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Sakalkale A, Choi CCM, Krawitz R, Yeung JM. Two cases of atraumatic adrenal hemorrhage: A review of active management, conservative management, and challenges faced. Radiol Case Rep 2024; 19:2395-2401. [PMID: 38645544 PMCID: PMC11026934 DOI: 10.1016/j.radcr.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 04/23/2024] Open
Abstract
Adrenal hemorrhage (AH) is an uncommon and potentially disastrous affliction that carries an accepted mortality risk of 15%. Variable symptomatology can cause a diagnostic dilemma and may be missed. We present 2 cases of right-sided AH; both cases were initially presumed to be renal colic. Case 1 was an 86-year-old gentleman, presenting with right flank pain found to have a right-sided atraumatic AH. He presented with hemorrhagic shock, requiring angioembolization of the bleeding vessel. Case 2 was a 62-year-old gentleman who presented with right flank pain and was found to have a right-sided atraumatic AH. He was hemodynamically stable and successfully managed conservatively. Adrenal hemorrhage is a potentially fatal affliction that may be missed. CT scans are the recommended imaging modality during an acute presentation due to wider availability and fast assessment. We demonstrate a hemodynamically stable patient managed with a 'watch and wait' approach and an unstable patient managed with resuscitation followed by urgent angioembolization.
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Affiliation(s)
- Aditya Sakalkale
- Department of General Surgery, Western Health, Melbourne, Australia
| | | | - Russel Krawitz
- Department of General Surgery, Western Health, Melbourne, Australia
| | - Justin M.C. Yeung
- Department of Colorectal Surgery, Western Health, Melbourne, Australia
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Australia
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Mavuduru RM, Mohd Ziauddin SA, Bora GS, Gorsi U. Renal artery pseudoaneurysm following robot assisted nephron sparing surgery: two case reports. J Med Case Rep 2024; 18:191. [PMID: 38637904 PMCID: PMC11027276 DOI: 10.1186/s13256-024-04510-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Renal artery pseudoaneurysm following partial nephrectomy is a rare entity, the incidence of this entity is more common following penetrating abdominal injuries, percutaneous renal interventions such as percutaneous nephrostomy(PCN) or Percutaneous nephrolithotomy (PCNL). Although rare, renal artery pseudoaneurysm can be life threatening if not managed timely, they usually present within two weeks postoperatively with usual presenting complains being gross haematuria, flank pain and/or anaemia. CASE PRESENTATION We report case of two female patients 34 and 57 year old respectively of South Asian ethnicity, presenting with renal artery pseudoaneurysm following left sided robot assisted nephron sparing surgery for interpolar masses presenting clinically with total, painless, gross haematuria with clots within fifteen days postoperatively and their successful treatment by digital subtraction angiography and coil embolization. CONCLUSION Renal artery aneurysm is a rare fatal complication of minimally invasive nephron sparing surgery however considering the preoperative and intraoperative risk factors for its development and prompt suspicion at the outset can be life saving with coil embolization of the bleeding arterial aneurysm.
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Affiliation(s)
| | | | | | - Ujjwal Gorsi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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3
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Gomella PT, Solomon J, Ahdoot M, Gurram S, Lebastchi AH, Levy E, Krishnasamy V, Kassin MT, Chang R, Wood BJ, Linehan WM, Ball MW. Timing, incidence and management of delayed bleeding after partial nephrectomy in patients at risk for recurrent, bilateral, multifocal renal tumors. Urol Oncol 2024:S1078-1439(24)00360-0. [PMID: 38614921 DOI: 10.1016/j.urolonc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/16/2024] [Accepted: 03/06/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION Delayed bleeding is a potentially serious complication after partial nephrectomy (PN), with reported rates of 1%-2%. Patients with multiple renal tumors, including those with hereditary forms of kidney cancer, are often managed with resection of multiple tumors in a single kidney which may increase the risk of delayed bleeding, though outcomes have not previously been reported specifically in this population. The objective of this study was to evaluate the incidence and timing of delayed bleeding as well as the impact of intervention on renal functional outcomes in a cohort primarily made up of patients at risk for bilateral, multifocal renal tumors. METHODS A retrospective review of a prospectively maintained database of patients with known or suspected predisposition to bilateral, multifocal renal tumors who underwent PN from 2003 to 2023 was conducted. Patients who presented with delayed bleeding were identified. Patients with delayed bleeding were compared to those without. Comparative statistics and univariate logistic regression were used to determine potential risk factors for delayed bleeding. RESULTS A total of 1256 PN were performed during the study period. Angiographic evidence of pseudoaneurysm, AV fistula and/or extravasation occurred in 24 cases (1.9%). Of these, 21 were symptomatic presenting with gross hematuria in 13 (54.2%), decreasing hemoglobin in 4(16.7%), flank pain in 2(8.3%), and mental status change in 2 (8.3%), while 3 patients were asymptomatic. Median number of resected tumors was 5 (IQR 2-8). All patients underwent angiogram with super-selective embolization. Median time to bleed event was 13.5 days (IQR 7-22). Factors associated with delayed bleeding included open approach (OR 2.2, IQR(1.06-5.46), P = 0.04 and left-sided surgery (OR 4.93, IQR(1.67-14.5), P = 0.004. Selective embolization had little impact on ultimate renal functional outcomes, with a median change of 11% from the baseline eGFR after partial nephrectomy and embolization. One patient required total nephrectomy for refractory bleeding after embolization. CONCLUSIONS Delayed bleeding after PN in a cohort of patients with multifocal tumors is an infrequent event, with similar rates to single tumor series. Patients should be counseled regarding timing and symptoms of delayed bleeding and multidisciplinary management with interventional radiology is critical for timely diagnosis and treatment.
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Affiliation(s)
- Patrick T Gomella
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Julie Solomon
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael Ahdoot
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sandeep Gurram
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amir H Lebastchi
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Elliot Levy
- Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Michael T Kassin
- University of Alabama Birmingham, Birmingham, AL; Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Richard Chang
- Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bradford J Wood
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD; Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD; Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - W Marston Linehan
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mark W Ball
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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Viswanathan A, Na HY, Breckenridge L, Muller A, Butts C, Reilly E, Geng T, Sigal A, Michels R, Ong A. Hypotension in the Emergency Department and Contrast Extravasation on Computerized Tomography Predict Blood Transfusion in Low-Energy Pelvic Fractures. J Surg Res 2024; 296:310-315. [PMID: 38306936 DOI: 10.1016/j.jss.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/29/2023] [Accepted: 01/02/2024] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Although low-energy pelvic fractures seldom present with significant hemorrhage, early recognition of at-risk patients is essential. We aimed to identify predictors of transfusion requirements in this cohort. METHODS A 7-y retrospective chart review was performed. Low-energy mechanism was defined as falls of ≤5 feet. Fracture pattern was classified using the Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen system as A, B, or C. Primary outcome was transfusion of ≥2 units of packed red blood cells in the first 48 h. Univariable analysis and logistic regression analysis were performed. A P value ≤0.05 was considered significant. RESULTS Five hundred forty six patients were included with median (interquartile range) age of 86 (79-91) and median (interquartile range) Injury Severity Score of 5 (4-8). Five hundred forty one (99%) had type A fractures. Twenty six (5%) had the primary outcome and 17 (3%) died. Logistic regression found that systolic blood pressure <100 mmHg at any time in the Emergency Department, Injury Severity Score, and pelvic angiography were predictors of the primary outcome. Seventeen percent of those who had the primary outcome died compared with 2% who did not (P = 0.0004). Three hundred sixty four (67%) received intravenous contrast for computerized tomography scans and of these, 44 (12%) had contrast extravasation (CE). CE was associated with the primary outcome but not mortality. CONCLUSIONS Hypotension at any time in the Emergency Department and CE on computerized tomography predicted transfusion of ≥2 units packed red blood cells in the first 48 h in patients with low-energy pelvic fractures.
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Affiliation(s)
| | - Hee Yun Na
- Drexel University College of Medicine, Wyomissing, Pennsylvania
| | - Leigham Breckenridge
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Alison Muller
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Christopher Butts
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Eugene Reilly
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Thomas Geng
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Adam Sigal
- Department of Emergency Medicine, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Ryan Michels
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Adrian Ong
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania.
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Baker JE, Werner NL, Burlew CC. Management of Pelvic Trauma. Surg Clin North Am 2024; 104:367-384. [PMID: 38453308 DOI: 10.1016/j.suc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.
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Affiliation(s)
- Jennifer E Baker
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO 80045, USA
| | - Nicole L Werner
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue H4/367, Madison, WI 53792, USA
| | - Clay Cothren Burlew
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 E 17th Avenue, Box C313, Aurora, CO 80045, USA.
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Salim A, Ali S, Sheikh MA, Latif T, Din IU. Emergency Angioembolization for Life-Threatening Hemorrhage in Wilms Tumor. J Cancer Allied Spec 2024; 10:603. [PMID: 38259681 PMCID: PMC10793714 DOI: 10.37029/jcas.v10i1.603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/23/2023] [Indexed: 01/24/2024]
Abstract
Introduction Renal artery embolization has been used in a palliative fashion for symptomatic relief of hematuria or flank pain in unresectable renal cell carcinoma in adults. There is limited data on the use of embolization for actively bleeding and unresectable tumors in the oncological pediatric population. Case Description A previously healthy 5-year-old boy with no significant past medical or surgical history presented to the clinic with gradually worsening abdominal distension associated with occasional abdominal pain, gross hematuria, and lethargy for four months. Diagnostic investigations showed an 18-cm left-sided metastatic (pulmonary) renal tumor (Wilms), which was deemed unresectable on imaging. Treatment was planned according to the SIOP-RTSG protocol. However, he became hemodynamically and vitally unstable with acute, sudden distension of the abdomen on the left side after the first cycle of chemotherapy. Imaging showed active bleeding from an inferior branch of the left renal artery. Selective angioembolization was done, and chemotherapy was reinitiated with a patent left main renal artery. Following the fourth cycle of chemotherapy, he developed hemodynamic instability and abdominal pain; imaging revealed the resolution of pulmonary nodules and bleeding from the left renal artery (main); this was again embolized, and the patient was stabilized. The patient was operated on after optimization, and a complete resection of the mass was done with negative margins. On six months follow-up, he is well. Practical Implications To the best of our knowledge, this is the first case where angioembolization has been done in conjunction with neoadjuvant chemotherapy to downsize a Wilms tumor to achieve favorable outcomes. Continued research efforts are necessary to optimize strategies and improve the prognosis for pediatric patients, and this case is one of the prime examples.
