Concomitant Intra-abdominal Injuries Research Articles

Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit.

The management of high-grade pancreatic trauma is controversial. To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries. A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified. Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies. We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.

Causes and management of blunt liver trauma in a tertiary care hospital in Peshawar

Trauma is the principal reason of deaths in kids and young adults globally. Objective: To determine the causes and management of blunt liver trauma in a tertiary care hospital in Peshawar. Methods: The present investigation observed a total of 150 individuals through non-probability consecutive sampling to determine the mean hospital stay in patients presented with blunt liver trauma. Results: In this study, age distribution among 150 patients was analyzed as n= 10-20 Years 51 34.0%), 21-30 Years 35 (23.3%), 31-40 Years 16 (10.7%), 41-50 Years 23 (15.3%), 51-60 Years 25 (16.7%). Mean age was 41.56±5.357 years. Gender wise Distribution among 150 Patients was analyzed as Male were 94 (62.7%) and female were 56 (37.3%) Distribution of BMI among 150 patients were analyzed as n=Below 18.5 Underweight 76 (50.7%), 18.5–24.9 Normal weight 35 (23.3%), 25.0–29.9 pre-obesity 21 (14.0%), 30.0–34.9 Obesity class 18 (12.0%). Distribution Mechanism of Injury among 150 patients were analyzed as n= RTA was 57 (38.0%), fall from height was 52 (34.7%), Sport's injury was 18 (12.0%), physical assault was 23 (15.3%). Successful Conservative Management among 150 patients were analyzed as n= Yes was 106 (70.7%) and No was 44 (29.3%), Distribution of Mortality among 150 patients were analyzed as n= Yes was found 66 (44.0%) and No was found 84 (56.0%). Conclusions: The severity of liver damage and concomitant intra-abdominal injuries demonstrated a strong association with the chance of success with conservative therapy. The restricted hospital facilities and lack of agreement on traditional therapy had a detrimental influence on success.

Difference in Presentation and Concomitant Intra-Abdominal Injury with Chance Fracture in Pediatric and Adult Populations.

Chance fracture (CFx) with concomitant intra-abdominal injury has variable occurrence rates ranging from 33 to 89%. No single study has compared the incidence of simultaneous abdominal injury between pediatric and adult populations. This study compares the rate of simultaneous intra-abdominal injury and chance fracture in these populations. A retrospective review of pediatric and adult patients with chance fracture in comparable pediatric and adult trauma centers was performed. Patient demographics, mechanism of injury (MOI), and injury patterns were collected from 2002 to 2019 for pediatric patients and 2015 to 2018 for adults. Student t-test analyses were performed to determine statistical significance between the cohorts. The pediatric group had a similar incidence of abdominal solid organ injuries compared to adults (16 [20.5%] vs. 40 [19.7%], p<0.879), but the pediatric group had a greater number of total intra-abdominal (49 [62.8%] vs. 47 [23.1%], p < 0.001) and hollow organ injuries (40 [51.3%] vs. 17 [8.4%], p < 0.001). Motor vehicle collision was the most common mechanism of injury for both groups (72 pediatric [92.3%] vs. 85 adult [41.7%]) but adults suffered from more falls (3 pediatric vs. 81 adult, p < 0.001). Pediatric patients with CFx caused by MVCs had more intra-abdominal injuries (48 [66.7%] vs. 25[29.8%], p < 0.001) and hollow organ injuries compared to adults (39 [54.2%] vs. 8[9.5%], p < 0.001). In the setting of Chance fracture after trauma, pediatric patients are more likely to have a concomitant intra-abdominal organ injury (63% vs. 23%), especially hollow viscus injury (51.3% vs. 8.4%) compared with adults regardless of mechanism.

