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.

Multicenter Study of Perioperative Hepatic Angioembolization as an Adjunct for Management of Major Operative Hepatic Trauma

BACKGROUND

The management of major liver trauma continues to evolve in trauma centers across the US with increasing use of minimally invasive techniques. Data on the outcomes of these procedures remain minimal. The objective of this study was to evaluate patient complications after perioperative hepatic angioembolization as an adjunct to management of major operative liver trauma.

STUDY DESIGN

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. Patients were divided into 2 groups: angioembolization (AE) and no angioembolization (NO AE). Univariate and multivariate analyses were performed.

RESULTS

A total of 442 patients were included with AE performed in 20.4% (n = 90 of 442) of patients. The AE group was associated with higher rates of biloma formation (p = 0.0007), intra-abdominal abscess (p = 0.04), pneumonia (p = 0.006), deep vein thrombosis (p = 0.0004), acute renal failure (p = 0.004), and acute respiratory distress syndrome (p = 0.0003), and it had longer ICU and hospital length of stay (p < 0.0001). On multivariate analysis, the AE had a significantly higher amount intra-abdominal abscess formation (odds ratio 1.9, 95% CI 1.01 to 3.6, p = 0.05).

CONCLUSIONS

This is one of the first multicenter studies comparing AE in specifically operative high-grade liver injuries and found that patients with liver injury that undergo AE in addition to surgery have higher rates of both intra- and extra-abdominal complications. This provides important information that can guide clinical management.

Leadership in Surgical Residency

Surgical training can be compared with a functioning military unit with chain of command, responsibility/accountability relationship, and graduated leadership assignments. Proficiency, commitment, communication, consistency, ownership, relationships, confidence, humility, feedback and evaluation, exemplary behavior, empathy, and humanity are all aspects of leadership. Leadership skills developed in the protected environment of residency are the basis for a successful career.

[Acute necrotizing pancreatitis: traditional laparotomy vs. minimally invasive procedures]

INTRODUCTION

Treatment of necrotizing pancreatitis continues to evolve. The standard therapeutic method for infected pancreatic necrosis and its subsequent septic complications is open surgical drainage. The advances in radiological imaging and interventional radiology have enabled the development of minimally invasive procedures, i.e. percutaneous drainage (PCD) under CT/USG control, endoscopic transgastric necrosectomy (ENE), laparoscopic transperitoneal necrosectomy (LNE) and retroperitoneal access to pancreatic necrosis (RENE).

METHODS

Patients with acute pancreatitis treated from 2002 to 2013 (n=932) were included in the study. In patients with a severe form of the disease, results obtained in two groups of patients were compared: the first group was treated by classic laparotomy (group A), the second one was treated by means of minimally invasive procedures (group B). Statistical analysis employed the chi-square test.

RESULTS

During the mentioned period, 677 (72.6%) patients with a mild form and 255 (27.4%) with a severe form of the disease were treated. The male/female ratio was 1.4:1. In the group of patients suffering from a severe form of acute pancreatitis, 171 patients were treated conservatively, mortality rate being at 16.4% (28/171). Surgery was indicated in a total of 84 patients, mortality rate reaching 26.2% (22/84). Fifty-two of the patients underwent laparotomy (group A), minimally invasive procedures were used in a total of 32 patients (group B). Overall mortality in group A was 30.8% (16/52) vs. 18.8% (6/32) in group B, p = 0.224. The average length of hospitalization was longer in group A (65.4 days; median 52.4 vs. 49 days; median 36.5 in group B). PCD was the most frequent procedure performed in 19 patients; 5 of them died due to ongoing sepsis and multiorgan failure and 2 of them underwent revisional laparotomy. RENE was performed in 8 patients; lumbotomy was used in 5 of them. ENE was performed on 2 patients, 1 of them died, and LNE was used once. A less invasive procedure, the linea alba fasciotomy, was performed in 2 patients with intra-abdominal hypertension.

CONCLUSION

Open surgical drainage represents the standard treatment for infected pancreatic necrosis. Minimally invasive procedures are suitable alternatives especially in critically ill patients providing lower morbidity and mortality rates.

Gastrointestinal stromal tumors (GIST): a single center experience

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract. They are believed to originate from the interstitial cells of Cajal (ICCs) or from the precursors of ICCs. Most GISTs show an activating mutation in either the c-kit or platelet-derived growth factor receptor alpha (PDGFRA) gene. Tumor size, mitotic rate, and anatomic location correlate with potential malignancy and recurrence rate.