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Affiliation(s)
- Areej Salim
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Sajid Ali
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Muhammad Ali Sheikh
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Tariq Latif
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
| | - Islah Ud Din
- Department of Radiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab, Pakistan
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Dantes G, Kolousek A, Doshi N, Dutreuil V, Sciarretta JD, Sola R, Shah J, Smith RN, Smith AD, Koganti D. Utilization of Angiography in Pediatric Blunt Abdominal Injury at Adult versus Pediatric Trauma Centers. J Surg Res 2024; 293:561-569. [PMID: 37832307 DOI: 10.1016/j.jss.2023.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/24/2023] [Accepted: 08/26/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Angiography has been widely accepted as an adjunct in the management of blunt abdominal trauma in adults. However, the role of angiography with or without angioembolization (AE) is still being defined in pediatric solid organ injury. We sought to compare the use of angiography in solid organ injury (SOI) at pediatric trauma centers (PTCs) versus an adult trauma center (ATC) in a large metropolitan city. METHODS Data were drawn from a collaborative effort of three Trauma centers (one adult and two pediatric) in Atlanta, GA. All pediatric patients (ages 1-18) treated for SOI between January 1, 2016 and December 31, 2021 were included (n = 350). Registry data obtained included demographics, mechanism of injury, injury grade, injury severity score (ISS), procedures performed, and transfusions. Multivariate regression analysis was used to identify factors associated with angiography. RESULTS A total of 350 patients were identified during the study period with 101 treated at ATC and 249 treated at the two PTCs. The median age at the ATC was 17 y (IQR 16, 18) compared to nine (6, 13) at the PTCs. ISS was significantly higher at the ATC 22 (14, 34) compared to 16 (9, 22) at PTCs (P < 0.001). At the ATC, 11 (10.9%) patients underwent angiography, 4 (4.9%) of which underwent AE compared to seven (2.8%) patients who underwent angiography and AE at PTCs. In the multivariate analysis, factors associated with angiography use included age (OR 1.44, 95% CI 1.09-1.90, P = 0.010) and ISS (OR 1.05, 95% CI 1.02-1.09, P = 0.004). Through setting, ATC versus PTC was significant on univariable analysis, it did not remain a significant predictor of angiography on multivariable regression. CONCLUSIONS Our study demonstrated increased utilization of angiography for the management of SOI in pediatric patients treated at ATCs versus PTCs. On regression analysis, age and ISS remained significant predictors for angiography utilization, while setting (ATC versus PTC) was notably not a significant predictor. This data would suggest that differences in angiography utilization for pediatric SOI at PTCs and ATCs are influenced by differing patient populations (older and higher ISS), with otherwise uniform use. These findings provide a basis for future treatment algorithm revisions for pediatric blunt abdominal trauma that include angiography and provide support for the development of formal guidelines.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Emory University, Atlanta, Georgia.
| | | | - Neil Doshi
- Morehouse School of Medicine, Morehouse University, Atlanta, Georgia
| | - Valerie Dutreuil
- Pediatric Biostatistics Core, Department of Pediatrics, Emory School of Medicine Atlanta, Georgia
| | - Jason D Sciarretta
- Department of Surgery, Emory University, Atlanta, Georgia; Department of Trauma Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia
| | - Richard Sola
- Morehouse School of Medicine, Morehouse University, Atlanta, Georgia
| | - Jay Shah
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Randi N Smith
- Department of Surgery, Emory University, Atlanta, Georgia; Department of Trauma Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alexis D Smith
- Department of Surgery, Emory University, Atlanta, Georgia; Pediatric Biostatistics Core, Department of Pediatrics, Emory School of Medicine Atlanta, Georgia
| | - Deepika Koganti
- Department of Surgery, Emory University, Atlanta, Georgia; Department of Trauma Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
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Dhillon NK, Harfouche MN, Hawley KL, DuBose JJ, Kozar RA, Scalea TM. Embolization of Pseudoaneurysms is Associated With Improved Outcomes in Blunt Splenic Trauma. J Surg Res 2024; 293:656-662. [PMID: 37839096 DOI: 10.1016/j.jss.2023.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The necessity of angioembolization for all splenic pseudoaneurysms (PSAs) is unknown after blunt trauma. We compared the outcomes of patients with PSAs managed with splenic artery embolization (EMBO) versus no embolization (NO-EMBO). METHODS We retrospectively reviewed all patients with blunt splenic trauma and PSA on initial computed tomography scan admitted to an academic, urban, Level I trauma center from 2016 to 2021. Patients who had emergent splenectomy or died before discharge were excluded. Demographics, injury and computed tomography characteristics, and details regarding angiography, if pursued, were collected. The primary outcome was failure of nonoperative management (FNOM), as defined by need for delayed splenectomy for the EMBO group versus delayed splenectomy or embolization for the NO-EMBO group. RESULTS One hundred and fifty-six patients were in the final study population, of which 96 (61.5%) were in the EMBO group and 60 (38.5%) were in the NO-EMBO group. Patient demographics and mechanism of injury were similar between the two cohorts. The two cohorts had similar imaging findings, however, EMBO patients had more compartments with hemoperitoneum (2 versus 1, P < 0.01). Patients who underwent embolization had a lower FNOM rate (3.1% versus 13.3%, P = 0.02). CONCLUSIONS Splenic artery embolization in the setting of PSA is associated with lower rates of FNOM versus nonembolization. It is unclear if addressing the PSA itself with embolization drives the decreased FNOM rate.
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Affiliation(s)
- Navpreet K Dhillon
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Melike N Harfouche
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Kristy L Hawley
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Joseph J DuBose
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Texas
| | - Rosemary A Kozar
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland.
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Beltzer C, Imach S, Wafaisade A, Lefering R, Kölbel B. Use of angioembolization, treatment modalities and mortality in association with blunt liver trauma in Germany - a data analysis of the TraumaRegister DGU®. Langenbecks Arch Surg 2023; 409:6. [PMID: 38093037 PMCID: PMC10719148 DOI: 10.1007/s00423-023-03196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Angioembolization (ANGIO) is highly valued in national and international guideline recommendations as a treatment adjunct with blunt liver trauma (BLT). The literature on BLT shows that treatment, regardless of the severity of liver injury, can be accomplished with a high success rate using nonoperative management (NOM). An indication for surgical therapy (SURG) is only seen in hemodynamically instable patients. For Germany, it is unclear how frequently NOM ± ANGIO is actually used, and what mortality is associated with BLT. METHODS A retrospective systematic data analysis of patients with BLT from the TraumaRegister DGU® was performed. All patients with liver injury AIS ≥ 2 between 2015 and 2020 were included. The focus was to evaluate the use ANGIO as well as treatment selection (NOM vs. SURG) and mortality in relation to liver injury severity. Furthermore, independent risk factors influencing mortality were identified, using multivariate logistic regression. RESULTS A total of 2353 patients with BLT were included in the analysis. ANGIO was used in 18 cases (0.8%). NOM was performed in 70.9% of all cases, but mainly in less severe liver trauma (AIS ≤ 2, abbreviated injury scale). Liver injuries AIS ≥ 3 were predominantly treated surgically (64.6%). Overall mortality associated with BLT was 16%. Severity of liver injury ≥ AIS 3, age > 60 years, hemodynamic instability (INSTBL), and mass transfusion (≥ 10 packed red blood cells/pRBC) were identified as independent risk factors contributing to mortality in BLT. CONCLUSION ANGIO is rarely used in BLT, contrary to national and international guideline recommendations. In Germany, liver injuries AIS ≥ 3 are still predominantly treated surgically. BLT is associated with considerable mortality, depending on the presence of specific contributing risk factors.
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Affiliation(s)
- Christian Beltzer
- Department of General, Abdominal and Thoracic Surgery, German Armed Forces Hospital Ulm, Ulm, Germany.
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Benny Kölbel
- Department of General, Abdominal and Thoracic Surgery, German Armed Forces Hospital Ulm, Ulm, Germany
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10
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Mete UK, Deshpande RS. Confronting urethrorrhagia after Otis urethrotomy: a case report. J Med Case Rep 2023; 17:522. [PMID: 38057872 DOI: 10.1186/s13256-023-04261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/16/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Otis urethrotomy can sometimes lead to troublesome bleeding after seemingly uneventful procedures. This case report highlights one such case which went unnoticed initially; the bleeding was erroneously ascribed to the prostate, thereby falsely indicting the "decoy" prostate. CASE PRESENTATION A 78-year-old Asian gentleman was referred to our hospital with complaint of intractable bleeding after undergoing laser enucleation of prostate at another institute, wherein he further underwent unsuccessful bilateral angioembolization of pudendal arteries. On endoscopy (for hemostasis), we found a spurting vessel in the navicular fossa, which was effectively controlled. CONCLUSIONS This case report highlights the importance of performing prompt endoscopy in case of uncontrolled bleeding after prostate endoscopic surgery.
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11
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Aziz H, Nordan T, Feng LR, Kwon YK, Khreiss M, Karagozian R, Schnelldorfer T. Association Between Preoperative Angioembolization and Bleeding Complications in Patients With Benign Liver Tumors: Analysis of a National Database. J Surg Res 2023; 291:536-545. [PMID: 37540971 DOI: 10.1016/j.jss.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION The role of angioembolization (AE) in patients with benign liver diseases is an area of active research. This study aims to assess any difference in liver resection outcomes in patients with benign tumors dependent on utilization of preoperative AE. METHODS A retrospective cohort study of patients undergoing elective liver resections for benign liver tumors was performed using the National Surgical Quality Improvement Program database (2014-2019). Only tumors of 5 cm in size or more were included in the analysis. We categorized the patients based on preoperative AE (AE + versus AE -). The primary outcome measured included bleeding complications within 72 h. The secondary outcomes were to determine predictors of bleeding. RESULTS After propensity score matching, there were 103 patients in both groups. There was no difference in intraoperative or postoperative blood transfusions within 72 h of surgery (14.6% versus 12.6%; P = 0.68), reoperation (1.9% versus 1.9%; P = 1), or mortality (1.0% versus 0.0%; P = 1) between the two groups. Multivariate regression analysis revealed an open surgical approach (odds ratio [OR]: 4.59 confidence interval [CI]: 2.94-7.16), use of Pringle maneuver (OR: 1.7, CI: 1.26-2.310), preoperative anemia (OR: 2.79, CI: 2.05-3.80), and preoperative hypoalbuminemia (OR: 1.53 [1.14-2.05]) were associated with the need for intraoperative or postoperative blood transfusions within 72 h of surgery. CONCLUSIONS Preoperative AE was not associated with reducing intraoperative or postoperative bleeding complications or blood transfusions within 72 h after surgery.
