graduate School of Medicine, Incheon, South Korea
| | - Su Joa Ahn
- Department of Radiology, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Seung Joon Choi
- Department of Radiology, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea.
| | - Dae Hong Park
- Department of Radiology, Compensation and Welfare Service Ansan Hospital, Ansan, South Korea
| | - Hyung Sik Kim
- Department of Radiology, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Jeong Ho Kim
- Department of Radiology, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
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5
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Johnsen NV, Betzold RD, Guillamondegui OD, Dennis BM, Stassen NA, Bhullar I, Ibrahim JA. Surgical Management of Solid Organ Injuries. Surg Clin North Am 2017; 97:1077-1105. [PMID: 28958359 DOI: 10.1016/j.suc.2017.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.
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Affiliation(s)
- Niels V Johnsen
- Urological Surgery, Department of Urological Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA
| | - Richard D Betzold
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Nicole A Stassen
- Surgical Critical Care Fellowship and Surgical Sub-Internship, University of Rochester, Kessler Family Burn Trauma Intensive Care Unit, 601 Elmwood Avenue, Box Surg, Rochester, NY 14642, USA
| | - Indermeet Bhullar
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
| | - Joseph A Ibrahim
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
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6
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Kim MJ, Oh JY, Park YS. Availability of angiography and therapeutic embolization for the treatment of acute bleeding in patients with hemophilia. Int J Hematol 2017; 106:787-793. [PMID: 28815418 DOI: 10.1007/s12185-017-2312-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
Clotting factor replacement therapy alone is often inadequate for acute bleeding in hemophilia patients, and surgery for such patients poses significant clinical challenges. Arterial angiographic intervention is used to control bleeding in local blood vessels. In the present study, we examined the clinical course and prognosis of hemophilia patients with bleeding who had undergone angiography, and evaluated the validity of diagnostic angiography and therapeutic embolization in these patients. Angiography was performed in five hemophilia patients, who experienced bleeding that was difficult to control even after treatment with clotting factor replacement or bypassing agent therapy. Of these patients, four were confirmed to have continued bleeding, and angiographic embolization was performed using clotting factor concentrates or bypassing agents. However, one patient developed uncontrollable bleeding at the puncture site, which eventually led to the patient's death. Thus, angiography and therapeutic embolization may be the preferred procedures for the treatment of hemorrhagic complications, refractory to treatment with clotting factor concentrates or bypassing agents. Further comprehensive, multidisciplinary team studies are needed to develop effective strategies to reduce hemorrhagic complications.
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Affiliation(s)
- Mi Jin Kim
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-Gu, Seoul, 05278, Korea
| | - Ji Young Oh
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-Gu, Seoul, 05278, Korea.
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7
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Melikian R, Goldberg S, Strife BJ, Halvorsen RA. Comparison of MDCT protocols in trauma patients with suspected splenic injury: superior results with protocol that includes arterial and portal venous phase imaging. Diagn Interv Radiol 2017; 22:395-9. [PMID: 27334296 DOI: 10.5152/dir.2016.15232] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to determine which intravenous contrast-enhanced multidetector computed tomography (MDCT) protocol produced the most accurate results for the detection of splenic vascular injury in hemodynamically stable patients who had sustained blunt abdominal trauma. METHODS We retrospectively reviewed 88 patients from 2003 to 2011 who sustained blunt splenic trauma and underwent contrast-enhanced MDCT and subsequent angiography. Results of MDCT scans utilizing single phase (portal venous only, n=8), dual phase (arterial + portal venous or portal venous + delayed, n=42), or triple phase (arterial + portal venous + delayed, n=38) were compared with results of subsequent splenic angiograms for the detection of splenic vascular injury. RESULTS Dual phase imaging was more sensitive and accurate than single phase imaging (P = 0.016 and P = 0.029, respectively). When the subsets of dual phase imaging were compared, arterial + portal venous phase imaging was more sensitive and accurate than portal venous + delayed phase imaging (P = 0.005 and P = 0.002, respectively). Triple phase imaging was more accurate (P = 0.015) than dual phase; however, when compared with the dual phase subset of arterial + portal venous, there was no statistical difference in either sensitivity or accuracy. CONCLUSION Our results support the use of dual phase contrast-enhanced MDCT, which includes the arterial phase, in patients with suspected splenic injury and question the utility of obtaining a delayed sequence.
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Affiliation(s)
- Raymond Melikian
- Departments of Radiology and Acute Care Surgical Service, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
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8
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Li S, Gupta N, Kumar Y, Mele F. Splenic laceration after routine colonoscopy, a case report of a rare iatrogenic complication. Transl Gastroenterol Hepatol 2017; 2:49. [PMID: 28616605 DOI: 10.21037/tgh.2017.04.11] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 04/11/2017] [Indexed: 12/16/2022] Open
Abstract
Colonoscopy is a common and routine procedure performed in the United States, most commonly performed for screening of colorectal cancer. Although colonoscopy is considered a safe procedure, it is associated with complications including intestinal hemorrhage and perforation. Splenic trauma, such as laceration or even complete rupture is a rarely reported, but potentially fatal complication if undetected. We present a case of splenic laceration with subcapsular hematoma status post routine colonoscopy. Fortunately, patient was able to be managed medically, without further operative intervention. We will also review the available literature related to this rare iatrogenic complication.
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Affiliation(s)
- Shuo Li
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, Connecticut 06610, USA
| | - Nishant Gupta
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, Connecticut 06606, USA
| | - Yogesh Kumar
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, Connecticut 06610, USA
| | - Frank Mele
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, Connecticut 06610, USA
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9
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Bhullar IS, Tepas JJ, Siragusa D, Loper T, Kerwin A, Frykberg ER. To nearly come full circle. J Trauma Acute Care Surg 2017; 82:657-664. [DOI: 10.1097/ta.0000000000001366] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Abstract
Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or "conservative" management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon's disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed. REPUBLISHED WITH PERMISSION FROM Stawicki SPA. Trends in nonoperative management of traumatic injuries - A synopsis. OPUS 12 Scientist 2007;1(1):19-35.