Intra-abdominal injury identified by CTA in stable blunt polytrauma patients

Background: Patients with multiple injuries are a challenge to evaluate and to exclude abdominal injury, especially those who are intubated and sedated. Ultrasound is a screening tool and peritoneal lavage is unreliable. The aim of the study was to determine the incidence of intra-abdominal injury and describe the subsequent management after CT “panscan” in patients sustaining blunt trauma with injuries both above the thoracic and below the pelvic diaphragm. Methods: In a retrospective analysis anonymised patient data were extracted from a prospective ethics approved database of patients admitted to the level I Trauma Unit at Inkosi Albert Luthuli Central Hospital for the period from April 2007 to March 2011. Blunt polytrauma patients, aged 2 years and older with injuries above the diaphragm and below the pelvic floor were included, provided they were investigated by a full-body trauma Computed Tomography contrast study. Descriptive statistics were employed for all variables of interest, with counts/frequencies and associated percentages being reported. Results: Of 284 patients with injuries above the thoracic and below the pelvic diaphragm, 87 (30.6%) had intra-abdominal injury and 197 (69.4%) had no intra-abdominal injuries. Of those 87 patients, 54 (62.1%) were treated non-operatively and 33 (37.9%) were treated surgically with regard to their abdominal injuries. Twenty (22.9%) patients died, 4 due to intraabdominal injuries and 16 due to of extra-abdominal injuries. Nine (45%) of the twenty patients who died were treated operatively for intra-abdominal injuries and the remaining 11 (55%) were treated non-operatively. Conclusion: Around thirty percent of patients with injuries above the thoracic and below the pelvic diaphragm had concomitant intra-abdominal injuries. Of those with abdominal injury, just over half required laparotomy. For haemodynamically stable patients CT scanning identified those who require surgical intervention and those who may be managed non-operatively, therefore liberal CT-scanning is advisable for this patient group.

Contemporary Role of Open Surgery in the Management of High-Grade Renal Injury

This review focuses on latest developments in kidney trauma management and the role of open surgical intervention. In the last decade, there had been an obvious drift towards conservative, non-operative, management of kidney trauma, undoubtedly when it is secondary to blunt trauma. Improved imaging, minimally invasive interventions, advancements including stent and nephrostomy insertions for urine extravasation, and angiography with angioembolization for acute or impending arterial bleeding have narrowed the necessity for open surgery, even when dealing with high-grade kidney injury. Still, open surgical intervention has its essential role, predominantly in the severely bleeding-unstable patient, high-grade penetrating kidney trauma, patients with concomitant intra-abdominal injuries, and the cases of non-operative surgical approach failure. Open surgical management has a contracted but still critical share in kidney trauma management. Being alert to the indications for open intervention and mastering the different surgical techniques could impact kidney salvageability and long-term clinical outcome.

When Should Abdominal Computed Tomography Be Considered in Patients with Lower Rib Fractures?

BackgroundLower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the “gold standard” examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%–40%. ObjectiveThe purpose of this study was to evaluate the incidence of intra-abdominal organ injuries in blunt trauma patients with lower rib fractures. MethodsMedical charts and radiology reports of patients with lower rib (from the 8th to 12th rib) fractures admitted to our center during a 6-year period were retrospectively reviewed. Patients were divided into two groups. Group I included patients with intra-abdominal injury (IAI) diagnosed either by CT or on urgent laparotomy, and Group II included those with normal abdominal CT scans. Data included demographics, mechanism of injury, laboratory tests, radiology results including number and location of fractured ribs, and incidence of IAI. ResultsOverall 318 patients were included in the study. Fifty-seven patients (17.9%) had 71 IAIs compared with 265 (82.1%) patients with no IAI. Logistic regression identified age younger than 55 years (relative risk [RR] = 7.2; 95% confidence interval [CI] 3.1–16.8; p = 0.001), bilateral rib fractures (RR = 3.9; 95% CI 1.1–13.5; p = 0.03) and decreased levels of hematocrit (RR = 2.4; 95% CI 1.2–4.8; p = 0.016) as independent risk factors for the presence of IAI. ConclusionsAbdominal CT should be considered in blunt trauma patients with lower rib fractures who are younger than 55 years of age and have bilateral rib fractures and decreased levels of hematocrit on admission.

Outcomes of Endovascular Management of Acute Thoracic Aorta Emergencies in an Academic Level 1 Trauma Center