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Affiliation(s)
- Hassan Aziz
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, Iowa.
| | - Taylor Nordan
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lawrence R Feng
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Yong K Kwon
- Division of Transplant and Hepatobiliary Surgery, University of Washington, Seattle, Washington
| | - Mohammad Khreiss
- Division of Surgical Oncology, Banner University Medical Center, Tucson, Arizona
| | - Raffi Karagozian
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
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Li QM, Ye B, Yang SW, Zhao H. Left hepatic artery pseudoaneurysm complicating endoscopic retrograde cholangiopancreatography: A case report. World J Clin Cases 2023; 11:5835-5839. [PMID: 37727720 PMCID: PMC10505992 DOI: 10.12998/wjcc.v11.i24.5835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/22/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Pseudoaneurysms of the hepatic artery or its branches have been reported following abdominal trauma, iatrogenic injury at the time of many operations such as percutaneous transhepatic biliary drainage and cholecystectomy. Hepatic artery pseudoaneurysms after endoscopic retrograde cholangiopancreatography (ERCP) are uncommon and potentially life threatening and should be identified and treated rapidly. CASE SUMMARY We report a case of intra-abdominal hemorrhage secondary to a left hepatic artery pseudoaneurysm resulting from guide wire injury at ERCP. The patient primary diagnosis was acute biliary pancreatitis with cholangitis, he underwent ERCP on the third day of admission. During ERCP, the left intrahepatic bile duct was cannulated three times. Over the sixth day, Contrast enhanced computed tomography scan demonstrated left hepatic lobe contusion and a pseudoaneurysm formation. The patient was successfully treated with the embolization of a small branch of left hepatic artery angiographically. CONCLUSION The common complications of ERCP are pancreatitis, bleeding and perforation. False aneurysms occur as a result of damage to the wall of an artery. As far as we know, it is rare complication has been reported following ERCP. We advise urgent referral for angiographic embolization in this situation to avoid aneurysm rupture.
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Affiliation(s)
- Qiao-Mei Li
- Department of Gastroenterology, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui 323000, Zhejiang Province, China
| | - Bin Ye
- Department of Gastroenterology, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui 323000, Zhejiang Province, China
| | - Shang-Wen Yang
- Department of Gastroenterology, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui 323000, Zhejiang Province, China
| | - Huan Zhao
- Department of Pathology, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui 323000, Zhejiang Province, China
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Tan T, Luo Y, Hu J, Li F, Fu Y. Nonoperative management with angioembolization for blunt abdominal solid organ trauma in hemodynamically unstable patients: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2023; 49:1751-1761. [PMID: 35853952 DOI: 10.1007/s00068-022-02054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The objective of the present study is to provide a comprehensive review of the literature on associated outcomes of angioembolization in blunt abdominal solid organ traumas. METHODS The databases of Medline, Embase, and Cochrane Library were explored until 24 September 2021. All studies with data on the efficacy or safety of angioembolization in patients suffering from hemodynamically unstable blunt abdominal solid organ trauma were included. The primary outcomes were clinical success rate and mortality. Pooled event rates were calculated using a double arcsine transformation to stabilize the variance of the original proportion. RESULTS In total, 13 reports of 12 studies were included in the systematic review. According to the current meta-analysis, the angioembolization for blunt abdominal solid organ trauma in hemodynamically unstable patients had a high clinical success rate [0.97 (95% CI 0.93-0.99)] and low mortality [0.03 (95% CI 0.01-0.07)]. Furthermore, no statistically significant difference was found between the various injured solid organs for either of these parameters. In addition, the technique-associated adverse events were seldom and tolerable. CONCLUSIONS For blunt abdominal solid organ trauma in hemodynamically unstable patients, this review shows that angioembolization exhibited a high clinical success rate, low mortality, and tolerable technique-related adverse events. Furthermore, the top possible indication for angioembolization in hemodynamically unstable patients is an individual who responds to rapid fluid resuscitation. However, high-quality and large-scale trials are needed to confirm these results and determine the selection criteria for appropriate patients in this setting.
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Affiliation(s)
- Taifa Tan
- Radiology Department, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yong Luo
- Trauma Centre and Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Jun Hu
- Cardiothoracic, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Fang Li
- Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China
| | - Yong Fu
- Trauma Orthopedic Department, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, China.
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Bana SKR, Lakshmanan S, Rajendran V, N S, Anil AA, L N. A Case of Massive Gastrointestinal Bleeding Due to Abdominal Tuberculosis. Middle East J Dig Dis 2023; 15:207-209. [PMID: 38023460 PMCID: PMC10660318 DOI: 10.34172/mejdd.2023.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/22/2023] [Indexed: 12/01/2023] Open
Abstract
This case is about a complication of abdominal tuberculosis in the form of a massive lower gastrointestinal (GI) bleed, which was timely intervened by angioembolization. A young man in his mid-20s on empirical anti-tubercular therapy (ATT) for abdominal tuberculosis, presented with severe abdominal pain. The patient then developed frank per rectal bleeding, leading to a significant drop in hemoglobin level, requiring multiple blood transfusions. Upper GI endoscopy and colonoscopy findings were inconclusive. Contrast-enhanced computed tomography (CECT) of the abdomen was performed, which revealed a contrast extravasation into the jejunum due to a leak in the jejunal branch of the superior mesenteric artery (SMA), followed by selective SMA angiography (digital subtraction angiography), which was arrested by angioembolization. The patient had multiple abdominal lymphadenopathies with omental nodules. Histopathological examination of the omental nodules revealed epithelioid granuloma with Langerhans-type cells. The patient is currently receiving ATT and is doing well.
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Affiliation(s)
- Sai Krishna Reddy Bana
- Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Suja Lakshmanan
- Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Vaasanthi Rajendran
- Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Senthil N
- Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Archa Anna Anil
- Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Nanthakumar L
- Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India
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Alasmi R. Case report of testicular failure and azoospermia after antegrade embolization of varicocele: A rare complication. Int J Surg Case Rep 2023; 106:108269. [PMID: 37148725 DOI: 10.1016/j.ijscr.2023.108269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023] Open
Abstract
INTRODUCTION Varicocele is a common condition affecting males of reproductive age and accounting for the most frequent cause of secondary infertility in males. PRESENTATION A young male presented with second infertility and bilateral varicoceles and underwent antegrade angioembolization. He developed testicular ischemia and testicular failure with new onset hypogonadism and cryptozoospermia. CONCLUSION Antegrade embolization is a valid option in patients with varicoceles but has its own unique risks of complications.
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Affiliation(s)
- Raed Alasmi
- Department of Surgery, College of Medicine, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia.
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16
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Sinha R, Gupta A. Late Hemorrhage Following Laparoscopic Cholecystectomy. JSLS 2023; 27:JSLS.2023.00006. [PMID: 37187807 PMCID: PMC10178626 DOI: 10.4293/jsls.2023.00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Background Excruciating generalized abdominal pain with features suggestive of shock, at the end of the first or early second week after laparoscopic cholecystectomy (LC), is a frightening and formidable diagnostic predicament. This is because the early known complications like biliary leak or vascular injuries are unlikely diagnoses. Hemoperitoneum, is not usually considered, but instead more common occurrences like acute pancreatitis, choledocholithiasis, and sepsis are suspected. A delay in diagnosis and subsequent management of hemoperitoneum could have disastrous consequences. Case Studies Two patients presented with hemoperitoneum, in the second week after laparoscopic cholecystectomy. The first was because of a leak from a pseudoaneurysm of the right hepatic artery and the other was a bleed from a subcapsular liver hemangioma as a part of Osler Weber Rendu syndrome. Initially, a clinical assessment in both the patients was diagnostically inconclusive. Ultimately the diagnosis could be made, based on computed tomography angiography and visceral angiography. In the second patient, a positive family history and genetic testing were helpful. The first patient was successfully managed by intravascular embolization, while the second patient was successfully managed conservatively with intraperitoneal drains and conservative management of comorbidities. Conclusions The presentation is to generate awareness that hemorrhage could be a presentation, in the early second week, after LC. A common cause to be considered is a pseudo aneurysmal bleed. Secondary hemorrhage and other rare coincidental unassociated conditions could also be responsible for the hemorrhage. A high index of suspicion, and early and timely management are keys to a successful outcome.
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Affiliation(s)
- Rajeev Sinha
- Department of General and Laparoscopic Surgery, MLB Medical College, Jhansi, India. (Dr. Sinha)
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India. (Dr. Gupta)
| | - Arun Gupta
- Department of General and Laparoscopic Surgery, MLB Medical College, Jhansi, India. (Dr. Sinha)
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India. (Dr. Gupta)
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17
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Aoki M, Matsushima K, Matsumoto S. Angioembolization versus preperitoneal packing for severe pelvic fractures: A propensity matched analysis. Am J Surg 2023; 225:408-413. [PMID: 36115706 DOI: 10.1016/j.amjsurg.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/22/2022] [Accepted: 09/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial. STUDY DESIGN This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3-5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis. RESULTS A total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321). CONCLUSIONS Though patients' characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan.
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
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18
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Aoki M, Abe T, Hagiwara S, Saitoh D. Variation in the utilization of angioembolization for splenic injury in hospitals: a nationwide cross-sectional study in Japan. Acute Med Surg 2023; 10:e837. [PMID: 37064787 PMCID: PMC10097635 DOI: 10.1002/ams2.837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/23/2023] [Indexed: 04/18/2023] Open
Abstract
Aim Substantial variations in the utilization of angioembolization have been reported internationally. However, the existence of variations in the utilization of angioembolization in Japan is currently unknown. Methods This was a cross-sectional study using data from a nationwide trauma registry in Japan. Of the 4,896 registered adult patients with splenic injury, we investigated 3,319 patients in the top 25% of the hospitals that registered the highest number of splenic injury patients in the Japan Trauma Data Bank. The primary outcome of this study was initial angioembolization. We calculated the expected initial angioembolization rates using multiple regression analysis adjusted for patient factors. In addition, we evaluated the range of observed-to-expected initial splenic angioembolization ratio for each hospital. Moreover, we assessed whether this ratio was increased with time. Results The frequency of initial splenic angioembolization ranged from 0% to 52%. The median expected initial angioembolization rate, calculated through multiple logistic regression analysis, was 19.7%. The observed-to-expected initial splenic angioembolization ratio for each hospital ranged from 0 to 2.36. The observed initial angioembolization rate tended to increase with time (P < 0.001). Conclusions Despite adjustment for patient factors, substantial variations were observed in the utilization of splenic angioembolization among hospitals in Japan.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care CenterJapan Red Cross Maebashi HospitalMaebashiJapan
| | - Toshikazu Abe
- Department of Emergency and Critical Care MedicineTsukuba Memorial HospitalTsukubaJapan
- Department of Health Services ResearchUniversity of TsukubaTsukubaJapan
| | - Shuichi Hagiwara
- Department of Emergency MedicineKiryu Kosei General HospitalKiryuJapan
| | - Daizoh Saitoh
- Division of TraumatologyResearch Institute, National Defense Medical CollegeTokorozawaJapan
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19
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Schellenberg M, Owattanapanich N, Emigh B, Nichols C, Dilday J, Ugarte C, Onogawa A, Matsushima K, Martin MJ, Inaba K. Pseudoaneurysms after high-grade blunt solid organ injury and the utility of delayed computed tomography angiography. Eur J Trauma Emerg Surg 2022; 49:1315-1320. [PMID: 36515703 DOI: 10.1007/s00068-022-02197-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Pseudoaneurysms (PSA) can occur following high-grade solid organ injury. PSA natural history is unclear but risk for spontaneous rupture and exsanguination exist. The yield of delayed CT Angiography (dCTA) for PSA diagnosis is not well delineated and optimal timing is undefined. The study objective was definition of dCTA utility in diagnosing and triggering intervention for PSA after high-grade blunt solid organ injury. METHODS All blunt trauma patients arriving to our ACS-verified Level 1 trauma center with AAST grade ≥ III liver, spleen, and/or kidney injury were included in this retrospective observational study (01/2017-10/2021). Exclusions were age < 18 year, transfers in, death < 48 h, and immediate nephrectomy/splenectomy. dCTA performance was not protocolized and pursued at attending surgeon discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was dCTA-triggered intervention. Statistical testing with ANOVA/Chi squared compared outcomes by type of solid organ. RESULTS 349 blunt trauma patients with 395 high-grade solid organ injuries met study criteria. Median AAST grade of solid organ injury was 3 [3-4]. dCTA for PSA screening was pursued in 175 patients (44%), typically on hospital day 4 [3-7]. dCTA identified vascular lesions in 16 spleen, 10 liver, and 6 kidney injuries. dCTA triggered intervention in 24% of spleen, 13% of kidney, and 9% of liver injured patients who were screened, for an overall yield of 14%. Intervention was typically AE (n = 23, 92%), although two splenic PSA necessitated splenectomy. CONCLUSION Delayed CTA for PSA screening after high-grade blunt solid organ injury was performed in half of eligible patients. dCTA identified numerous vascular lesions requiring endovascular or surgical intervention, with highest yield for splenic injuries. We recommend consideration of universal screening of high-grade blunt solid organ injuries with delayed abdominal CTA to avoid missing PSA.