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Affiliation(s)
- Stanislaw P A Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
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11
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Morris CS. Role of Vascular and Interventional Radiology in the Diagnosis and Management of Acute Trauma Patients. J Intensive Care Med 2016. [DOI: 10.1177/088506660201700302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vascular and interventional radiology provides an important service in the diagnosis and management of the acute trauma patient. Historically angiography was used primarily as a diagnostic tool for both vascular and solid organ injuries. However, with technological advances, such as the advent of stents, stent grafts, newer embolization materials and sophisticated delivery devices, micro-catheters, and steerable guide wires, vascular and interventional radiology can now offer definitive treatment in selected cases. Transcatheter embolization can effectively treat acute hemorrhage and is useful in locations that are difficult to access surgically, or when surgical disruption of fascial planes, which may eliminate a tamponade effect, is less desirable. Stents and stent grafts have been used to preserve, rather than sacrifice, an injured blood vessel. In splenic, hepatic, and renal trauma, a trend in nonoperative management has been developed by traumatologists. Transcatheter embolization can increase the success rate of nonoperative management in selected injuries. In general, despite the injury grade, if evidence of ongoing hemorrhage is present, angiography and transcatheter embolization should be considered. Peripheral vascular injuries can be treated with transcatheter embolization or stents and stent grafts. Transcatheter embolization in trauma was first applied to bleeding associated with pelvic fractures and dislocations, and continues to be an important treatment option. Carotid and vertebral artery injuries can now be repaired using stents or stent grafts, although the experience of this treatment strategy is somewhat limited. Likewise, acute traumatic aortic injury has been successfully treated with stent grafts in small series. Conventional catheter thoracic aortography is now used as an adjunctive diagnostic test for indeterminate or questionable findings on noninvasive imaging studies, primarily computed tomography scans of the chest. In summary, vascular and interventional radiology maintains an important role in the diagnosis and management of acute vascular and solid organ injury. The following review illustrates its current status in acute trauma.
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Affiliation(s)
- Christopher S. Morris
- Department of Radiology, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT,
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12
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Helaly AZ, Al-Warraky MS, El-Azab GI, Kohla MAS, Abdelaal EE. Portal and splanchnic hemodynamics after partial splenic embolization in cirrhotic patients with hypersplenism. APMIS 2016; 123:1032-9. [PMID: 26547369 DOI: 10.1111/apm.12470] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 09/28/2015] [Indexed: 01/28/2023]
Abstract
To assess the acute effects of partial splenic embolization (PSE) on portal and splanchnic hemodynamics in patients with cirrhosis. Ninety-five patients with hypersplenism were included in the study. Duplex examinations were performed before and 3 and 7 days after PSE. Portal and splanchnic hemodynamics including vessel cross-sectional area (CSA), mean flow velocities (cm/s), blood flows (mL/min), Doppler indices as portal congestion index (CI), liver vascular index, hepatic artery and superior mesenteric artery (SMA) pulsatility and resistive indices (PI and RI), were performed before and after PSE. In our study, 69 of 95 patients were males (72.6%) and 26 females (27.3%). Chronic hepatitis C virus infection was the main cause of cirrhosis (81.1%). PSE failed technically in six patients (6.3%). After PSE, both CSA and CI significantly decreased (p < 0.05 and <0.01). The portal vein velocity significantly increased (p < 0.01). The portal flow volume (892.4 ± 151 mL/min) did not show significant changes. The hepatic artery RI and PI showed a steady increase that became significant 7 days post-PSE (p < 0.05). The RI and PI of SMA increased significantly after 7 days of PSE (p < 0.05). PSE has an immediate portal decompression effect in patients with portal hypertension without reduction in portal flow. This effect on portal pressure should be investigated in future studies as a potential tool for management of acute variceal bleeding when other medical procedures fail.
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Affiliation(s)
- Ahmed Z Helaly
- Internal Medicine Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Mohamed S Al-Warraky
- Department of Radiology, National Liver Institute, Menoufiya University, Shebeen El kom, Egypt
| | - Gasser I El-Azab
- Department of Hepatology, National Liver Institute, Menoufiya University, Shebeen El kom, Egypt
| | - Mohamed A S Kohla
- Department of Hepatology, National Liver Institute, Menoufiya University, Shebeen El kom, Egypt
| | - Elsayed E Abdelaal
- Department of Hepatology, National Liver Institute, Menoufiya University, Shebeen El kom, Egypt
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13
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Freitas G, Olufajo OA, Hammouda K, Lin E, Cooper Z, Havens JM, Askari R, Salim A. Postdischarge complications following nonoperative management of blunt splenic injury. Am J Surg 2016; 211:744-749.e1. [PMID: 26830714 DOI: 10.1016/j.amjsurg.2015.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 11/11/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Nonoperative management (NOM) is the standard of care in majority of blunt splenic injuries. However, little is known about the postdischarge complications. METHODS Patients admitted for blunt splenic injury were identified in the California State Inpatient Database (2007 to 2011). We examined patterns and risk factors for postdischarge complications among these patients. RESULTS In total, 2,704 (61.45%) patients had NOM without splenic artery embolization (SAE) and 257 (5.84%) had NOM with adjunct SAE. Thirty-day readmission rate was higher in those who had adjunct SAE (12.84% vs 7.36%, P = .002). Subsequent operations during readmission were seen in 18.10% of readmitted patients and 38.10% of all patients were readmitted at nonindex hospitals. Major diagnoses on readmission were spleen injury (36.2%) and respiratory complications (9.05%). Adjunct SAE was an independent risk factor for readmission (adjusted odds ratio 1.82, 95% confidence interval 1.19 to 2.78). CONCLUSIONS Nearly one fifth of readmitted patients initially managed nonoperatively required an operative intervention. Improving predischarge assessments and postdischarge follow-up may reduce readmissions among these patients.