BACKGROUND: Thoracic aortic emergencies account for 10% of thoracic-related admissions in the United States and remain associated with high morbidity and mortality rates. Open repair has declined owing to the emergence of thoracic endovascular aortic repair (TEVAR), but data on emergency TEVAR use for acute aortic pathology remain limited. We therefore reviewed our experience. METHODS: We retrospectively evaluated emergency descending thoracic aortic endovascular interventions performed at a single academic level 1 trauma center between January 2005 and August 2013 including all cases of traumatic aortic injury, ruptured descending thoracic aneurysm, penetrating atherosclerotic ulcer, aortoenteric fistula, and acute complicated type B dissection. Demographics, clinical data, and outcomes were extracted. Stepwise logistic regression was used to identify independent risk factors for death. RESULTS: During the study period, 51 patients underwent TEVAR; 22 cases (43.1%) were performed emergently (11 patients [50.0%] traumatic aortic injury; 4 [18.2%] ruptured descending thoracic aneurysm; 4 [18.2%] complicated type B dissection; 2 [9.1%] penetrating aortic ulcer; and 1 [4.5%] aortoenteric fistula). Overall, 72.7% (n 5 16) were male with a mean age of 54.8 6 15.9 years. Nineteen patients (86.4%) required only a single TEVAR procedure, whereas 2 (9.1%) required additional endovascular therapy, and 1 (4.5%) open thoracotomy. Four traumatic aortic injury patients required exploratory laparotomy for concomitant intra-abdominal injuries. During a mean hospital length of stay of 18.9 days (range, 1 to 76 days), 3 patients (13.6%) developed major complications. In-hospital mortality was 27.2%, consisting of 6 deaths from traumatic brain injury (1); exsanguination in the operating room before repair could be achieved (2); bowel ischemia (1) and multisystem organ failure (1); and family withdrawal of care (1). A stepwise logistic regression model identified 24-hour packed red blood cell requirements R4 units, admission mean arterial pressure ,60 mm Hg, and

Outcomes of endovascular management of acute thoracic aortic emergencies in an academic level 1 trauma center

BackgroundThoracic aortic emergencies account for 10% of thoracic-related admissions in the United States and remain associated with high morbidity and mortality rates. Open repair has declined owing to the emergence of thoracic endovascular aortic repair (TEVAR), but data on emergency TEVAR use for acute aortic pathology remain limited. We therefore reviewed our experience. MethodsWe retrospectively evaluated emergency descending thoracic aortic endovascular interventions performed at a single academic level 1 trauma center between January 2005 and August 2013 including all cases of traumatic aortic injury, ruptured descending thoracic aneurysm, penetrating atherosclerotic ulcer, aortoenteric fistula, and acute complicated type B dissection. Demographics, clinical data, and outcomes were extracted. Stepwise logistic regression was used to identify independent risk factors for death. ResultsDuring the study period, 51 patients underwent TEVAR; 22 cases (43.1%) were performed emergently (11 patients [50.0%] traumatic aortic injury; 4 [18.2%] ruptured descending thoracic aneurysm; 4 [18.2%] complicated type B dissection; 2 [9.1%] penetrating aortic ulcer; and 1 [4.5%] aortoenteric fistula). Overall, 72.7% (n = 16) were male with a mean age of 54.8 ± 15.9 years. Nineteen patients (86.4%) required only a single TEVAR procedure, whereas 2 (9.1%) required additional endovascular therapy, and 1 (4.5%) open thoracotomy. Four traumatic aortic injury patients required exploratory laparotomy for concomitant intra-abdominal injuries. During a mean hospital length of stay of 18.9 days (range, 1 to 76 days), 3 patients (13.6%) developed major complications. In-hospital mortality was 27.2%, consisting of 6 deaths from traumatic brain injury (1); exsanguination in the operating room before repair could be achieved (2); bowel ischemia (1) and multisystem organ failure (1); and family withdrawal of care (1). A stepwise logistic regression model identified 24-hour packed red blood cell requirements ≥4 units, admission mean arterial pressure <60 mm Hg, and 24-hour fresh frozen plasma to packed red blood cell (pRBC) ratio <1:1.5 as independent risk factors for death in this cohort. During a mean follow-up of 369 days (range, 35 to 957 days), no subsequent major complications or deaths occurred. All patients underwent serial computed tomographic angiography surveillance, and no device-related problems were identified during intermediate follow-up. ConclusionsThoracic aortic emergencies remain challenging. Our experience in a moderate-volume center supports the utilization of TEVAR in the acute setting. Twenty-four-hour pRBC requirements ≥4 units, admission mean arterial pressure <60 mm Hg, and 24 hour fresh frozen plasma to pRBC ratio <1:1.5 were independently associated with death.