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Affiliation(s)
- Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.
| | - Natthida Owattanapanich
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Brent Emigh
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Chance Nichols
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Joshua Dilday
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Chaiss Ugarte
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Atsushi Onogawa
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Matthew J Martin
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
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20
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Chavez MA, Weinberg JA, Jacobs JV, Soe-Lin H, Chapple KM, Ryder M, Conley I, Bogert JN. Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy. Am J Surg 2022; 224:1464-1467. [PMID: 35623945 DOI: 10.1016/j.amjsurg.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/06/2022] [Accepted: 04/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.
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Affiliation(s)
- Marin A Chavez
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan A Weinberg
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan V Jacobs
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Hahn Soe-Lin
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Kristina M Chapple
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Madison Ryder
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - Ian Conley
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - James N Bogert
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States.
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Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
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Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
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22
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Segalini E, Morello A, Leati G, Di Saverio S, Aseni P. Primary angioembolization in liver trauma: major hepatic necrosis as a severe complication of a minimally invasive treatment-a narrative review. Updates Surg 2022; 74:1511-1519. [PMID: 36059024 PMCID: PMC9481502 DOI: 10.1007/s13304-022-01372-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/27/2022] [Indexed: 11/25/2022]
Abstract
The liver is the second most commonly solid organ injured in blunt abdominal trauma. Liver injuries are classified according to the American Association for the Surgery of Trauma Injury Scale. The choice of Non-Operative Management is based on generalized clinical patients’ conditions combined with the evidence on CT scan imaging. To date, there are no consensus guidelines on appropriate patient selection criteria for those who would benefit from angiography and angioembolization. Major hepatic necrosis is a clinical condition of extended liver damage and is the most common complication after angioembolization. Large amounts of necrotic liver require therapy, but it is unclear if the better technique is debridements supplemented by percutaneous drainage procedures or definitive resection. A systematic review of the literature was performed with a computerized search in a database such as Medline for published papers on the use of angioembolization in trauma patients with hepatic injuries and on the most common complication, the major hepatic necrosis. The systematic review was conducted according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A total of 3643 patients were included in the study, suffering liver trauma and 1703 (47%) were treated with Non-Operative Management; angioembolization was performed 10% of cases with a variable rate between 2 and 20%. Patients developed different complications. Hepatic necrosis accounted for 16% ranging from 0 to 42%. 74% of patients underwent operative management with a mortality rate of 11%. High-grade liver injuries pose significant challenges to surgeons who care for trauma patients. Many patients can be successfully managed nonoperatively. In hemodynamically stable patients with arterial blush, without other lesions requiring immediate surgery, selective and super-selective AE of the hepatic artery branches is an effective technique. However, these therapies are not without complications and major hepatic necrosis is the most common complication in high-grade injures. Level III, Systematic review
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Affiliation(s)
- Edoardo Segalini
- Department of General and Emergency Surgery, ASST Ospedale Maggiore, Crema, CR, Italy
| | - Alessia Morello
- Department of General and Emergency Surgery, ASST Ospedale Maggiore, Crema, CR, Italy
| | - Giovanni Leati
- Department of Interventional Radiology, ASST Ospedale Maggiore, Crema, CR, Italy
| | - Salomone Di Saverio
- Department of General Surgery, Ospedale Civile "Madonna del Soccorso", San Benedetto del Tronto, AP, Italy.
| | - Paolo Aseni
- Department of Emergency, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Virdis F, Podda M, Di Saverio S, Kumar J, Bini R, Pilasi C, Reccia I. Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature. Chin J Traumatol 2022; 25:257-63. [PMID: 35487854 DOI: 10.1016/j.cjtee.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 01/30/2022] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. METHODS A systematic literature review searched "liver trauma", "hepatic trauma", "conservative management", "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. RESULTS A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. CONCLUSION NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
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Li P, Liu F, Li Q, Zhou D, Dong J, Wang D. Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis. J Orthop Traumatol 2022; 23:29. [PMID: 35799073 PMCID: PMC9263021 DOI: 10.1186/s10195-022-00647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of pelvic packing (PP) in pelvic fracture patients with hemodynamic instability. MATERIALS AND METHODS Three databases-PubMed, Embase and the Cochrane Library-were systematically searched to identify studies presenting comparisons between a protocol including PP and a protocol without PP. Mortality, transfusion requirement and length of hospitalization were extracted and pooled for meta-analysis. Relative risk (RR) and standard mean difference (SMD), along with their confidence intervals (CIs), were used as the pooled statistical indices. RESULTS Eight studies involving 480 patients were identified as being eligible for meta-analysis. PP usage was associated with significantly reduced overall mortality (RR = 0.61, 95% CI = 0.47-0.79, p < 0.01) as well as reduced mortality within 24 h after admission (RR = 0.42, 95% CI = 0.26-0.69, p < 0.01) and due to hemorrhage (RR = 0.26, 95% CI = 0.14-0.50, p < 0.01). The usage of PP also decreased the need for pre-operative transfusion (SMD = - 0.44, 95% CI = - 0.69 to - 0.18, p < 0.01), but had no influence on total transfusion during the first 24 h after admission (SMD = 0.05, 95% CI = - 0.43-0.54, p = 0.83) and length of hospitalization (ICU stay and total stay). CONCLUSIONS This meta-analysis indicates that a treatment protocol including PP could reduce mortality and transfusion requirement before intervention in pelvic fracture patients with hemodynamic instability vs. angiography and embolization. This latter technique could be used as a feasible and complementary technique afterwards. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Pengyu Li
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China.,Department of Orthopedic, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, 324 Jingwu Road, Jinan, 250021, Shandong, China.,Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Fanxiao Liu
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Qinghu Li
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Dongsheng Zhou
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Jinlei Dong
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China.
| | - Dawei Wang
- Department of Orthopedic, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, 324 Jingwu Road, Jinan, 250021, Shandong, China. .,Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China.
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Tanaka C, Tagami T, Nakayama F, Otake K, Kudo S, Takehara A, Fukuda R, Kaneko J, Ishiki Y, Sato S, Kuno M, Unemoto K. Effect of angioembolization for isolated complex pelvic injury: A post-hoc analysis of a nationwide multicenter trauma database in Japan. Injury 2022; 53:2133-8. [PMID: 35300867 DOI: 10.1016/j.injury.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/06/2022] [Accepted: 03/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND IMPORTANCE Complex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries. OBJECTIVE To investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality. DESIGN, SETTINGS, AND PARTICIPANTS We used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3-5) from 2004 to 2018. OUTCOME MEASURES AND ANALYSIS The primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation. MAIN RESULTS We analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37-0.96; p = 0.03). CONCLUSION Urgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival.
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Anwer M, Kumar A, Kumar A, Kumar S, Kumar D, Ahmed F. Pseudoaneurysm of the uterine artery with presentation of haematuria; a rare case report. Int J Surg Case Rep 2021; 90:106675. [PMID: 34952319 PMCID: PMC8715074 DOI: 10.1016/j.ijscr.2021.106675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/04/2021] [Accepted: 12/04/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Pseudoaneurysm of the uterine artery is a condition in which extra luminal collection of blood with a turbulent flow that communicates with flowing blood of uterine artery through a defect in its arterial wall. As per literature uterine artery pseudoaneurysm is a very rare condition and its incidence is 2–3/1000 deliveries. Clinical diagnosis is very challenging and in the index case haematuria was the presenting complaint which in fact is the extremely rare presenting complaint. Angioembolization is the ideal treatment modality for such a rare condition. Case presentation A 25-year old female presented in a shock state with history of massive haematuria two months after delivering a baby. She was resuscitated with fluid, blood and blood products. A computed tomography angiogram was done which showed a large pseudoaneurysm of the left uterine artery so consequently angioembolization was done with n-butyl cyanoacrylate (NBCA) and lipoid mixture. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up. Discussion A post-partum massive haematuria could be due to pseudo aneurysm of uterine artery. The presentation of haematuria may occur due to communication of aneurysm with urinary bladder and which further get ruptured. Aggressive resuscitation and angioembolization of the pseudoaneurysm is employed to treat such patients. Conclusion Pseudoaneurysm of uterine artery is rare condition which may present as haematuria. Once clinical diagnosis is suspected it's better to first resuscitate and plan for angioembolization for better outcome. Pseudoaneurysm of uterine artery presented with haematuria is the first case to be reported in the leterature. Clinically the pseudoaneurysm of uterine artery should be considered in mind in patients with massive haematuria after caesarean/normal deliveries. Aggressive resuscitation and definitive management with embolization is the ideal treatment for such cases.