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Affiliation(s)
- Gil Freitas
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, Boston, MA 02120, USA
| | - Khaled Hammouda
- Surgical ICU Translational Research Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Elissa Lin
- Faculty of Arts and Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Zara Cooper
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, Boston, MA 02120, USA
| | - Joaquim M Havens
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, Boston, MA 02120, USA
| | - Reza Askari
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, Boston, MA 02120, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, Boston, MA 02120, USA.
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Abstract
OBJECTIVE The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization. CONCLUSION Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension.
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Foley PT, Kavnoudias H, Cameron PU, Czarnecki C, Paul E, Lyon SM. Proximal Versus Distal Splenic Artery Embolisation for Blunt Splenic Trauma: What is the Impact on Splenic Immune Function? Cardiovasc Intervent Radiol 2015; 38:1143-51. [PMID: 26139039 DOI: 10.1007/s00270-015-1162-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/04/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare the impact of proximal or distal splenic artery embolisation versus that of splenectomy on splenic immune function as measured by IgM memory B cell levels. MATERIALS AND METHODS Patients with splenic trauma who were treated by splenic artery embolisation (SAE) were enrolled. After 6 months splenic volume was assessed by CT, and IgM memory B cells in peripheral blood were measured and compared to a local normal reference population and to a post-splenectomy population. RESULTS Of the 71 patients who underwent embolisation, 38 underwent proximal embolisation, 11 underwent distal embolisation, 22 patients were excluded, 1 had both proximal and distal embolisation, 5 did not survive and 16 did not return for evaluation. There was a significant difference between splenectomy and proximal or distal embolisation and a trend towards greater preservation of IgM memory B cell number in those with distal embolisation-a difference that could not be attributed to differences in age, grade of injury or residual splenic volume. CONCLUSION IgM memory B cell levels are significantly higher in those treated with SAE compared to splenectomy. Our data provide evidence that splenic embolisation should reduce immunological complications of spleen trauma and suggest that distal embolisation may maintain better function.
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Affiliation(s)
- P T Foley
- Department of Medical Imaging, The Canberra Hospital, Yamba Drive, Garran, ACT, 2605, Australia.
| | - H Kavnoudias
- Radiology Research Unit, Radiology Department, The Alfred Hospital, Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - P U Cameron
- Infectious Diseases Unit, The Alfred Hospital, Commercial Rd, Melbourne, VIC, 3004, Australia. .,Department of Microbiology and Immunology, Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth St, Melbourne, VIC, 3000, Australia.
| | - C Czarnecki
- Radiology Department, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC, 3050, Australia.
| | - E Paul
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Alfred Hospital, Monash University, Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - S M Lyon
- Melbourne Endovascular, 5 Chesterville Rd, Cheltenham, VIC, 3192, Australia. .,Radiology Department, The Alfred Hospital, Commercial Rd, Melbourne, VIC, 3004, Australia.
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16
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Abstract
High-volume crystalloid resuscitation is associated with increased length of stay, ICU and ventilator days, and organ failure and infection rates. Rapid evaluation of a hemodynamically unstable trauma patient is vital to diagnosis and treatment of the cause of shock. CT scanning should be used liberally in trauma patients to effect decreased mortality. Nonoperative management and catheter-based interventions are becoming the standard of care in appropriately selected patients with solid organ injuries.
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Affiliation(s)
- Kimberly Boswell
- Department of Emergency Medicine, University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201-1559, USA.
| | - Jay Menaker
- Department of Surgery (Primary)/Emergency Medicine (Secondary), University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21201, USA
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17
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Blunt splenic injury: Outcomes of proximal versus distal and combined splenic artery embolization. Diagn Interv Imaging 2014; 95:825-31. [DOI: 10.1016/j.diii.2014.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Ding P, Li Z, Han XW, Wang ZG, Zhang WG, Fu MT. Portal, Mesenteric, and Splenic Vein Thromboses after Endovascular Embolization for Gastrointestinal Bleeding Caused by a Splenic Arteriovenous Fistula. Ann Vasc Surg 2014; 28:1322.e1-5. [DOI: 10.1016/j.avsg.2013.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 10/09/2013] [Accepted: 11/10/2013] [Indexed: 11/25/2022]
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Smith A, Ouellet JF, Niven D, Kirkpatrick AW, Dixon E, D'Amours S, Ball CG. Timeliness in obtaining emergent percutaneous procedures in severely injured patients: how long is too long and should we create quality assurance guidelines? Can J Surg 2014; 56:E154-7. [PMID: 24284155 DOI: 10.1503/cjs.020012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Modern trauma care relies heavily on nonoperative, emergent percutaneous procedures, particularly in patients with splenic, pelvic and hepatic injuries. Unfortunately, specific quality measures (e.g., arrival to angiography times) have not been widely discussed. Our objective was to evaluate the time interval from arrival to initiation of emergent percutaneous procedures in severely injured patients. METHODS All severely injured trauma patients (injury severity score [ISS] > 12) presenting to a level 1 trauma centre (2007-2010) were analyzed with standard statistical methodology. RESULTS Among 60 severely injured patients (mean ISS 31, hypotension 18%, mortality 12%), the median time interval to the initiation of an angiographic procedure was 270 minutes. Of the procedures performed, 85% were therapeutic embolizations and 15% were diagnostic procedures. Splenic (median time 243 min, range 32-801 min) and pelvic (median time 278 min, range 153-466 min) embolizations accounted for 43% and 25% of procedures, respectively. The median embolization procedure duration for the spleen was 28 (range 15-153) minutes compared with 59 (range 34-171) minutes for the pelvis. Nearly 22% of patients required both an emergent percutaneous and subsequent operative procedure. Percutaneous therapy typically preceded open operative explorations. CONCLUSION The time interval from arrival at the trauma centre to emergent percutaneous procedures varied widely. Improved processes emphasizing patient transition from the trauma bay to the angiography suite are essential. Discussion regarding the appropriate time to angiography is needed so this marker can be used as a quality outcome measure for all level 1 trauma centres.