PATIENTS AND METHODS

A total of 12 patients were diagnosed to have GIST based on histology or immunohistochemistry of a biopsy or resection specimen obtained from the GI tract in the 2004-2009 period. The material was obtained using retrospective data collection.

RESULTS

The male to female ratio was 1:1; mean age 68.2 +/- 7.0 years. The stomach was involved in seven cases (58.3%), the small intestine in four (33.3%), and from a lymph node without the finding of a primary tumor was material obtained in one case (8.3%). The course was asymptomatic in four patients (incidental findings). All 12 patients had surgery; a curative procedure was undertaken in 11 patients. A spindle-cell pattern was present in 8/12 of the specimens examined, epithelioid in 2/12 and a mixed pattern in two cases. Ten specimens were CD117 positive (83.3%), two were negative; all 10 examined specimens exhibited CD34 positivity while two were not examined. The findings were classified as GISTs with a high risk of progressive disease in three patients, with a moderate risk in one patient, and a low or very low degree of malignancy in five patients. GISTs smaller than 2 cm in three patients were regarded as essentially benign. All patients with low and very low risk of progressive disease survive for 1 to 5 years free of signs. Of the three patients with high degree of malignancy, one died within one year for dissemination, the two remaining patients survive for over two years and six month postoperatively on therapy with tyrosine kinase inhibitors.

CONCLUSION

Tumors classified as GISTs with low and very low risk of progression are associated with a very good prognosis, with virtually all patients surviving 5 years. In patients with high risk or progressive diseases, the prognosis of 5-year survival is much poorer. The main therapeutic option is surgical removal of the tumor (resection or broad excision). Agents showing promise for patients with malignant forms of GISTs are tyrosine kinase receptor inhibitors. Although imatinib is currently used as a first line treatment for all patients with metastatic or unresectable GISTs, it is likely that this treatment will change in the future based on the underlying mutational status.

[Post-traumatic pseudocyst of the spleen]

INTRODUCTION

Post-traumatic splenic pseudocysts are rare condition and comprise more than 75% of non-parasitic cysts. They result from subcapsular or intraparenchymatous hematoma, by its liquefaction and creation of the fibrous peripheral capsula. Splenic pseudocysts have no epithelial lining, its diameter could be more than 15 cm and are mostly symptomatic.

CASE REPORT

A female, 53 years old, was admitted to the Clinic of surgery with blunt pains in the left hypochondrium after falling on the left side of body 6 months ago. Ultrasonography and CT scan reveal posttraumatic pseudocyst of the spleen, 156 x 135 x 148 mm in diameter. The splenic parenchyma was reduced to 15 mm dorso-caudal. Extirpation of the pseudocyst and splenectomy during laparotomy was performed with healing per primam. The patient was discharged 6 day after surgery.

CONCLUSION

Posttraumatic splenic pseudocysts are good diagnosed in CT scan. Giant pseudocysts and psuedocysts in splenic hilus require surgical resection. Spleen parenchyma preserving operations, currently recommended in small cysts, reduce the risk of early and late septic complications, particularly overwhelming postsplenectomy sepsis. Partial splenectomy offers a definitive treatment of a splenic cyst while preserving splenic functions. Miniinvasive surgery as a percutaneous drainage and laparoscopic fenestration have an unacceptably high rate of failure.

[Hemorrhagic complications of warfarin therapy]

INTRODUCTION

Introduction of warfarin use in prevention and treatment of thromboembolic diseases resulted in lower rates of thromboembolic complications, however, on the other hand, it has been associated with increased incidence of hemorrhagic complications,which often require surgical management. AIM, MATERIAL, METHODS: The aim of the study was a retrospective analysis of hemorrhagic complications in 184 patients, hospitalized in the FNKV (Královské Vinohrady Faculty Hospital) Surgical Clinic during 2000-2008, following warfarin overdose. The following diagnostic or treatment methods were used: endoscopy of the upper or lower GIT in GIT hemorrhages and spiral CT when peritoneal bleeding was suspected.

RESULTS

GIT bleeding, such as hematemesis, melena, enterorrhagy, was the commonest complication observed in 147 patients, ie. 79.9%. Upper GIT was identified as the source of bleeding in 76 subjects, i.e. 51.7%, lower GIT was the identified source in 26 subjects, ie. 17.7%, and the source remained unidentified in 45 patients, ie. in 30.6%. 10 patients suffered from soft tissue bleeding, m. rectus abdominis hematoma was detected in 7 subjects, hemoperitoneum and/or retrohemoperitoneum was identified in 8 subjects. Intestinal wall or its intestinal peritoneum was affected in 3 subjects and 3 patients suffered from liver or splenic intraparenchymal hematoma. Out of the total of 184 patients, 165 subjects were treated conservatively (89.7%), 19 subjects underwent surgery (10.3%), including 14 laparotomies for acute abdomen symptoms and 5 incisions with removal of hematomas. Overall lethality rate was 7/184, ie. 3.8%, 5 subjects undergoing conservative treatment and 2 subjects undergoing surgery exited.