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Affiliation(s)
- Majid Anwer
- Department of Trauma & Emergency (Gen Surgery), All India Institute of Medical Sciences, Patna, India
| | - Anil Kumar
- Department of Trauma & Emergency (Gen Surgery), All India Institute of Medical Sciences, Patna, India.
| | - Anurag Kumar
- Department of Trauma & Emergency (Gen Surgery), All India Institute of Medical Sciences, Patna, India
| | - Subhash Kumar
- Department of Radio Diagnosis, All India Institute of Medical Sciences, Patna, India.
| | - Deepak Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Farheen Ahmed
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, India
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Swendiman RA, Abramov A, Fenton SJ, Russell KW, Nance ML, Nace GW, Iii MA. Use of angioembolization in pediatric polytrauma patients: WITH BLUNT SPLENIC INJURYAngioembolization in Pediatric Blunt Splenic Injury. J Pediatr Surg 2021; 56:2045-2051. [PMID: 34034882 DOI: 10.1016/j.jpedsurg.2021.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/07/2021] [Accepted: 04/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE We sought to analyze the use of angioembolization (AE) after pediatric splenic injuries at adult and pediatric trauma centers (ATCs/PTCs). METHODS The National Trauma Data Bank (2010-2015) was queried for patients (<18 years) who experienced blunt splenic trauma. Multivariate logistic regression was used to determine the association of AE with splenectomy. Propensity score matching was used to explore the relationship between trauma center designation and AE utilization. RESULTS 14,027 encounters met inclusion criteria. 514 (3.7%) patients underwent AE. When compared to PTCs, patients were older, had a higher ISS, and more often presented in shock at ATCs (p<0.001 for all). Regression models demonstrated no difference in mortality between cohorts. Odds of splenectomy were lower for patients undergoing AE (OR 0.16 [CI: 0.08-0.31]), however this effect was mostly driven by utilization at ATCs. Using a 1:1 propensity score matching model, patients treated at ATCs were 4 times more likely to undergo AE and 7 times more likely to require a splenectomy compared to PTCs (p<0.001). Over 6 years, PTCs performed only 27 splenectomies and 23 AEs (1.1% and 0.9%, respectively). CONCLUSIONS AE was associated with improved splenic salvage at ATCs in select patients but appeared overutilized when compared to outcomes at PTCs. PTCs accomplished a higher splenic salvage rate with a lower AE utilization. LEVEL OF EVIDENCE III - Retrospective cohort study.
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Affiliation(s)
- Robert A Swendiman
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Alexey Abramov
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Michael L Nance
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Gary W Nace
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Myron Allukian Iii
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Renzulli M, Ierardi AM, Brandi N, Battisti S, Giampalma E, Marasco G, Spinelli D, Principi T, Catena F, Khan M, Di Saverio S, Carrafiello G, Golfieri R. Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma. Eur J Med Res 2021; 26:123. [PMID: 34649598 PMCID: PMC8518287 DOI: 10.1186/s40001-021-00594-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/27/2021] [Indexed: 12/02/2022] Open
Abstract
Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.
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Affiliation(s)
- Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy. .,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | | | - Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Daniele Spinelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Tiziana Principi
- Intensive Care Unit and Anesthesia, Emergency Department, ASUR MARCHE AV5, San Benedetto del Tronto, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, UK.,Royal College of Surgeons of England, DSTS Faculty, London, UK
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Regione Lombardia, Italy
| | - Giampaolo Carrafiello
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
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Kauvar DS, Polykratis IA, De Guzman R, Prince MD, Voelker A, Kheirabadi BS, Dubick MA. Evaluation of a novel hydrogel intravascular embolization agent in a swine model of fatal uncontrolled solid organ hemorrhage and coagulopathy. JVS Vasc Sci 2021; 2:43-51. [PMID: 34617057 PMCID: PMC8489201 DOI: 10.1016/j.jvssci.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/25/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Current agents for the intravascular embolization of traumatic hemorrhage are used off-label and have been minimally studied with respect to their performance under differing coagulation conditions. We studied the hemorrhage control efficacy of a novel, liquid, polyethylene glycol-based hydrogel delivered as two liquid precursors that polymerize within the target vessel in a unique animal model of severe solid organ injury with and without dilutional coagulopathy. Methods Anesthetized swine (n = 36, 45 ± 3 kg) had laparotomy and splenic externalization. Half underwent 50% isovolemic hemodilution with 6% hetastarch and cooling to 33°C-35°C (coagulopathic group). All animals had controlled 20 mL/kg hemorrhage and endovascular proximal splenic artery access with a 4F catheter via a right femoral sheath. Splenic transection and 5-minute free bleeding were followed by treatment (n = 5/group) with 5 mL of gelfoam slurry, three 6-mm coils, up to 6 mL of hydrogel, or no treatment (n = 3, control). Animals received 15 mL/kg plasma and were monitored for 6 hours with continuous blood loss measurement. Results Coagulopathy was successfully established, with coagulopathic animals having greater pretreatment blood loss and earlier mean time to death regardless of the treatment group. All control animals died within 100 minutes. Overall survival without coagulopathy was 5/5 for hydrogel, 4/5 for coil, and 3/5 for gelfoam. With coagulopathy, one hydrogel animal survived to the end of the experiment, with 2/4 hydrogel deaths occurring in the final hour of observation. In noncoagulopathic animals, hydrogel demonstrated improved survival time (P < .01) and post-treatment blood loss (1.46 ± 0.8 mL/kg) over controls (18.8 ± 0.7, P = .001), gelfoam (4.7 ± 1.3, P > .05), and coils (4.6 ± 1.5, P > .05). In coagulopathic animals, hydrogel had improved survival time (P = .003) and decreased blood loss (4.2 ± 0.8 mL/kg) compared with control (20.4 ± 4.2, P = .003). Conclusions The hydrogel demonstrated equivalent hemorrhage control performance to standard treatments under noncoagulopathic conditions and improved performance in the face of dilutional coagulopathy. This agent should be explored as a potential preferable treatment for the embolization of traumatic solid organ and other injuries. (JVS–Vascular Science 2021;2:43-51.) Clinical Relevance In a translational model of severe solid organ injury hemorrhage with and without coagulopathy, a novel hydrogel transarterial embolization agent demonstrated equivalent hemorrhage control performance to standard agents under noncoagulopathic conditions and improved performance in the face of dilutional coagulopathy. This agent represents a promising future treatment for the embolization of traumatic solid organ and other injuries.
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Affiliation(s)
- David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Tex.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md
| | - I Amy Polykratis
- Combat Casualty Care, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Tex
| | - Rodolfo De Guzman
- Combat Casualty Care, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Tex
| | - M Dale Prince
- Combat Casualty Care, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Tex
| | - Amber Voelker
- Combat Casualty Care, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Tex
| | - Bijan S Kheirabadi
- Combat Casualty Care, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Tex
| | - Michael A Dubick
- Combat Casualty Care, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Tex
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Sivashankar M, Balagobi B, Perera ND, Ruvinda PGN. A case report of post-surgical page kidney due to extensive renal hematoma following percutaneous nephrolithotomy. Int J Surg Case Rep 2021; 86:106382. [PMID: 34507187 PMCID: PMC8433242 DOI: 10.1016/j.ijscr.2021.106382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Post-surgical Page kidney due to large renal hematoma following percutaneous nephrolithotomy (PCNL) is a rare significant complication that may lead to loss of a kidney. CASE PRESENTATION A 50-year-old lady underwent elective left side PCNL for a 3 cm renal pelvis stone, and one week later, she presented back with a massive renal hematoma with high blood pressure. CLINICAL DISCUSSION The ultrasound abdomen and computed tomography diagnosed a page kidney due to massive intrarenal and perirenal hematoma as a complication of PCNL. Angioembolization and percutaneous aspiration were failed, and the antihypertensives also failed to control the blood pressure. Therefore, she underwent a left-side simple nephrectomy and had an uneventful recovery with reversal of normal blood pressure. CONCLUSION Post-surgical page kidney needs to identify early to facilitate the percutaneous radiological interventions that may preserve the renal parenchyma and avoid further surgeries. Nevertheless, late cases or the failed radiologically intervened cases need open renal exploration and simple nephrectomy, which may be the bailed-out procedure to reverse the consequence of page kidney.
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Affiliation(s)
| | - B Balagobi
- Professorial Surgical Department, Teaching Hospital Jaffna, Sri Lanka
| | - Neville D Perera
- National Institute of Urology and Nephrology, Colombo, Sri Lanka
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Liguori G, Rebez G, Larcher A, Rizzo M, Cai T, Trombetta C, Salonia A. The role of angioembolization in the management of blunt renal injuries: a systematic review. BMC Urol 2021; 21:104. [PMID: 34362352 PMCID: PMC8344199 DOI: 10.1186/s12894-021-00873-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/20/2021] [Indexed: 12/22/2022] Open
Abstract
Background Recently, renal angioembolization (RAE) has gained an important role in the non-operative management (NOM) of moderate to high-grade blunt renal injuries (BRI), but its use remains heterogeneous. The aim of this review is to examine the current literature on indications and outcomes of angioembolization in BRI. Methods We conducted a search of MEDLINE, EMBASE, SCOPUS and Web of Science Databases up to February 2021 in accordance with PRISMA guidelines for studies on BRI treated with RAE. The methodological quality of eligible studies and their risk of bias was assessed using the Newcastle–Ottawa scale Results A total of 16 articles that investigated angioembolization of blunt renal injury were included in the study. Overall, 412 patients were included: 8 presented with grade II renal trauma (2%), 97 with grade III renal trauma (23%); 225 with grade IV (55%); and 82 with grade V (20%). RAE was successful in 92% of grade III–IV (294/322) and 76% of grade V (63/82). Regarding haemodynamic status, success rate was achieved in 90% (312/346) of stable patients, but only in 63% (42/66) of unstable patients. The most common indication for RAE was active contrast extravasation in hemodynamic stable patients with grade III or IV BRI. Conclusions This is the first review assessing outcomes and indication of angioembolization in blunt renal injuries. The results suggest that outcomes are excellent in hemodynamic stable, moderate to high-grade renal trauma. Supplementary Information The online version contains supplementary material available at 10.1186/s12894-021-00873-w.
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Affiliation(s)
- Giovanni Liguori
- Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, 34149, Trieste, Italy
| | - Giacomo Rebez
- Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, 34149, Trieste, Italy.
| | | | - Michele Rizzo
- Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, 34149, Trieste, Italy
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Kanani A, Sandve KO, Søreide K. Management of severe liver injuries: push, pack, pringle - and plug! Scand J Trauma Resusc Emerg Med 2021; 29:93. [PMID: 34256814 PMCID: PMC8278654 DOI: 10.1186/s13049-021-00907-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Arezo Kanani
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Knut Olav Sandve
- Department of Radiology, Interventional Radiology Unit, Stavanger University Hospital, Stavanger, Norway
- Stavanger Medical Image Laboratory, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Tamura S, Maruhashi T, Kashimi F, Kurihara Y, Masuda T, Hanajima T, Kataoka Y, Asari Y. Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29:66. [PMID: 34256826 PMCID: PMC8278697 DOI: 10.1186/s13049-021-00881-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. Methods This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III–V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. Results Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV–V were predictors of complications (OR, 6.61; p < 0.01). Conclusions TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.
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Affiliation(s)
- Satoshi Tamura
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Fumie Kashimi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yutaro Kurihara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Tomonari Masuda
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Tasuku Hanajima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yuichi Kataoka
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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Budzyn J, Leavitt D. Life threatening hepatic hemorrhage after shockwave lithotripsy - A case report and review of literature. Urol Case Rep 2021; 38:101724. [PMID: 34136358 PMCID: PMC8178103 DOI: 10.1016/j.eucr.2021.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 11/28/2022] Open
Abstract
We report a 31 year old female with urologic history significant for right ureteropelvic junction obstruction managed with open right pyeloplasty in 1996 with recurrent stricture managed with right ureterocalycostomy in 1997 along with right distal ureteroneocystostomy for iatrogenic distal ureteral stricture. She developed symptomatic stone episodes and recurrent urinary tract infections and elected to proceed with shockwave lithotripsy. Postoperatively she developed a large liver hemorrhage requiring supportive care and endovascular embolization.