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Affiliation(s)
- Andrew Smith
- From the Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
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20
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Abstract
Overwhelming postsplenectomy sepsis is a rare but devastating and often lethal disease. Although vaccines are available, their proper use may be questioned. Standardization of protocols for the immunization of asplenic patients should be universal, thus, likely improving on their use. This article reviews the vaccines to be administered to the asplenic patient.
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Affiliation(s)
- David V Shatz
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of Miami School of Medicine, PO Box 016960 (D-40), Miami, FL 33101, USA.
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21
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Uyeda JW, LeBedis CA, Penn DR, Soto JA, Anderson SW. Active Hemorrhage and Vascular Injuries in Splenic Trauma: Utility of the Arterial Phase in Multidetector CT. Radiology 2014; 270:99-106. [DOI: 10.1148/radiol.13121242] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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22
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Abstract
Significant advancements in nonsurgical and surgical approaches to control bleeding in severely injured patients have also improved the treatment of critical trauma-related coagulopathy. Nonsurgical procedures such as angiographic embolization are progressively considered to terminate arterial bleeding from pelvic fractures. The disturbance of coagulation may aggravate bleeding and hamper surgical procedures. The administration of coagulation factors and factor concentrates may be useful for correcting systemic coagulopathy and reducing the need for fresh frozen plasma, platelet, and red blood cell transfusions, which are associated with various adverse outcomes. In this review, nonsurgical management of critical trauma bleeding is discussed.
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Affiliation(s)
- Christian Zentai
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany.
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23
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Bhullar IS, Frykberg ER, Tepas JJ, Siragusa D, Loper T, Kerwin AJ. At first blush. J Trauma Acute Care Surg 2013; 74:105-11; discussion 111-2. [DOI: 10.1097/ta.0b013e3182788cd2] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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25
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Sliker CW, Steenburg SD, Archer-Arroyo K. Emergency radiology eponyms: part 2--Naclerio's V sign to Fournier gangrene. Emerg Radiol 2012; 20:185-95. [PMID: 23065070 DOI: 10.1007/s10140-012-1082-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022]
Abstract
An eponym is a name based on the name of a person, frequently as a means to honor him/her, and it can be used to concisely communicate or summarize a complex abnormality or injury. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in medicine. Many commonly used eponyms applied to extremity fractures should be familiar to most emergency radiologists and have been previously reported. Yet, a number of non-extremity eponyms can be encountered in an emergency radiology practice as well. This other group of eponyms encompasses a spectrum of traumatic and nontraumatic pathology. In this second part of a two-part series, the authors discuss a number of non-extremity emergency radiology eponyms, including relevant clinical and imaging features, as well biographical information of the eponyms' namesakes.
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Affiliation(s)
- Clint W Sliker
- Diagnostic Imaging Department, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201, USA.
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26
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Embolization for Multicompartmental Bleeding in Patients in Hemodynamically Unstable Condition: Prognostic Factors and Outcome. J Vasc Interv Radiol 2012; 23:751-760.e4. [DOI: 10.1016/j.jvir.2012.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/15/2012] [Accepted: 02/18/2012] [Indexed: 11/23/2022] Open
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Parihar ML, Kumar A, Gamanagatti S, Bhalla AS, Mishra B, Kumar S, Jana M, Misra MC. Role of splenic artery embolization in management of traumatic splenic injuries: a prospective study. Indian J Surg 2012; 75:361-7. [PMID: 24426477 DOI: 10.1007/s12262-012-0505-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 04/05/2012] [Indexed: 11/30/2022] Open
Abstract
The objective of our study was to evaluate the role of splenic artery embolization (SAE) in the management of traumatic splenic injuries. From September 2008 to September 2010, a total of 67 patients underwent nonoperative management (NOM) for blunt splenic injuries. Twenty-two patients were excluded from the study because of associated significant other organ injuries. Twenty-five patients underwent SAE followed by NOM (group A) and 20 patients underwent standard NOM (group B). Improvement in clinical and laboratory parameters during hospital stay were compared between two groups using Chi-square test and Mann-Whitney test. SAE was always technically feasible. The mean length of the total hospital stay was lower in the group A patients (5.4 vs. 6.6 day, [P = 0.050]). There was significant increase in hemoglobin and hematocrit levels and systolic blood pressure (SBP) in group A patients after SAE, whereas in group B patients there was decrease in hemoglobin and hematocrit levels and only slight increase in SBP (pre- and early posttreatment relative change in hemoglobin [P = 0.002], hematocrit [P = 0.001], and SBP [P = 0.017]). Secondary splenectomy rate was lower in group A (4 % [1/25] vs. 15 % [3/20] [P = 0.309]). No procedure-related complications were encountered during the hospital stay and follow-up. Minor complications of pleural effusion, fever, pain, and insignificant splenic infarct noted in 9 (36 %) patients. SAE is a technically feasible, safe, and effective method in the management of splenic injuries. Use of SAE as an adjunct to NOM of splenic injuries results improvement in hemoglobin, hematocrit levels, and SBP. SAE also reduces secondary splenectomy rate and hospital stay.
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Affiliation(s)
- Mohan Lal Parihar
- Department of Radiology, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Atin Kumar
- Department of Radiology, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Shivanand Gamanagatti
- Department of Radiology, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Ashu Seith Bhalla
- Department of Radiology, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Biplab Mishra
- Department of Surgery, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Subodh Kumar
- Department of Surgery, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Manisha Jana
- Department of Radiology, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Mahesh C Misra
- Department of Surgery, JPNA Trauma centre, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
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28
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Abstract
Evaluation for splenic injury is an important component of patient assessment after blunt abdominal trauma. Key imaging modalities include ultrasound, particularly for rapid identification of hemoperitoneum, and computed tomography (CT), which permits a more detailed and accurate determination of splenic integrity. Specific findings at contrast-enhanced multidetector CT (MDCT) should prompt the consideration of catheter angiography with arterial embolization as an adjunct to nonsurgical management. This article reviews the roles of imaging in the management of splenic trauma, illustrates the MDCT appearance of various splenic injuries, and discusses imaging-based indications for operative and angiographic intervention.