CONCLUSION

Uncontrolled warfarin administration may cause serious, even life- threatening complications. Therefore, patients undergoing warfarin therapy should be adequately informed about potential complications and regular INR monitoring is required.

Massive, life-threatening bleeding in Crohn's disease

BACKGROUND

Acute lower gastrointestinal bleeding is a rare complication in Crohn's disease (CD).

MATERIALS AND METHODS

We characterized the clinical features and course of such bleeding in six of 156 patients with CD, treated between 1985 and 2003 at our institution. The data on the patients were gathered through retrospective data analysis.

RESULTS

The six patients discussed here consisted of three males and three females, ranging in age from 17 to 42 years. Three patients were known to have CD, whereas three presented with acute bleeding, as the initial symptom of CD. There were 11 separate episodes of severe hemorrhage: three patients bled only once, two bled twice, and one bled four times. The precise bleeding site was correctly identified in four of eleven episodes: twice by colonoscopy and twice by angiography. Primary bleeding episodes subsided without surgery in four of six patients, but three of these four patients re-bled massively, and surgery followed in two of these cases. An emergency surgery was necessary to stop the hemorrhage in four patients; two of them underwent surgery during their first haemorrhagic episodes, and two patients underwent surgery during a repeated episode of hemorrhage. As a consequence, one ileectomy and three ileocolectomies had to be performed. During follow-up of the resected patients, no recurrence of haemorrhagic or non-haemorrhagic CD was observed in three patients two, five, and six years after surgery and only one patient required further therapy three years after surgery for recurrent bleeding. For this, super selective embolization of the periphery branch of the superior mesenteric artery was used. Two non-resected patients are doing well in a course of remission.

CONCLUSION

A conservative approach may be suggested as first-line therapy, but surgery is inevitable in patients suffering from massive bleeding and in patients with recurrent bleeding.

[Acute bleeding in the Crohn's disease]

Acute bleeding is a rare, however a very serious complication of the Crohn's disease. Stabilization of the circulation, identification of its source and a consecutive therapeutical strategy remain the principal problem of its management. In addition to classical diagnostic methods, such as colonoscopy, enteroscopy, angiography or radionucleotide scanning, several other methods have emerged recently, e.g. capsule endoscopy, angiography in combination with methylene blue application and angio-CT, all of them enabling to identify the source of the bleeding. Although conservative therapeutical methods have advanced considerably, the bleeding relapse rates remain high. Surgical intervention is essential in unstable patients with massive bleeding and is frequently applied in patients with relapsing bleeding. The surgical treatment results with respect to postoperative mortality rates and to bleeding relapse rates and to relapse rates of the disorder itself, are very good. The haemorrhaging form of the Crohn's disease is considered a specific phenotype prone to relapses of bleeding, although in other Crohn's disease patients the massive bleeding does not occur during the course of the disease.

[Indications for emergency surgery in thoraco-abdominal injuries]

PURPOSE OF THE STUDY

Under the conditions of an increasing number of car accidents and criminal injuries the thoracis and abdominal trauma is a source of a significant morbidity and mortality in blunt and penetrating mechanism of injury. On the basis of a group of patients operated on for blunt and penetrating injury of the chest and abdomen evaluation was made of the current indication and results of lifesaving surgery in case of these injuries.

PATIENTS

The group included 68 patients requiring a lifesaving surgery for a blunt and penetrating injury of the chest and abdomen hospitalized between the beginning of 1966 and the end of April 2001. Forty-five patients sustained a blunt injury and 23 a penetrating injury.

METHODS

In case of blunt injuries the indication for surgery was determined on the basis of clinical examination supplemented with a radiograph examination of the chest and spiral computer tomography. In case of penetrating stab wounds the surgery was indicated on the basis of clinical examination, in gunshot wounds by means of x-ray examination and spiral computer tomography performed in order to assess the scope of the injury of intraabdominal organs and the location of the projectile. Indicated on the basis of the examination in the blunt injury was thoracotomy in 6 cases, laporatomy in 34 cases and the combination of thoracotomy and laparotomy in 5 patients. In case of the penetrating injury thoracotomy was performed in 8 cases, laparotomy in 11 cases and the combination of thoracotomy and laparotomy in 4 patients.