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Affiliation(s)
- Jeffrey Budzyn
- Henry Ford Health System, Department of Urology, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - David Leavitt
- Henry Ford Health System, Department of Urology, 2799 W Grand Blvd, Detroit, MI, 48202, USA
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Aoki M, Abe T, Matsumoto S, Hagiwara S, Saitoh D, Oshima K. Delayed embolization associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. World J Emerg Surg 2021; 16:21. [PMID: 33941216 PMCID: PMC8094563 DOI: 10.1186/s13017-021-00366-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/23/2021] [Indexed: 11/23/2022] Open
Abstract
Background Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture. Methods A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0–30, 30–60, 60–90, 90–120, 120–150, and 150–180 min). We compared the adjusted 30-day mortality rate according to time to embolization. Results We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48–79) years and 55% were male. The median injury severity score was 26 (18–38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran–Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0–30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2–23.9) for the 150–180 min group. Conclusion Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.
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Affiliation(s)
- Makoto Aoki
- Department of Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan. .,Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Shokei Matsumoto
- Department of Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Shuichi Hagiwara
- Department of Emergency Medicine, Kiryu Kosei General Hospital, Kiryu, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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Hammerschlag J, Hershkovitz Y, Ashkenazi I, Shapira Z, Jeroukhimov I. Angiography in patients with pelvic fractures and contrast extravasation on CT following high-energy trauma. Eur J Trauma Emerg Surg 2021. [PMID: 33665753 DOI: 10.1007/s00068-021-01628-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Pelvic fracture may be accompanied by severe bleeding. Computed tomography (CT) is a gold standard diagnostic tool in stable trauma patients. Contrast extravasation detected on CT of pelvis is a sign of hemorrhage, but its significance is not clear. We aimed to evaluate the need for angiography in patients with pelvic fracture and CT revealed contrast extravasation. We tried to identify parameters that might help to choose patients who will benefit from therapeutic angiography. METHODS Electronic medical records of patients with pelvic fracture admitted to Level II Trauma Center during 10 years were retrospectively reviewed. Patients who had contrast extravasation on CT were included. Data base consisted of demographics, injury severity, initial physiologic parameters, laboratory data, results of CT and angiography. RESULTS Forty out of 396 patients had contrast extravasation detected by CT. Twelve patients underwent angiography and 4 of them benefited from embolization. The sensitivity of contrast extravasation in evaluating the need for embolization was 1.0 (95% CI 0.398, 1.0), positive predictive value was 0.1 (95% CI 0.028, 0.237), and the negative predictive value was 1.0 (95% CI 0.990, 1.0). CONCLUSION The role of angiography in stable patients with pelvic fracture and CT identified contrast extravasation remains questionable. Most of these patients are not in need of angioembolization.
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Theodorou CM, Coleman LE, Mateev SN, Signoff JK, Salcedo ES. Successful extracorporeal life support in a pediatric trauma patient following angioembolization of pelvic hemorrhage. J Pediatr Surg Case Rep 2021; 67. [PMID: 33747786 DOI: 10.1016/j.epsc.2021.101812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Extracorporeal Life Support (ECLS) is rarely used in pediatric trauma patients due to bleeding risk, and the use of ECLS following angioembolization of traumatic hemorrhage has never been reported in a child. We report a case of a 10-year-old boy run over by a parade float resulting in severe thoracic, abdominal, and pelvic trauma, with hemorrhage from pelvic fractures requiring massive transfusion. Due to ongoing blood product requirements and contrast extravasation near the symphysis pubis, angioembolization of the internal iliac arteries was performed. Extreme hypoxemia persisted despite maximal ventilator support due to pulmonary contusions and aspiration pneumonitis. Six hours after angioembolization, venovenous ECLS was initiated. Following an initial heparin bolus, ECLS was run without anticoagulation for 12 h, but development of circuit clot required resumption of low-dose heparin. After four days, his respiratory status improved substantially and ECLS was discontinued. There were no hemorrhagic complications. The patient was discharged home in good health following inpatient rehabilitation. In this case, ECLS was successfully used in the treatment of post-traumatic respiratory failure 6 h following angioembolization of pelvic hemorrhage in a pediatric trauma patient. Further research is needed to determine the safest interval between hemorrhage control and ECLS in severely injured children.
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Affiliation(s)
| | - Lauren E Coleman
- University of California Davis Medical Center, Department of Surgery, USA
| | - Stephanie N Mateev
- University of California Davis Medical Center, Division of Pediatric Critical Care, USA
| | - Jessica K Signoff
- University of California Davis Medical Center, Division of Pediatric Critical Care, USA
| | - Edgardo S Salcedo
- University of California Davis Medical Center, Department of Surgery, USA
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Villarreal JA, Yoeli D, Masand PM, Galvan NTN, Olutoye OO, Goss JA. Hepatic separation of conjoined twins: Operative technique and review of three-dimensional model utilization. J Pediatr Surg 2020; 55:2828-2835. [PMID: 32792165 DOI: 10.1016/j.jpedsurg.2020.06.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The separation of conjoined twins is a challenging and rare operation. Recent technological advances in imaging and three-dimensional printing (3DP) have allowed for enhancements in preoperative surgical planning and intraoperative anatomical orientation for complex operations. This report aims to consolidate the current clinical evidence utilizing 3DP models as an effective tool for surgical planning of conjoined twin separation and to detail our surgical approach for complex hepatic separation and management. METHODS A literature review was conducted for conjoined twin separations with preoperative use of 3D models including age at attempted separation, operative outcome, 3D modality, and postoperative course between 1998 and 2020. We also conducted a chart review of our electronic medical record for conjoined twin separations between January 2015 and December 2019. RESULTS We report two cases of conjoined twin separation with preoperative use of 3DP models from our institution: one set in the thoracoomphaloischiopagus orientation and the other set in the thoracoomphalopagus orientation with the presence of intrahepatic vascular anomalies. The literature review produced 10 case reports of conjoined twin separation with use preoperative 3D models accounting for 17 individual separation procedures. We summarize our preoperative radiological planning, the evidence of 3DP models as an educational and preoperative tool, ideal timing for separation, and our surgical approach for complex hepatic separation. CONCLUSIONS Conjoined twin separation requires a multidisciplinary effort to address the multisystem surgical and medical needs of these patients. These complex patients require extensive preoperative imaging for planning separation, and we strongly recommend utilizing 3D printed models when possible for better surgeon understanding of complex variable anatomy. We have found numerous reports of successful conjoined twin separation using 3DP technology in preoperative planning. The use of three-dimensional printed models for preoperative assessments is an invaluable tool and is rapidly improving in fidelity. TYPE OF STUDY Operative technique and case series. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Joshua A Villarreal
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Texas Children's Hospital, Houston, TX.
| | - Dor Yoeli
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Prakash M Masand
- Texas Children's Hospital, Houston, TX; Department of Pediatric Radiology, Baylor College of Medicine, Houston, TX
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Texas Children's Hospital, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Hospital, Houston, TX; Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Texas Children's Hospital, Houston, TX
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Abstract
Purpose Angioembolization (AE) has been questioned as first-line modality for hemorrhage control of pelvic fracture (PF)-associated bleeding due to its potential inconsistent timely availability. We aimed to describe the patterns of AE use with hemostatic resuscitation and hypothesized that time to AE improved during the study period. Methods A Level-1 trauma center’s prospective PF database was analyzed. All consecutive PFs referred to angiography between 01/01/2009 and 12/31/2018 were included. All suspected pelvic hemorrhage was managed with AE; pelvic packing was not performed. Demographics, injury/shock severity, 24-h transfusion data, time to AE and mortality were recorded. Data are presented as median (IQR). Results During the 10-year study period, 1270 PF patients were treated. Thirty-six (2.8%) [75% male, 49 (33;65) years, ISS 36 (24;43), base deficit 3.65 (5.9;0.6), transfusions 4(2;7)] had AE. The indication for AE was clinical suspicion (CS) of pelvic bleeding [CS 24(67%)] or arterial blush on CT [CT 12 (33%)]. Median time to AE was 141 min for CS, and 223 min for CT, with no change over the study period. Patients with CS had a higher ISS, worse base deficit, greater transfusion requirements and faster time to AE. Five patients (14%) died. There were no deaths attributed to exsanguination. Conclusions Time to AE did not improve. Patients referred from CT are physiologically different from CS and should be analyzed accordingly, with CS resulting in faster time to AE in sicker patients. Contemporary resuscitation challenges the need for hyperacute AE as no patients exsanguinated despite time to AE of more than 2 h.
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Affiliation(s)
- Giles Lawrence Devaney
- Division of Surgery, Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW 2310 Australia
| | - Kate Louise King
- Division of Surgery, Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW 2310 Australia
| | - Zsolt Janos Balogh
- Division of Surgery, Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW 2310 Australia
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Edwards A, Passoni NM, Chen CJ, Schlomer BJ, Jacobs M. Renal artery angiography in pediatric trauma using a national data set. J Pediatr Urol 2020; 16:559.e1-559.e6. [PMID: 32611488 DOI: 10.1016/j.jpurol.2020.05.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/07/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking. OBJECTIVE This study uses the National Trauma Data Bank (NTDB), to evaluate renal outcomes after use of renal artery angiography. We hypothesized that patients undergoing renal artery angiography for renal trauma are unlikely to require additional surgical interventions. STUDY DESIGN All children ≤18 years old treated for traumatic renal injuries from 2012 to 2015 were identified by the Abbreviated Injury Scaled Score (AISS) codes in the NTDB. AISS codes were converted to American Association for Surgery of Trauma (AAST) grades. ICD-9 codes were used to identify patients that had renal artery angiography, and additional renal interventions such as nephrectomy, partial nephrectomy, percutaneous nephrostomy tube or ureteral stent placement. RESULTS 536,379 pediatric trauma cases were in the NTDB from 2012 to 2015, with 4506 renal injury cases identified. A total of 88 patients had renal artery angiography (ICD-9 88.45). Only 10% (n = 9) of patients who received renal artery angiography underwent an additional urological intervention. Of those nine, two patients were excluded due to renal angiography taking place after nephrectomy was performed. The remaining seven patients had high grade laceration (AAST grade 4-5). Overall, two patients underwent post angiography nephrectomies, two patients had partial nephrectomies, one percutaneous nephrostomy tube was placed (prior to partial nephrectomy), one aspiration of a kidney (prior to ureteral stent placement), and three had ureteral stent placements. DISCUSSION The limitations of this study include: the NTDB is a national dataset that is not population based, inclusion is limited to the first hospitalization, inaccuracies exist in encounter coding, and the database is lacking laterality of the renal injury. Based on nonspecific nature of ICD-9 coding for angioembolization, we are unable to discern the number of cases that subsequently had angioembolization after or at the time of angiography. CONCLUSION Renal artery angiography in children remains a rare procedure, 88/4,506, in children with renal trauma. In pediatric trauma cases that undergo renal artery angiography additional procedures are more common with higher grade injuries. Further studies are needed to create pediatric specific trauma management algorithms.