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van der Vlies CH, Hoekstra J, Ponsen KJ, Reekers JA, van Delden OM, Goslings JC. Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury. Cardiovasc Intervent Radiol 2011; 35:76-81. [PMID: 21431976 PMCID: PMC3261389 DOI: 10.1007/s00270-011-0132-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 02/09/2011] [Indexed: 01/10/2023]
Abstract
Introduction Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center. Methods An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment. Results A total of 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%. Conclusions SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.
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Affiliation(s)
- C H van der Vlies
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 Amsterdam, The Netherlands.
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Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2011; 70:252-60. [PMID: 21217497 DOI: 10.1097/ta.0b013e3181f2a92e] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this systematic review and meta-analysis was to assess the outcomes after angioembolization in blunt trauma patients with splenic injuries and to examine specifically the impact of the technique used. Studies evaluating adult trauma patients who sustained blunt splenic injuries managed by angioembolization were systematically evaluated. The following data were required for inclusion: grade of splenic injury, indication for embolization, and site of embolization (proximal [main splenic artery] or distal [selective]). In addition, major (requiring splenectomy) or minor (not requiring splenectomy) rebleeding, infarction, and infection in relation to the site of embolization (proximal vs. distal) was required. Pooled outcomes were compared between proximal and distal embolizations. To eliminate between-study heterogeneity, a sensitivity analysis was conducted on three reduced sets of studies. Fifteen of 147 evaluated studies were included for analysis. All were retrospective cohort studies and incorporated a total of 479 embolized patients. The overall failure rate of angioembolization was 10.2% (range, 0.0-33.3%). Injury severity and basic demographics did not differ among the study populations. However, the indications for angioembolization (contrast extravasation, large amount of hemoperitoneum, or high-grade splenic injury) differed between the populations but were not associated with a change in the failure rates. Rebleeding was the most common reason for failure; however, it did not differ statistically between the used techniques, and with the 95% confidence interval crossing the 5% zone of clinical indifference, this result was inconclusive. Minor complications occurred statistically and clinically more often after distal than after proximal embolization. The available literature is inconclusive regarding whether proximal or distal embolization should be used to avoid significant rebleeding and larger prospective cohort studies are required. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur more often after distal embolization. This is primarily explained by the higher rate of segmental infarctions after distal embolization.
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31
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Wu SC, Fu CY, Chen RJ, Chen YF, Wang YC, Chung PK, Yu SF, Tung CC, Lee KH. Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients. Am J Emerg Med 2011; 29:135-40. [DOI: 10.1016/j.ajem.2009.07.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 07/24/2009] [Accepted: 07/28/2009] [Indexed: 01/26/2023] Open
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Angle JF, Siddiqi NH, Wallace MJ, Kundu S, Stokes L, Wojak JC, Cardella JF. Quality Improvement Guidelines for Percutaneous Transcatheter Embolization. J Vasc Interv Radiol 2010; 21:1479-86. [DOI: 10.1016/j.jvir.2010.06.014] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 06/08/2010] [Accepted: 06/26/2010] [Indexed: 10/19/2022] Open
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Doppler ultrasound for the assessment of conservatively treated blunt splenic injuries: a prospective study. Eur J Trauma Emerg Surg 2010; 37:197-202. [PMID: 26814956 DOI: 10.1007/s00068-010-0044-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 08/13/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The type and need for follow-up of non-operatively managed blunt splenic injuries remain controversial. The use of Doppler ultrasound to identify post-traumatic splenic pseudoaneurysms, considered to be the main cause of "delayed" splenic rupture, has not been well described. PATIENTS AND METHODS A 5-year prospective study was performed from 2004 to 2008. All patients with blunt splenic injury diagnosed with computerized tomography, who were treated non-operatively, were included in the study. Doppler ultrasound examination was performed 24-48 h post-injury. Consecutive Doppler ultrasound examinations were done on 7, 14 and 21 days post-injury for patients diagnosed with a splenic pseudoaneurysm. Demographic and clinical data were collected. Ambulatory follow-up continued for 4 weeks after hospital discharge. RESULTS A total of 38 patients were enrolled in the study. Grading of splenic injury demonstrated 19 (50%) patients with Grade I, 16 (42%) with Grade II and 3 (8%) with Grade III injuries. Two patients (5%) had pseudoaneurysms. All pseudoaneurysms underwent complete resolution within 2 weeks after diagnosis. No patients received blood products, or had angio-embolization or surgery during the study period. All patients were found to be asymptomatic and stable at the 4-week follow-up. CONCLUSIONS Doppler ultrasound can be an effective and a safe noninvasive modality for evaluation and follow-up of patients with blunt splenic injury. The utility and cost-effectiveness of routine surveillance requires further study.
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Literature review of the role of ultrasound, computed tomography, and transcatheter arterial embolization for the treatment of traumatic splenic injuries. Cardiovasc Intervent Radiol 2010; 33:1079-87. [PMID: 20668852 PMCID: PMC2977075 DOI: 10.1007/s00270-010-9943-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 06/14/2010] [Indexed: 11/05/2022]
Abstract
Introduction The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series. Diagnostics Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM. Angiography and Embolization The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.