Chance fractures in the pediatric population

The pediatric Chance fracture (PCF) is an uncommon injury, but it has been increasingly reported. Knowledge is limited to few case reports and short series. To understand the various aspects of this injury, the authors reviewed the current literature. A literature search was conducted using the PubMed and Ovid online databases and relevant key words. All articles that were in English and provided information regarding PCF as a sole or part of the objective were retrieved. Seventy-three articles were found to fulfill the inclusion criteria. Relevant information about PCF collected from these articles included: 1) mode of trauma, 2) associated injuries, 3) radiological classification, and 4) treatment. Chance fractures in children are potentially devastating injuries largely caused by motor vehicle collisions, and these fractures may be more common than previously thought. Concomitant intraabdominal injuries are common and should be suspected, particularly when a seat belt sign is observed. Blunt abdominal aortic injuries are rarely associated, but should be evaluated for and treated appropriately. Magnetic resonance imaging is best for defining ligamentous injury, which aids in defining the pattern of injury, facilitating appropriate treatment regimens.

Open-Book Pelvic Fractures with Perineal Open Wounds: A Significant Morbid Combination

Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group (P < 0.001), with cost of $120,647.30 and $62,952.72 respectively (P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.

Laparotomy and unstable pelvic fractures

The requirement for laparotomy was analysed in 91 patients with unstable pelvic fractures. Laparotomies were classified as positive or negative. Injuries found at laparotomy were compared with the pelvic fracture pattern. Laparotomy was carried out in 28 patients but was unnecessary in 8. Eleven of the 28 patients died, a mortality of 39%. Vertical shear and combined mechanical injury pelvic fracture patterns had the highest incidence of abdominal injuries (28%) but the fracture pattern was not a reliable guide to the presence or nature of intra-abdominal injury. Inadequate preoperative investigations contributed to the eight negative laparotomies and three of these patients died. Laparotomy was only necessary in 22% of our patients. Major pelvic fractures with concomitant intra-abdominal injuries have a high mortality rate. Preoperative CT scanning was 98% accurate in the identification of intra-abdominal injury and was the most useful investigation for determining the need for laparotomy and minimising the risk of negative laparotomy.

Bleeding Pelvic Fractures: Updates and Controversies in Acute Phase Management

Background The management of patients with haemodynamic instability related to pelvic fractures is a major challenge with high mortality and morbidity. The treatment priorities have long been a source of debate. Many advocate emergent external fixation (EX-FIX) as the first line of treatment, whereas another school favours the efficacy of transcatheter arterial embolisation (TAE). Decision-making within the ‘Golden Hour’ in the emergency department (ED) is crucial to patients' ultimate outcome. Our aim was to evaluate the current management pathways in our centre and to review the latest literature. Methods We present a 2-year case series (from January 2005 to December 2006) of patients with pelvic ring disruption and haemodynamic instability. Data were collected regarding patients' demographics, fracture patterns according to the Young &amp; Burgess classification, concomitant intra-abdominal injuries, treatment pathway and the response to treatment. Results There were 7 patients identified. Five were males and 2 were females, with a mean age of 42 years. Fracture types included 3 lateral compression, 1 anteroposterior compression, 2 vertical shear, and 1 combined mechanism. Four patients had significant intraperitoneal haemorrhage identified by Focused Assessment by Sonography for Trauma (FAST). They all needed laporotomy and pelvic packing, initially or subsequently. EX-FIXs were offered to 6 patients as the primary intervention, and 4 of them subsequently required diagnosis with angiography followed by therapeutic embolisation to restore haemodynamic stability. Only 1 patient underwent a second angiographic study to control the arterial bleeding. Two patients died of severe intra-abdominal injuries within 24 hours after admission. Conclusion In patients with pelvic fractures and hypotension, EX-FIX is currently the first line of treatment, with variable efficacy. On the other hand, the high successful embolisation rate and reasonable safety profile of TAE in our patients have been impressive. The latter offers a much better alternative to surgical intervention in selected patients. However, precautions should be taken including proper pelvic stabilisation by non-invasive devices, creation of a safe environment in the angiography suite, and early multidisciplinary decision in the ED.

Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.

Blunt traumatic rupture of the diaphragm: Study of 33 cases

Objective: to assess the role of clinical manifestations and radiological findings in the early recognition and diagnosis of blunt diaphragmatic rupture, with determination of the operative findings during surgical intervention. Design: a prospective case series study. Setting: Al-Jamhori Teaching Hospital in Mosul, during the period July 1999-June 2004. Participants: thirty three (33) patients with blunt traumatic rupture of the diaphragm proved by surgery. Results: three quarters of the blunt diaphragmatic rupture were caused by motor vehicle accidents, 91% of the patients had respiratory embarrassment. Only 27.2% of the patients were diagnosed by chest x-ray, the remaining 72.8% were discovered during laparotomy. The left dome of the diaphragm was ruptured in 75.8%, whereas herniation of the abdominal viscera into the chest was found in 45.8%. Concomitant intra-abdominal injury was found in 84.8% of the patients. The mortality is sharply increased when the right dome of the diaphragm is ruptured.Conclusion: the clinical features may be masked by other chest or abdominal injuries. Chest-x ray is a reliable test to diagnose diaphragmatic rupture. The left hemi-diaphragm is more commonly injured; in addition concomitant intra- abdominal injuries are very common. A meticulous inspection of the diaphragm should be undertaken during all exploratory laparotomies for trauma.