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Affiliation(s)
| | | | | | | | - Micah Jacobs
- University of Texas Southwestern Department of Urology, USA
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Aldughiman AW, Alsunbul A, Al-Gadheeb A, Almuaiqel M, Alzahrani A, Alzahrani T, Alghamdi A, Alakrash H. Does spontaneous renal hemorrhage mandate close surveillance for impending renal cell carcinoma? A case report and literature review. Int J Surg Case Rep 2020; 73:44-7. [PMID: 32634616 DOI: 10.1016/j.ijscr.2020.06.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/09/2020] [Accepted: 06/13/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Renal cell carcinoma (RCC) classically presents as a triad of hematuria, loin pain, and a palpable mass. However, Renal cell carcinomas (RCCs) nowadays are more commonly present as incidental findings rather than symptomatic. Wunderlich syndrome is a rare first presentation of RCC. PRESENTATION OF CASE We present a clinical case of spontaneous renal hemorrhage with unclear etiology that was treated with therapeutic embolization and was found to have renal mass after long follow up. DISCUSSION AND CONCLUSION In regards to treating Wunderlich syndrome, some authors favor angioembolization and follow up. Others proposed radical nephrectomy in conditions with no apparent etiology and normal contralateral kidney because of the high incidence of small renal tumors. Spontaneous perinephric hematoma of unknown etiology should be followed up regularly with a CT image for concerning of impending renal tumor.
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Chen HT, Wang YC, Hsieh CC, Su LT, Wu SC, Lo YS, Chang CC, Tsai CH. Trends and predictors of mortality in unstable pelvic ring fracture: a 10-year experience with a multidisciplinary institutional protocol. World J Emerg Surg 2019; 14:61. [PMID: 31889991 PMCID: PMC6935111 DOI: 10.1186/s13017-019-0282-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background Pelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture. Material and methods This retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications. Results During the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure < 90 mmHg (odds ratio [OR] 2.53; confidence interval [CI] 1.11–5.73), Glasgow Coma Scale < 9 (OR 3.87; CI 1.57–9.58), 24 > ISS > 15 (OR 4.84; CI 0.85–27.65), pulse rate < 50 (OR 11.54; CI 1.21–109.6), and diabetes mellitus (OR 3.18; CI 1.10–9.21) were associated with higher mortality. No other specific system in the high Abbreviated Injury Scale increased the rates of mortality or complications. Conclusion Poor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.
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Affiliation(s)
- Hsien-Te Chen
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yu-Chun Wang
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,5Department of Surgery, School of Medicine, China Medical University, Taichung, Taiwan.,6Division of Emergency Disease Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chen-Chou Hsieh
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Li-Ting Su
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,6Division of Emergency Disease Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Chi Wu
- 4Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,5Department of Surgery, School of Medicine, China Medical University, Taichung, Taiwan.,6Division of Emergency Disease Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yuan-Shun Lo
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Chien-Chun Chang
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Chun-Hao Tsai
- 1Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan.,2Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.,3Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan.,7Department of Orthopedic Surgery, School of Medicine, China Medical University, #91 Hsueh-Shih Road, Taichung, 404 Taiwan
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Aletaha N, Hamid H, Ayoobi Yazdi N, Taslimi R, Shahbazkhani B, Ketabi Moghadam P. A Rare Cause of Gastrointestinal Bleeding in a 65-Year-Old Man with History of Polycythemia Vera. Middle East J Dig Dis 2019; 11:225-229. [PMID: 31824626 PMCID: PMC6895857 DOI: 10.15171/mejdd.2019.153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 09/04/2019] [Indexed: 01/08/2023] Open
Abstract
Polycythemia vera (PV) is classified as a myeloproliferative disorder (MPD). Such patients are prone to both thrombotic and hemorrhagic events. Although gastrointestinal (GI) bleeding is not a prominent manifestation of PV, it would be life threatening and necessitating hospital admission and blood transfusion if it occurs. GI hemorrhage in these patients may be due to Aspirin usage, peptic ulcer disease (PUD), acquired Von Willbrand disease, Dieulafoy lesion (DL), Mallory Weiss tear, and esophageal and gastric varices. DL is an enlarged, thick-walled artery in the muscularis mucosa with a small submucosal defect. In this case report, we describe a 65-year-old man with history of PV presented with a massive upper GI bleeding. After a therapeutic endoscopic hemostasis failure and reoccurrence of bleeding during hospital admission, an abdominal computed tomography (CT) was ordered, which revealed an aberrant artery originated from aorta directly into the stomach. An angiographic embolization was considered for the patient, which was successfully performed. Our patient was complicated by splenic infarction due to splenic collateral arteries embolization and the overwhelming thrombotic tendency of the patient himself due to the history of PV. Fortunately, our patient's signs and symptoms responded to supportive therapies and eventually he discharged well.
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Affiliation(s)
- Najmeh Aletaha
- Department of Gastroenterology, Tehran University of Medical Sciences, Imam Hospital, Tehran, Iran
| | - Hoda Hamid
- Department of Gastroenterology, Tehran University of Medical Sciences, Imam Hospital, Tehran, Iran
| | - Niloofar Ayoobi Yazdi
- Department of Radiology, Liver Transplantation Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Taslimi
- Department of Gastroenterology, Tehran University of Medical Sciences, Imam Hospital, Tehran, Iran
| | - Bijan Shahbazkhani
- Department of Gastroenterology, Tehran University of Medical Sciences, Imam Hospital, Tehran, Iran
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Jarvis S, Orlando A, Blondeau B, Banton K, Reynolds C, Berg GM, Patel N, Meinig R, Carrick M, Bar-Or D. The effect of orthopaedic surgeons' and interventional radiologists' availability on the priority treatment sequence for hemodynamically unstable pelvic fractures: a survey of US Level I trauma centers. J Orthop Surg Res 2019; 14:411. [PMID: 31801568 PMCID: PMC6894122 DOI: 10.1186/s13018-019-1417-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/15/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Most guidelines recommend both pelvic packing (PP) and angioembolization for hemodynamically unstable pelvic fractures, however their sequence varies. Some argue to use PP first because orthopaedic surgeons are more available than interventional radiologists; however, there is no data confirming this. METHODS This cross-sectional survey of 158 trauma medical directors at US Level I trauma centers collected the availability of orthopaedic surgeons and interventional radiologists, the number of orthopaedic trauma surgeons trained to manage pelvic fractures, and priority treatment sequence for hemodynamically unstable pelvic fractures. The study objective was to compare the availability of orthopaedic surgeons to interventional radiologists and describe how the availability of orthopaedic surgeons and interventional radiologists affects the treatment sequence for hemodynamically unstable pelvic fractures. Fisher's exact, chi-squared, and Kruskal-Wallis tests were used, alpha = 0.05. RESULTS The response rate was 25% (40/158). Orthopaedic surgeons (86%) were on-site more often than interventional radiologists (54%), p = 0.003. Orthopaedic surgeons were faster to arrive 39% of the time, and interventional radiologists were faster to arrive 6% of the time. There was a higher proportion of participants who prioritized PP before angioembolization at centers with above the average number (> 3) of orthopaedic trauma surgeons trained to manage pelvic fractures, as among centers with equal to or below average, p = 0.02. Arrival times for orthopaedic surgeons did not significantly predict prioritization of angioembolization or PP. CONCLUSIONS Our results provide evidence that orthopaedic surgeons typically are more available than interventional radiologists but contrary to anecdotal evidence most participants used angioembolization first. Familiarity with the availability of orthopaedic surgeons and interventional radiologists may contribute to individual trauma center's treatment sequence.
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Affiliation(s)
- S. Jarvis
- Clinical Epidemiologist, ION Research, 383 Corona St. #319, Denver, CO 80218 USA
| | - A. Orlando
- Clinical Epidemiologist, ION Research, 383 Corona St. #319, Denver, CO 80218 USA
| | - B. Blondeau
- Research Medical Center, 2316 East Meyer Blvd., Kansas City, MO 64132 USA
- University of Connecticut Hartford Hospital, Hartford, CT 06106 USA
| | - K. Banton
- Swedish Medical Center, 501 E Hampden Ave., Englewood, CO 80113 USA
| | - C. Reynolds
- Swedish Medical Center, 501 E Hampden Ave., Englewood, CO 80113 USA
| | - G. M. Berg
- Wesley Medical Center, 550 N. Hillside St., Wichita, KS 67214 USA
| | - N. Patel
- Orthopaedic Trauma Surgeon, St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - R. Meinig
- Orthopaedic Trauma Surgeon, Penrose Hospital, 2222 North Nevada Ave., Colorado Springs, CO 80907 USA
| | - M. Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - D. Bar-Or
- Swedish Medical Center, 501 E Hampden Ave., Englewood, CO 80113 USA
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45
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Binetti M, Lauro A, Golfieri R, Vaccari S, D'Andrea V, Marino IR, Cervellera M, Renzulli M, Tonini V. False in Name Only-Gastroduodenal Artery Pseudoaneurysm in a Recurrently Bleeding Patient: Case Report and Literature Review. Dig Dis Sci 2019; 64:3086-3091. [PMID: 31559552 DOI: 10.1007/s10620-019-05853-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although the diagnosis of visceral pseudoaneurysm is unusual, it requires emergent attention due to the risk of rupture. We describe a 70-year-old man with a gastroduodenal artery pseudoaneurysm that manifested as recurrent hemorrhage. We highlight the possible etiologies, clinical presentations, diagnostic tools, and treatment options for this condition. In this instance, the patient was successfully treated by selective angioembolization. A visceral pseudoaneurysm should be considered in patients with abdominal pain and GI hemorrhage. At present, angioembolization is a first-line therapy.