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Fu CY, Wu SC, Chen RJ, Chen YF, Wang YC, Huang HC, Huang JC, Lu CW, Lin WC. Evaluation of Need for Operative Intervention in Blunt Splenic Injury: Intraperitoneal Contrast Extravasation has an Increased Probability of Requiring Operative Intervention. World J Surg 2010; 34:2745-51. [DOI: 10.1007/s00268-010-0723-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Angiography and embolisation for solid abdominal organ injury in adults - a current perspective. World J Emerg Surg 2010; 5:18. [PMID: 20584325 PMCID: PMC2907361 DOI: 10.1186/1749-7922-5-18] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 06/28/2010] [Indexed: 01/02/2023] Open
Abstract
Over the past twenty years there has been a shift towards non-operative management (NOM) for haemodynamically stable patients with abdominal trauma. Embolisation can achieve haemostasis and salvage organs without the morbidity of surgery, and the development and refinement of embolisation techniques has widened the indications for NOM in the management of solid organ injury. Advances in computed tomography (CT) technology allow faster scanning times with improved image quality. These improvements mean that whilst surgery is still usually recommended for patients with penetrating injuries, multiple bleeding sites or haemodynamic instability, the indications for NOM are expanding. We present a current perspective on angiography and embolisation in adults with blunt and penetrating abdominal trauma with illustrative examples from our practice including technical advice.
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Davies DA, Ein SH, Pearl R, Langer JC, Traubici J, Mikrogianakis A, Wales PW. What is the significance of contrast "blush" in pediatric blunt splenic trauma? J Pediatr Surg 2010; 45:916-20. [PMID: 20438926 DOI: 10.1016/j.jpedsurg.2010.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Accepted: 02/02/2010] [Indexed: 11/19/2022]
Abstract
PURPOSE Contrast extravasation (CE) associated with blunt splenic injuries (BSIs) in adults is commonly treated with embolization or splenectomy. Whether this is necessary in children is unclear. We sought to determine if CE on initial computed tomography (CT) is associated with negative outcomes in children with BSI. METHODS Blunt splenic injuries presented to our pediatric trauma center between January 21, 1999, and December 31, 2006, were reviewed (minimum follow-up = 2 years). Those with initial CTs available were reviewed by a pediatric radiologist blinded to outcomes. Descriptive analysis and multivariable logistic regression were performed using Stata S/E 10.0 (Stata Corporation, College Station, Tex). RESULTS One hundred eighty-two BSIs were treated at our center. One hundred twenty-three had available CTs (mean age, 10.7 years; male, 70.7%; mean Injury Severity Score, 17; median injury grade, 3; transfusion rate, 13.8%; overall mortality, 2.44%). Those with associated injuries comprised 47.1%. No splenectomies or splenorrhaphies were performed. One delayed splenic bleed occurred. Eight patients (6.5%) had CE on initial CT. Multivariable logistic regression controlling for multiple injuries found no association between CE and the need for transfusion, mortality, delayed splenic bleeding, length of hospitalization, or splenectomy. Contrast extravasation was positively associated with low initial and lowest hemoglobin levels (<90 g/L) (odds ratio [OR], 6.45; 95% confidence interval [CI], 1.00-39.47; P = .044 and OR, 5.63; 95% CI, 1.20-26.49; P = .029), respectively. CONCLUSION Contrast extravasation occurred in 6.5% of our pediatric patients with BSIs. The presence of contrast "blush" on abdominal CT was not associated with negative outcomes after a minimum of 2 years of follow-up. Pediatric patients with CE can be treated without surgery and can be managed using the standard American Pediatric Surgical Association guidelines.
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Affiliation(s)
- Dafydd A Davies
- Department of Pediatric Surgery, The Hospital for Sick Children, Toronto, Canada M5G 1X8
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van der Vlies CH, Saltzherr TP, Wilde JCH, van Delden OM, de Haan RJ, Goslings JC. The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review. J Pediatr Surg 2010; 45:1044-9. [PMID: 20438952 DOI: 10.1016/j.jpedsurg.2010.01.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Revised: 12/22/2009] [Accepted: 01/02/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE Nonoperative management (NOM) is the treatment of choice for hemodymically stable pediatric patients with spleen or liver trauma. The aim of this study was to assess the failure rate of NOM in children with blunt liver and/or splenic injury when a contrast blush is present on a computed tomography (CT) scan. METHODS A systematic review of the literature published between 1985 and 2009 was performed by searching the EMBASE and MEDLINE database for English and German articles. Articles were eligible if they reported the failure rate of NOM with or without angioembolization (AE) in pediatric patients with splenic and/or liver injuries with a contrast blush on CT and included 2 or more trauma patients. Two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. Interrater differences were resolved by discussion. RESULTS Nine studies were included describing 117 pediatric patients. The median sample size was 5 (range, 2-44). Seven studies (including 71 patients) reported a total of 16 patients with failure after NOM without AE. Failure rates across these studies ranged from 4.5% to 100%; the pooled percentage was 28.2% (95% confidence interval, 8.9%-61.3%). The failure percentages after NOM with or without AE ranged from 0 to 100%; the pooled percentage was 21% (95% confidence interval, 7.5%-46.8%). Two studies (including 46 patients) reported a total of 3 patients (6.5%) with failure after NOM with primary AE. CONCLUSION Despite the current low level of evidence on failure rate of NOM when a contrast blush is present on CT, we emphasize that there is a significant number of patients in whom NOM fails. We therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiologic response but should include consideration of the presence of a contrast blush.