RESULTS

In the post-operative period 6 patients (9%) died: 3 patients with a polytrauma died from an irreversible damage caused by a protracted hemorrghagic shock, one female patient from the contusion of brain, one patient after splenectomy for an isolated injury died from cardiorespiratory failure and pneumonia, one patient with a stab wound of the left ventricle of the heart died from the heart failure by hypoxy.

DISCUSSION

Indication for a lifesaving thoracotomy and laparotomy in our group of patients operated on corresponds to the overviews of surgeries in thoracoabdominal injuries presented in literature. The procedure in preoperative examination is identically limited by the stability of hemodynamics in the patient after the injury using mainly ultrasound and computer tomography of the stabilized patient. In contrast to a number of authors in our conditions we have not performed some of the intervention examinations such as diagnostic peritoneal lavage or thoracoscopy and laparoscopy. The improvement of results in patients operated on for thoracoabdominal injury is in our conditions given both by the timeliness of the operation in the availability of examination methods (US, spiral CT) and by adequate stabilization of the patient in the peroperative period at the emergency department.

CONCLUSION

Priority indication for a lifesaving surgery in thoracoabdominal injuries is significant intraabdominal bleeding diagnosed on the basis of the result of the clinical examination in hemodynamically unstable patients. In a stabilized patient the lifesaving surgery is performed on the basis of the result of visualization methods (spiral computer tomography, ultrasound, angiography, endoscopy) revealing apart from significant bleeding also severe injuries of intrathoracic and intraabdominal organs. Protracted hypovolemic shock with the development of multi-organ failure or the occurrence of simultaneous severe associated injuries in polytrauma are the most frequent causes of mortality in patients operated on for thoracoabdominal injury.

[Acute hemorrhage in Crohn's disease]

The authors present a case of profuse haemorrhage into the lower part of the digestive tract in a 17-year-old patient where Crohn's disease of the terminal ileum and right colon up to the hepatal flexure was diagnosed by sonographic examination. The haemorrhage occurred after preparation for coloscopic examination with Fortrans only 2 months after the onset of the first symptoms of the disease. Because of developing signs of haemorrhagic shock emergency surgery was necessary. Resection of the terminal ileum and dextrolateral hemicolectomy was performed and during operation coloscopy to eliminate further sources of haemorrhage. The patient recovered p.p.i. and was discharged on the 10th day after surgery. The authors discuss diagnostic and therapeutic pitfalls of this rare complication of Crohn's disease and compare their findings with data from the literature.

[Myogenic tumors of the digestive tract]

BACKGROUND

Myogenic tumours of the digestive tract are not very frequent. Most often they are found in the stomach, less frequently in the colon and rectum. Many are symptom-free and are an incidental finding on examination or surgery. Treatment is surgical and the type and extent depends on the type, size, site and spread of the tumour. The objective of the submitted paper is to present a group of patients and to confront the findings with those of other authors.

METHODS AND RESULTS

In the course of ten years (1992-1996) the authors diagnosed a myogenic tumour of the digestive tract only in 10 patients. Seven patients were males, three females, mean age 64 years (range 46-89 years). The most frequent symptoms were haemorrhage into the GI tract (6x), abdominal pain (4x), palpable resistance in the abdomen (2x), subileus (1x). Most frequently the stomach was affected (7x) and the small intestine (3x). From the histological aspect the tumour was qualified as benign only 3x (site stomach, leiomyoma). Seven times the tumour was malignant (4x stomach: leiomyoblastoma, 3x small intestine: leiomyosarcoma). Five times surgery was curative, 3x palliative, 2x only explorative. At present only three patients with a benign tumour survive.

CONCLUSIONS

Myogenic tumours of the GI tract are relatively rare, preoperative diagnosis is an exception. The clinical picture is non-pathognomic. The only effective therapeutic procedure is surgery: survival depends on the type of tumour.

[Significance of blunt injury of thorax in polytrauma.]

Based on the analysis of a group of 100 patients with polytrauma evaluation was made of the impact of thoracic injury on post-injury period, including the incidence of complications, and on the outcome of the treatment. Blunt thoracic injury occurred in 64 patients. The most frequent complications of intrathoracic injury were pneumothorax, haemothorax and contusion of lungs. In the group of patients with polytrauma involving also the chest there was a more frequent incidence of respiratory insufficiency, higher morbidity (higher incidence of insufficiencies of organs and septic complications) and higher mortality (34%). The cause of mortality within 24 hours after admission was irreversible traumatic hemorrhagic shock, later the consequences of craniocerebral injury. The injury of chest in polytrauma deteriorates its prognosis. Key words: polytrauma, blunt thoracic injury, diagnostic - therapeutical algorithm, outcomes of the treatment.