Ultrasound detection of blunt splenic injury

The purpose of this study was to determine the sensitivity of emergency ultrasound (US) for the detection of blunt splenic injury (BSI), and to describe sonographic parenchymal patterns. Over 3 years, 2138 emergency US were performed, and 162 patients had BSI. CT was performed for 76 patients, and there were 86 laparotomies. Seventy patients (43%) had concomitant intraabdominal injuries. Ultrasound detected free fluid in 109 patients (67%), and parenchymal injury in 31 patients (19%). There were 48 false negative US (30%). Sonographic patterns included a diffuse heterogeneous appearance, hyperechoic and hypoechoic perisplenic crescents, and discrete hypoechoic or hyperechoic areas within the spleen. Overall sensitivity of US for detection of BSI was 69%, but was 86% for grade III or higher injuries. Ultrasound is most sensitive for the detection of grade III or higher BSI based on the presence of haemoperitoneum. Ultrasound may also identify BSI on the basis of parenchymal abnormality, with a diffuse heterogeneous pattern most commonly encountered. Sonographic evaluation for both free fluid and parenchymal injury improves sensitivity of US.

Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury.

To determine the sensitivity and utility of emergency sonography for the detection of blunt hepatic injury (BHI) in patients with abdominal trauma and to describe parenchymal sonographic patterns of BHI. This report was a prospective clinical study in which the findings of all patients who had emergency sonograms were recorded on a data sheet by the initial sonographer and interpreting physicians. All patients with hepatic injuries during this period were identified and physical examination, laboratory, computed tomographic and intraoperative findings were compared with the prospective data sheets. From January of 1995 to December of 1998, 2,622 emergency sonograms were performed, and in this group, a total of 146 patients had BHI. Emergency sonograms allowed detection of free fluid in 98 patients (67%), and parenchymal injury with no free fluid in seven patients (5%). There were 41 false negatives (28%). The most common pattern identified on a sonogram was a discrete area of increased echogenicity followed by a diffuse hyperechoic pattern. Seventy-six patients (52%) had concomitant intra-abdominal injuries, including spleen (n = 46), bowel (n = 30), and kidney (n = 19). There were 102 exploratory laparotomies performed. Abdominal tenderness or distention was present in 127 patients (87%), and 108 patients had right rib fractures (74%). Based on detection of free fluid, parenchymal injury, or both, the overall sensitivity of sonography for the detection of BHI was 72 % but was 98 % for grade III or higher injuries. Emergency sonography is sensitive for the detection of grade III or higher liver injuries resulting from blunt abdominal trauma. Sonography may also reveal BHI on the basis of parenchymal abnormality, with a discrete hyperechoic area the most commonly encountered pattern.

Liver trauma

Background: The choice of indications favoring an operative or a conservative approach in liver trauma is difficult, and can be a matter of life and death for the patient. Methods: Evaluation of the abdomen in trauma cases is discussed with regard to assessment of the clinical picture and the value of individual imaging modalities and invasive diagnostic procedures such as arteriography and peritoneal lavage. The various surgical techniques are appraised with respect to the kind and extent of liver trauma involved. Results: Management of liver trauma has tended to become more conservative when the course allows. On average, 30% to 50% of all liver-trauma patients can be treated conservatively. Conservative observation does, however, require continuous monitoring, regular re-evaluation with CT or sonography, hemodynamic stability (no more than 2 units of packed erythrocytes) and absence of concomitant intraabdominal injuries. Shock and peritonism require an immediate laparotomy. Conclusions: Today, hematoperitoneum is no longer an indication for immediate laparotomy. With severe liver ruptures (grades IV and V) requiring surgery, debridement rather than resection is favored as it reduces risk and spares parenchyma. With shock and/or manifest coagulopathies, a perihepatic tamponade can serve as a bridging measure until the liver trauma can be treated definitively.