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Hara K, Yoshida H, Taniai N, Mineta S, Kawano Y, Uchida E. Successful management of a symptomatic splenic artery aneurysm with transcatheter embolization. J NIPPON MED SCH 2010; 76:308-18. [PMID: 20035097 DOI: 10.1272/jnms.76.308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe a symptomatic splenic artery aneurysm (SAA) with occasional left-sided abdominal pain which was successfully treated with transcatheter embolization. A 65-year-old man was referred to a nearby clinic because of left shoulder and abdominal pain developing the day after blunt trauma to the shoulder and abdomen. Radiography revealed no fracture, and the patient went home. He stopped working for 7 months. Left-sided abdominal pain then developed several times after strenuous physical labor, and the patient was referred to a nearby hospital. The patient had a history of asthma and untreated hypertension; the use of iodinated contrast material was therefore avoided. Unenhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a hematoma in the splenic hilum. The patient was referred to Nippon Medical School Hospital. His neurologic status was stable. Unenhanced CT of the abdomen at a nearby hospital revealed a low-density area in the splenic hilum. Fat-suppressed, T1-weighted images showed a hyperintense lesion adjacent to the splenic hilum. Fat-suppressed, T2-weighted images showed a dark hemosiderin rim, a bright ring, and an intermediate central core, which indicated a recurrent chronic hematoma in the abdomen. Dynamic contrast-enhanced MRI revealed a small hyperenhanced lesion adjacent to the hematoma, which appeared to be an SAA. After an injection of corticosteroids, selective splenic arteriography was performed. The splenic artery was catheterized via a right femoral approach. Arteriography showed an SAA, 1 cm in diameter with extravasation of contrast material. The neck of the SAA was catheterized with a microcatheter, and coils were placed successfully into the SAA to prevent recurrent bleeding. Postembolization angiography showed total occlusion of the SAA. The patient was discharged 7 days after embolization and has since resumed normal activities, with no residual symptoms.
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Affiliation(s)
- Keisuke Hara
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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Ekeh AP, Izu B, Ryan M, McCarthy MC. The impact of splenic artery embolization on the management of splenic trauma: an 8-year review. Am J Surg 2009; 197:337-41. [PMID: 19245911 DOI: 10.1016/j.amjsurg.2008.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Revised: 11/13/2008] [Accepted: 11/14/2008] [Indexed: 01/20/2023]
Abstract
BACKGROUND Splenic artery embolization (SAE) is an adjunct to nonoperative management (NOM) of splenic injuries. We reviewed our experience with SAE to identify its impact on splenic operations. METHODS Patients admitted with splenic injuries over an 8-year period were identified and the initial method of management noted (simple observation, SAE, or splenic surgery). The first 4 years (period 1) during which SAE was introduced was compared with the latter 4 years (period 2) when it was used frequently. RESULTS There were 304 patients in period 1 and 416 in period 2. NOM was initial management in 59.9% in period 1% and 60.1% in period 2 (P = 1.0) and failure rates were 5.3% versus 2.9%, respectively (P = .12). More SAE procedures were performed in period 2 -- 13.7% versus 4.9% (P < or = .001) -- and there was a reduction in the proportion of splenic operations -- 35.2% versus 26.2% (P <.01). CONCLUSIONS SAE is associated with a reduction in splenic operations, although it did not alter the failure rate of NOM.
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Affiliation(s)
- Akpofure Peter Ekeh
- Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.
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Krohmer SJ, Hoffer EK, Burchard KW. Transcatheter embolization for delayed hemorrhage caused by blunt splenic trauma. Cardiovasc Intervent Radiol 2009; 33:861-5. [PMID: 19267152 DOI: 10.1007/s00270-009-9535-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 01/14/2009] [Accepted: 01/28/2009] [Indexed: 10/21/2022]
Abstract
Although the exact benefit of adjunctive splenic artery embolization (SAE) in the nonoperative management (NOM) of patients with blunt splenic trauma has been debated, the role of transcatheter embolization in delayed splenic hemorrhage is rarely addressed. The purpose of this study was to evaluate the effectiveness of SAE in the management of patients who presented at least 3 days after initial splenic trauma with delayed hemorrhage. During a 24-month period 4 patients (all male; ages 19-49 years) presented with acute onset of pain 5-70 days after blunt trauma to the left upper quadrant. Two had known splenic injuries that had been managed nonoperatively. All had computed axial tomography evidence of active splenic hemorrhage or false aneurysm on representation. All underwent successful SAE. Follow-up ranged from 28 to 370 days. These cases and a review of the literature indicate that SAE is safe and effective for NOM failure caused by delayed manifestations of splenic arterial injury.
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Affiliation(s)
- Steven J Krohmer
- Section of Vascular and Interventional Radiology, Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Abstract
BACKGROUND Nonoperative management (NOM) of blunt splenic injuries is widely accepted, and the use of splenic artery embolization (SAE) has become a valuable adjunct to NOM. We retrospectively review and discuss the complications derived from SAE. MATERIALS AND METHODS The medical records of 152 consecutive patients with blunt splenic trauma admitted to our trauma center during a 33-month period were retrospectively reviewed. The patients were managed according to an established algorithm. The record review focused on the method of patient management (operative versus nonoperative) and use of SAE. The complications encountered following SAE are discussed in detail. RESULTS Altogether, 73 patients underwent emergency surgery (58 splenectomies, 15 splenorrhaphies), and 79 patients had NOM. Of the 79 patients with NOM, 58 were successfully treated; 2 patients required splenectomy after 24 hours. The remaining 21 patients had SAE, including 18 distal and 3 proximal embolizations. Major complications occurred in 28.5% of the SAE-treated patients and included total splenic infarction, splenic atrophy, and postprocedure bleeding. Minor complications occurred in 61.9% of the patients and included fever, pleural effusion, and partial splenic infarction. CONCLUSION SAE is considered a valuable adjunct to NOM in the treatment of blunt splenic injuries; however, risks of major and minor complications do exist, and SAE should be offered with caution and followed up appropriately.
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Abstract
The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.
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Abstract
BACKGROUND Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury. METHODS This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI. RESULTS During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored approximately 5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM. CONCLUSIONS We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.