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Affiliation(s)
- M Binetti
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - A Lauro
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy.
| | - R Golfieri
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, St. Orsola University Hospital, Bologna, Italy
| | - S Vaccari
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - V D'Andrea
- Department of Surgical Sciences, La Sapienza University, Umberto I Hospital, Rome, Italy
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - M Cervellera
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - M Renzulli
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, St. Orsola University Hospital, Bologna, Italy
| | - V Tonini
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
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46
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Saqib Y. A systematic review of the safety and efficacy of non-operative management in patients with high grade liver injury. Surgeon 2019; 18:165-177. [PMID: 31399317 DOI: 10.1016/j.surge.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 06/09/2019] [Accepted: 07/13/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The liver is the most frequently damaged organ in blunt abdominal trauma. It is widely accepted that hemodynamically stable patients with low-grade liver trauma should be treated with non-operative management, however there is controversy surrounding its safety and efficacy in high-grade trauma. The purpose of this review is to investigate the role of non-operative management in patients with high-grade liver trauma. METHODS PubMed and reference lists of PubMed articles were searched to find studies that examined the efficacy of non-operative management in high-grade liver injury patients, and compare it to operative management. Non-operative management was considered successful if rescue surgery was avoided. Outcomes considered were success, mortality, and complication rates. RESULTS The electronic search revealed 2662 records, 8 of which met the inclusion criteria. All 8 studies contained results suggesting that non-operative management was safe and effective in hemodynamically stable patients with high-grade liver trauma. By combining the outcomes of the different studies, non-operative management had a high success rate of 92.4% (194/210) in high-grade liver trauma patients, which was near the overall 95.0% non-operative management success rate. Non-operative management also had mortality and complication rates of 4.6% (9/194) and 9.7% (7/72) in high-grade injury patients, respectively, compared to operative management's 17.6% (26/148) and 45.5% (5/11). CONCLUSION Non-operative management of liver trauma is safe and effective in hemodynamically stable patients with high-grade liver injury. It is associated with significantly lower mortality compared with operative management. More studies are required to evaluate complications of non-operative management in high-grade liver injury.
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Affiliation(s)
- Yosuf Saqib
- Saba University School of Medicine, The Bottom, Caribbean Netherlands, the Netherlands.
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Samuels JM, Urban S, Peltz E, Schroeppel T, Heise H, Dorlac WC, Britton LJ, Burlew CC, Robinson C, Swope ML, McIntyre RC. A modern, multicenter evaluation of hepatic angioembolization - Complications and readmissions persist. Am J Surg 2019; 219:117-122. [PMID: 31272677 DOI: 10.1016/j.amjsurg.2019.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Indications for angioembolization (AE) following liver injury are not clearly defined. This study evaluated the outcomes and complications of hepatic AE. We hypothesize hepatic angioembolization is a useful adjunct to non-operative management of liver injury but with significant morbidity. METHODS Subjects were identified utilizing trauma registries from centers in a regional trauma network from 2010 to 2017 with an Abbreviated Injury Scale (AIS) coded hepatic injury and an ICD9/10 for hepatic angiography (HA). RESULTS 1319 patients with liver injuries were identified, with 30 (2.3%) patients undergoing HA: median ISS was 26, and median liver AIS was 4. Twenty-three subjects required AE. 81% had extravasation on CT from a liver injury. 63% underwent HA as initial intervention. 43% of AE subjects had liver-related complications with 35% 30-day readmission but with zero 30-day mortality. CONCLUSIONS While there were zero reported deaths, a high rate of morbidity and readmission was found. This may be due to the angioembolization or the liver injury itself.
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Affiliation(s)
- Jason M Samuels
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA.
| | - Shane Urban
- Trauma Services, University of Colorado Hospital, Mail Stop-F756, 12401 E 17th Ave Aurora, CO, 80045, USA.
| | - Erik Peltz
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA.
| | - Thomas Schroeppel
- Department of Surgery, UC Health Memorial Hospital, 1400 E. Boulder Street, Suite 600, Colorado Springs, CO, 80909, USA.
| | - Holly Heise
- Department of Surgery, UC Health Memorial Hospital, 1400 E. Boulder Street, Suite 600, Colorado Springs, CO, 80909, USA.
| | - Warren C Dorlac
- Department of Surgery, UC Health Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Suite 2200 Loveland, CO, 80538, USA.
| | - Linda J Britton
- Department of Surgery, UC Health Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Suite 2200 Loveland, CO, 80538, USA.
| | - Clay Cothren Burlew
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA; Department of Surgery, Denver Health Medical Center, 700 Delaware St., Davis Pavilion, Pavilion D & E Denver, CO, 80204, USA.
| | - Caitlin Robinson
- Department of Surgery, Denver Health Medical Center, 700 Delaware St., Davis Pavilion, Pavilion D & E Denver, CO, 80204, USA.
| | - Megan L Swope
- Department of Surgery, Denver Health Medical Center, 700 Delaware St., Davis Pavilion, Pavilion D & E Denver, CO, 80204, USA.
| | - Robert C McIntyre
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA.
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Jarvis S, Orlando A, Blondeau B, Banton K, Reynolds C, Berg GM, Patel N, Kelly M, Carrick M, Bar-Or D. Variability in the timeliness of interventional radiology availability for angioembolization of hemodynamically unstable pelvic fractures: a prospective survey among U.S. level I trauma centers. Patient Saf Surg 2019; 13:23. [PMID: 31249625 PMCID: PMC6587295 DOI: 10.1186/s13037-019-0201-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with hemodynamically unstable pelvic fractures have high mortality due to delayed hemorrhage control. We hypothesized that the availability of interventional radiology (IR) for angioembolization may vary in spite of the mandated coverage at US Level I trauma centers, and that the priority treatment sequence would depend on IR availability. METHODS This survey was designed to investigate IR availability and pelvic fracture management practices. Six email invitations were sent to 158 trauma medical directors at Level I trauma centers. Participants were allowed to skip questions and irrelevant questions were skipped; therefore, not all questions were answered by all participants. The primary outcome was the priority treatment sequence for hemodynamically unstable pelvic fractures. Predictor variables were arrival times for IR when working off-site and intervention preparation times. Kruskal-Wallis and ordinal logistic regression were used; alpha = 0.05. RESULTS Forty of the 158 trauma medical directors responded to the survey (response rate: 25.3%). Roughly half of participants had 24-h on-site IR coverage, 24% (4/17) of participants reported an arrival time ≥ 31 min when IR was on-call. 46% (17/37) of participants reported an IR procedure setup time of 31-120 min. Arrival time when IR was working off-site, and intervention preparation time did not significantly affect the sequence priority of angioembolization for hemodynamically unstable pelvic fractures. CONCLUSIONS Trauma medical directors should review literature and guidelines on time to angioembolization, their arrival times for IR, and their procedural setup times for angioembolization to ensure utilization of angioembolization in an optimal sequence for patient survival.
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Affiliation(s)
| | | | - Benoit Blondeau
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO 64132 USA
- University of Connecticut, Hartford Hospital, Hartford, CT 06106 USA
| | - Kaysie Banton
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
| | | | - Gina M. Berg
- Wesley Medical Center, 550 N. Hillside St, Wichita, KS 67214 USA
| | - Nimesh Patel
- St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Michael Kelly
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - David Bar-Or
- Trauma Research, LLC, 383 Corona St. #319, Denver, CO 80218 USA
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
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Chou CH, Wu YT, Fu CY, Liao CH, Wang SY, Bajani F, Hsieh CH. Hemostasis as soon as possible? The role of the time to angioembolization in the management of pelvic fracture. World J Emerg Surg 2019; 14:28. [PMID: 31210779 PMCID: PMC6567387 DOI: 10.1186/s13017-019-0248-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/03/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction While transcatheter arterial embolization (TAE) is an effective way to control arterial bleeding associated with pelvic fracture, delayed TAE may increase mortality risk. The purpose of the current study was to determine how time to TAE affects outcomes in patients with pelvic fracture in the emergency department. Methods From January 2014 to December 2016, the trauma registry and medical records of patients with pelvic fracture who underwent TAE were retrospectively reviewed. The relationship between the time to TAE and patient outcomes was evaluated. The characteristics of surviving and deceased patients were also compared to search for prognostic factors affecting survival. Results Eighty-four patients were enrolled in the current study. Among patients with pelvic fracture who underwent TAE, the overall mortality rate was 16.7%. There were positive relationships between the time to TAE and the requirement for blood transfusion and between the time to TAE and intensive care unit (ICU) length of stay (LOS). Nonsurviving patients were significantly older (57.4 ± 23.3 vs. 42.7 ± 19.3 years old, p = 0.014) and had higher injury severity scores (ISSs) (36.4 ± 11.9 vs. 23.9 ± 10.9, p < 0.001) than were observed in surviving patients. There was no significant difference in the time to TAE between nonsurviving and surviving patients (76.9 ± 47.9 vs. 59.0 ± 29.3 min, p = 0.068). The multivariate logistic regression analysis showed that ISS and age served as independent risk factors for mortality. Every one unit increase in ISS or age resulted in a 1.154- or 1.140-fold increase in mortality, respectively (p = 0.033 and 0.005, respectively). However, the time to TAE serves as an independent factor for ICU LOS (p = 0.015). Conclusion In pelvic fracture patients who require TAE for hemostasis, longer time to TAE may cause harm. An early hemorrhage control is suggested.
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Affiliation(s)
- Chang-Hua Chou
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Yu-Tung Wu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Francesco Bajani
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
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50
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Lauerman MH, Brenner M, Simpson N, Shanmuganathan K, Stein DM, Scalea T. Angioembolization significantly improves vascular injuries in blunt splenic trauma. Eur J Trauma Emerg Surg 2019; 47:99-103. [PMID: 31172200 DOI: 10.1007/s00068-019-01151-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Non-operative management (NOM) of blunt splenic injury (BSI) uses angioembolization (AE) or observation (OBS). AE improves the success of NOM. However, how AE improves BSI is unknown. We hypothesized AE would decrease rate of pseudoaneurysm (PSA) presence, PSA size, PSA number, and rate of active extravasation. METHODS We performed a retrospective review of computerized tomography (CT)-diagnosed BSI over a 2-year period. Patients undergoing NOM with an initial and repeat CT were included. Patients were excluded if they underwent primary splenectomy after BSI diagnosis or did not have repeat CT imaging. RESULTS One hundred and fifteen patients with BSI had repeat CT imaging; 55/115 (47.8%) had AE; and 60/115 (52.2%) had OBS. On the initial CT, AE patients had more frequent PSA presence (52.7% vs. 6.7%, p < 0.001), higher median number of PSA (1.0 vs. 0, p < 0.001), higher median PSA size (1.15 mm vs. 0 mm, p < 0.001), and more frequent rates of active extravasation (10.9% vs. 0%, p = 0.01) compared with OBS patients. On repeat CT compared to the initial CT, AE patients had significant decrease in rate of PSA presence (21.8% vs. 52.7%, p < 0.001), median PSA size (0 mm vs. 1.15 mm, p < 0.001), median PSA number (p < 0.001), and rate of active extravasation (0% vs. 10.9%, p = 0.03). On repeat CT compared to the initial CT, OBS patients had an increase in rate of PSA presence (18.3% vs. 6.7%, p = 0.04). CONCLUSIONS AE significantly decreases PSA presence, number, and size as well as rates of active extravasation. AE should be standard practice in vascular injuries undergoing NOM to maximize splenic salvage.
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Affiliation(s)
- Margaret H Lauerman
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene St, Baltimore, MD, 21201, USA.
| | - Megan Brenner
- Department of Surgery, University of California Riverside School of Medicine, Moreno Valley, CA, 92555, USA
| | - Nana Simpson
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Kathirkamanathan Shanmuganathan
- Division of Radiology, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Deborah M Stein
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Thomas Scalea
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene St, Baltimore, MD, 21201, USA
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