[Immunotherapy as part of comprehensive therapy in abdominal reoperations with septic complications]

On the base of literature and clinical experience indications of human immunoglobulins in the treatment of infections in surgical patients are presented. Besides prophylactic using in elective operations immunoglobulins were administered as a part of treatment in septic complications, postinjured infections, hospital acquired infections in ICU and immunosuppression. Application of immunoglobulins are regularly part of adjuvant therapy of sepsis in surgical patients. Intravenous immunoglobulins--Pentaglobin and Endobulin were administered postoperatively in patients with reoperations for postoperative peritonitis. For evaluation of effects of immunoglobulins there are presented some clinical and laboratory parameters of sepsis.

[Crohn's disease of the duodenum]

Affection of the stomach and duodenum by Crohn's disease is rare and varies according to the majority of data in the literature between 0.5 and 4%. A pre-existing or concurrent distal affection, most frequently on the ileum, is common. The authors describe a rare isolated affection of the pylorus and duodenum in a 17-year-old boy with manifestations of a severe inflammatory obstruction. Crohn's disease was suspected already before operation and was confirmed by laparotomy and histological examination of a portion of the pyloric wall. The author discusses the difficulties of preoperative diagnosis and common methods of surgical treatment.

[Acute terminal ileitis and Crohn's disease]

The finding of acute inflammation of the terminal ileus frequently leads to differential diagnostic reflections whether it is the first stage of Crohn's disease or acute ileitis with a different aetiology. At the Surgical Clinic of the Third Medical Faculty in Prague 10 in 1981-1992 21 patients with this condition were hospitalized and operated. Crohn's disease developed subsequently only in six patients and in five of them the development of the disease called for another operation. The remaining 15 patients are free from clinical complaints. The mean age of these patients at the time of operation was 30.4 years, the mean length of the gut affection was 9.7 cm, the mean follow up period is 6.4 years. The author analyzes possible causes of these cases of ileitis and discusses the relationship with Crohn's disease.

[Appendicitis, pseudoappendicitis and Crohn's disease]

Abdominal pain which is a basic symptom of Crohn's disease was in a group of 53 patients treated in 1981-1982 at the Surgical Clinic of the Third Medical Faculty in Prague 10 the initial symptom in 73.3% of the patients. The inflammation was most frequently in the terminal ileum and in the ileocaecal region, in the authors' group in 49.0% and 30.2% resp. In 18 patients appendectomy was performed, incl. 10 where it was performed a long time before the development of the first complaints caused by Crohn's disease. In these patients the authors do not assume, because of the long symptom-free period, that there existed a direct relationship with Crohn's disease which developed later. In six patients during laparotomy performed on account of pain in the right hypogastrium acute terminal ileitis, the first stage of Crohn's disease, was detected. In two patients the initial finding was granulomatous appendicitis.

[Prophylactic and therapeutic use of Avrazor in abdominal surgery]

The authors investigated in a group of 30 patients the prophylactic and therapeutic action of ornidazole (the Czech preparation Avrazor) injections for infusion produced by Léciva Co. Prophylactically Avrazor was used most frequently in elective colorectal surgery, therapeutically in peritonitis. In a control group comprising 30 patients with the same indications the commonly used Metronidazole was administered and the results in the two groups were compared. Avrazor was administered most frequently combined with aminoglycosides. The authors did not observe side-effects after Avrazor administration and the preparation was very well tolerated. Because of its antimicrobial effect in the prophylaxis and therapy of intraabdominal infections the preparation can be recommended for clinical use.

[Surgical complications in Crohn's disease]

Although the primary role of the specialist in internal medicine in treatment of Crohn's disease is generally accepted, frequently the surgeon is the first person to take action. In patients with hitherto not diagnosed Crohn's disease he performs laparotomy because of suspected acute appendicitis or on account of surgical complications, most frequently ileus, which may be a very early manifestation of the disease. In a group of 40 patients with Crohn's disease and treatment ileitis the author gives an account of surgical indications, affections of different portions of the gastrointestinal tract and surgical operations.

[Malignant lymphoma of the stomach]

The authors present their own experience with the diagnosis and therapy of six primary malignant gastric lymphomas. They draw attention to the pitfalls of preoperative and peroperative diagnosis. From six patients treated in the department in 1978-1985 the correct diagnosis was established before operation only in one patient. In three patients an urgent operation had to be performed on account of signs of perforation of the lymphoma. The authors discuss the possibilities of surgical treatment and supplementary postoperative radio- and chemotherapy.