Surgical Exposure and Repair of the Traumatized Kidney

In the past, renal exploration after major trauma often resulted in total nephrectomy. With primary vascular control and meticulous reconstructive techniques, we have demonstrated that 87% of renal injuries requiring surgical exploration can be successfully reconstructed.6 Our goal for all renal explorations is to control renal bleeding, preserve the maximal amount of viable renal parenchyma, and minimize the degree of potential postoperative complications. We generally surgically reconstruct kidneys with major parenchymal lacerations or vascular injuries, particularly when concomitant intra-abdominal injuries are present. In our experience, renal exploration and repair can be performed safely on patients with major renal injuries. When reconstructive surgical tenets are strictly adhered to, the resulting loss of renal parenchyma and function is a direct result of the nature and severity of the initial renal injury itself. Of the surgically repaired blunt and penetrating renal injuries at San Francisco General Hospital (SFGH), we have been able to preserve more than one third of the injured kidney in about 80% of the cases.' Thus, surgical reconstruction of the kidney can successfully preserve function and is an appropriate method for managing major traumatic renal injuries. Kidney parenchymal preservation is often poor, however, in patients with renovascular injuries and in those with severe associated intra-abdominal injuries, shock, and major blood loss.

Posttraumatic peritoneal fluid: Is it a reliable indicator of intraabdominal injury in children?

Clinical data and computed tomographic (CT) scans for 1,486 children evaluated after blunt abdominal trauma were reviewed to determine whether peritoneal fluid is a reliable indicator of the presence and severity of associated intraabdominal injury and the need for laparotomy. The CT scans were assessed for presence, location, and severity of intraabdominal injury, and amount of peritoneal fluid. Type of management (surgical or nonsurgical), indications for surgical management, overall hospital course, and clinical outcome were recorded at the time of discharge. Of the 326 children with abdominal injuries detected by CT, 121 (37%) had no associated peritoneal fluid collections. Eighteen (15%) of these children had injury to more than one abdominal organ. Splenic injuries by CT criteria were more severe in children with associated peritoneal fluid than in those with no associated fluid ( P < .003). There were no significant differences in CT grading of liver and renal injuries among those with and without associated peritoneal fluid ( P > .67). Two hundred fifty-nine (17%) of the 1,486 children had peritoneal fluid demonstrated by CT. Eighty percent of these children had concomitant intraabdominal injury. Associated injuries included solid organ injuries (in 68% of patients) hollow viscus or mesenteric injury (11%), isolated pelvic fracture (4%), and hypoperfusion syndrome (5%). Thirty-one patients (12%) had injury to more than one abdominal organ. Only 27 (11%) patients had small “unexplained” collections of peritoneal fluid in which no associated injury was detected through CT or clinical follow-up. The authors conclude that (1) solid organ injury is frequently present in the absence of peritoneal fluid, and (2) the identification of peritoneal fluid after blunt trauma should lead one to suspect that a specific intraabdominal injury is the causes of the fluid.

INDICATION OF OPERATIVE TREATMENT FOR BLUNT LIVER INJURY

We reviewed the indication for surgery in patients with blunt liver trauma. Patients were divided into two groups: Group A, in which emergent surgery was performed and Group B, in which initial therapy was conservative. In Group A, the blood pressure upon arrival at our hospital was 90±29 mmHg (mean±S. D.), versus 117±21 mmHg in Group B. The blood pressure after rapid fluid infusion was 98±22 mmHg in Group A and 117±15 mmHg in Group B. Peritoneal signs were elicited in 61% of patients in Group A and 15% of those in Group B. This difference was significant. Free fluid within the peritoneal cavity was observed ultrasonography in all patients in Group A in whom the examination was performed, but in only 15% of patients in Group B. Ultrasonographic signs of intrahepatic hematoma and hepatic rupture were found in 25% and 19% in Group A and 32% and 5% of patients in Group B, respectively. As to multiple trauma, there was no significant difference in the incidence of associated rib fracture, pulmonary contusion, or hemo/pneumothorax between both groups. A predominant concomitant injury to the spleen or pancreas was observed in group A compared to the other. Patients with blunt trauma may have concomitant intra-abdominal injury even when the degree of liver injury is not severe. Patients with hypotension unresponsive to fluid challenge, peritoneal signs, and a large, or expanding, intra-abdominal fluid collection may require laparotomy to control bleeding.