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Intraparenchymal Doppler ultrasound after proximal embolization of the splenic artery in trauma patients. Eur Radiol 2008; 18:1224-31. [DOI: 10.1007/s00330-008-0860-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 11/18/2007] [Accepted: 01/02/2008] [Indexed: 11/30/2022]
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Sweat JA, Dort JM, Smith RS. Splenic Embolization for Splenic Laceration in a Patient with Mononucleosis. Am Surg 2008. [DOI: 10.1177/000313480807400213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Splenomegaly is a sequela of infectious mononucleosis. The potential for traumatic rupture of an enlarged spleen is well recognized. Recently, splenic artery embolization has gained popularity for the treatment of splenic injury. However, embolization has not been described for splenic injury in an enlarged spleen secondary to mononucleosis. We report the case of a 15-year-old girl who was the restrained passenger in a motor vehicle crash. On examination at an American College of Surgeons-verified Level 1 trauma center, the patient was found to have abdominal pain. A focused assessment with sonography for trauma examination revealed fluid in Morison's pouch. A subsequent spiral CT scan with intravenous contrast revealed a markedly enlarged spleen with a shattered upper pole. The patient denied symptoms of mononucleosis; however, a spot mononucleosis test was positive. The patient was admitted to the pediatric intensive care unit for observation. She remained hemodynamically stable, but her initial hemoglobin of 9.2 g/dL fell to 7.1 g/dL 6 hours later. Splenic artery embolization was performed and the upper pole of the spleen was selectively embolized. The hemoglobin remained stable and the patient was transferred to the pediatric ward. On postembolization day five, the patient was dismissed with a hemoglobin of 9.7 g/dL. This case demonstrates that splenic embolization is a viable alternative to operative treatment even in the presence of splenomegaly secondary to mononucleosis.
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Affiliation(s)
- Jeffrey A. Sweat
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas
| | - Jonathan M. Dort
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas
- Division of Trauma, Via Christi Regional Medical Center, Wichita, Kansas
| | - R. Stephen Smith
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas
- Division of Trauma, Via Christi Regional Medical Center, Wichita, Kansas
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Lin WC, Chen YF, Lin CH, Tzeng YH, Chiang HJ, Ho YJ, Shen WC, Chen JH. Emergent transcatheter arterial embolization in hemodynamically unstable patients with blunt splenic injury. Acad Radiol 2008; 15:201-8. [PMID: 18206619 DOI: 10.1016/j.acra.2007.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Revised: 08/21/2007] [Accepted: 09/10/2007] [Indexed: 10/22/2022]
Abstract
RATIONALE AND OBJECTIVES Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury. MATERIALS AND METHODS In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture. RESULTS Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications. CONCLUSIONS TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.
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Inoue Y, Ikegawa H, Ukai I, Yoshiya K, Sumi Y, Ogura H, Kuwagata Y, Tanaka H, Shimazu T, Sugimoto H. Spontaneous occlusion of splenic and renal pseudoaneurysm after blunt abdominal trauma: a case report and literature review. J Emerg Med 2008; 38:e17-22. [PMID: 18180131 DOI: 10.1016/j.jemermed.2007.07.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2006] [Revised: 03/24/2007] [Accepted: 07/12/2007] [Indexed: 11/16/2022]
Abstract
Pseudoaneurysms caused by blunt abdominal trauma are rarely observed in solid organs. The preferred therapy for pseudoaneurysm after blunt abdominal trauma is often angiography and embolization. Here, we report a case of a spontaneous occlusion of splenic pseudoaneurysm and renal pseudoaneurysm after blunt abdominal trauma. Angiography and embolization were not required, and contrast-enhanced multi-detector computed tomography was used to monitor the patient. This case shows that spontaneous occlusion can be one of the possible outcomes of intraparenchymal splenic pseudoaneurysm and renal pseudoaneurysm after blunt abdominal trauma.
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Affiliation(s)
- Yoshiaki Inoue
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Bessoud B, Duchosal MA, Siegrist CA, Schlegel S, Doenz F, Calmes JM, Qanadli SD, Schnyder P, Denys A. Proximal Splenic Artery Embolization for Blunt Splenic Injury: Clinical, Immunologic, and Ultrasound-Doppler Follow-Up. ACTA ACUST UNITED AC 2007; 62:1481-6. [PMID: 17563670 DOI: 10.1097/ta.0b013e318047dfb8] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To evaluate the clinical, US (ultrasound)-Doppler and hematologic findings after proximal splenic artery embolization (PSAE) for blunt injury. METHODS From August 1998 to February 2003, 37 patients (28 men and 9 women; 20-89 years old, mean 40 years) underwent PSAE for blunt injuries. One patient required secondary splenectomy after PSAE. Early complications were investigated during the hospital stay. Delayed follow-up included review of the outpatient records, telephone interview, consultation, US-Doppler splenic study, Howell-Jolly body search, and serum antibody titer determinations (pneumococcus and Haemophilus influenzae B). RESULTS No early postprocedural complications were depicted. Ten patients were lost on follow-up. Two patients had a telephone interview that revealed no complication. Twenty-four patients were examined 6 to 63 (mean 26) months after the embolization. No late complication was reported. Splenic measurements were in the normal range: length (53-110 mm; mean, 73), width (49-110 mm; 76), thickness (26-56 mm; 38), volume (61-508 mL; 226), standard ellipsoid formula volume (32-265 mL; 118), corrected volume (29-238 mL; 106), and splenic volumetric index (2.3-18.8; 8.4). The spleen was homogeneous in 23 patients (96%). Intrasplenic vascularization was present and splenic vein was patent in all patients. Howell-Jolly bodies were found in two patients. All patients (24 of 24) evaluated for exposure-driven immunity against Haemophilus Influenza b had sufficient immunity. Seventeen of the 18 patients (94%) evaluated for exposure-driven immunity against pneumococcus had sufficient immunity. Five of the six patients (83%) evaluated for pneumococcus vaccine response had a sufficient response. CONCLUSIONS Proximal splenic artery embolization in blunt splenic injuries is a well-tolerated technique without major long-term impact on the splenic anatomy and immune function.
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Affiliation(s)
- Bertrand Bessoud
- Department of Radiology and Interventional Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
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Dondelinger RF, Trotteur G, Ghaye B. Hemostatic Arterial Embolization in Trauma Victims at Admission. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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