Evidence Of Solid Organ Injury Research Articles

Introduction of Laparoscopy in an Urban High-Volume Sub-Saharan Trauma Centre

IntroductionTrauma is a major disease burden in low and middle-income countries like South Africa. Abdominal trauma is one of the leading reasons for emergency surgery. The standard of care for these patients is a laparotomy. In selected trauma patients, laparoscopy has both diagnostic and therapeutic usage. The trauma burden and the number of cases seen in a busy trauma unit make laparoscopy challenging.AimWe wanted to describe our journey with laparoscopy in the management of abdominal trauma in a busy urban trauma unit in Johannesburg, South Africa.MethodsWe reviewed all trauma patients who underwent diagnostic laparoscopy (DL) or therapeutic laparoscopy (TL) between 01 January 2017 and 31 October 2020 for blunt and penetrating abdominal trauma. The demographic data, indications for laparoscopy, injuries identified, procedures performed, intraoperative laparoscopic complications, conversion to laparotomy, morbidity, and mortality were evaluated.ResultsA total of 54 patients who had laparoscopy were included in the study. The median age was 29 years (IQR 25–25). Most injuries were penetrating 85.2% (n = 46/54) and 14.8% blunt trauma. Most patients were males, 94.4% (n = 51/54). Indications for laparoscopy included diaphragm evaluation (40.7%), pneumoperitoneum for evaluation of potential bowel injury (16.7%), free fluid with no evidence of solid organ injury (12.9%) and colostomy (5.5%). There were 8 (14.8%) cases converted to laparotomy. There were no missed injuries or mortality in the study group.ConclusionLaparoscopy in selected trauma patients is safe even in a busy trauma unit. It is associated with less morbidity and shortened hospital length of stay.

145 Characteristics and Three-Month Outcomes of Individuals Presenting to the Emergency Department after Physical Assault

More than 1.6 million individuals present to US EDs each year for care after physical assault. However, little is known about posttraumatic outcomes of this population. We assessed the incidence of adverse posttraumatic neuropsychiatric sequelae (APNS) in a prospective longitudinal sample of individuals presenting to the ED after physical assault. ED patients aged 18-75 who presented to one of 28 ED sites after physical assault were eligible for enrollment if they had no evidence of solid organ injury > grade 1, no significant hemorrhage, no indication for chest tube placement or operation under general anesthesia, and were unlikely to be admitted for more than 72 hours. Baseline assessments included sociodemographic characteristics, maximal AIS score, and characteristics of the assault. Three-month outcome assessments included assessment of substantial posttraumatic stress (PTS, PCL-5 ≥ 38), pain (numeric pain scale score ≥ 4), and depressive (PROMIS-8b depression ≥ 60) symptoms. Associations between patient characteristics and APNS were evaluated using logistic regression. A total of 271 patients were enrolled in the study following physical assault. The mean age was 33.5 (SD 11.7), and 48% were female. Most participants identified as non-Hispanic Black (64%), non-Hispanic White (21%), or Hispanic (11%). The majority n= 206 (76%) reported being attacked by another person, 46 (17%) reported starting or intentionally joining an altercation, and 19 (7%) reported another assault mechanism. Average maximal AIS score was 1.3 (range 1-3), 99% were discharged to home after evaluation. Three month follow-up results were available for 207/271 patients (76%). Substantial PTS symptoms 3 months after assault were present in 63/199 (32%), substantial pain was present in 107/206 (52%), and substantial depressive symptoms were present in 70/207 (34%). After controlling for age and sex, patients who were attacked had more severe PTS symptoms (b=0.18, t=2.40, p=0.018) and depressive symptoms (b=0.18, t=2.45, p=0.015) than those who reported intentionally joining an altercation, but not more severe pain symptoms (b=0.12, t=1.67, p = 0.097). In 60% of cases (n = 163/271) the assailant was unknown to the patient. After controlling for age and sex, individuals in an altercation with an unknown assailant did not report more severe PTS (b=0.005, t=0.06, p=0.949), pain (b=-0.11, t=-1.47, p=0.142), or depressive symptoms (b=-0.08, t= -1.05, p =0.292) than individuals in an altercation with a known assailant. Among patients treated in the ED after physical assault, even when injury severity is low APNS are common. Secondary preventive interventions are needed to reduce the incidence of PTS, pain, and depressive symptoms after physical assault. Funded by NIMH U01MH110925, the US Army Military Operational Medicine Research Program, The One Mind Foundation, and The Mayday Fund.

The role of diagnostic laparoscopy for trauma at a high-volume level one center.

BackgroundThe role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries.ObjectiveWhile the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center.MethodsAll trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated.ResultsA total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4–18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05).ConclusionIn this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

Isolated Small Bowel Perforation Following Blunt Trauma

&#x0D; Small bowel perforation is common following blunt abdominal trauma. Intra-abdominal injury with isolated small bowel perforation however, is a rare entity and diagnosis can be ambiguous. Nonisolated small bowel perforation, which carries a higher mortality rate, will be identified early during the assessment of the patient following a blunt abdominal trauma. A case of an isolated small bowel perforation following a road traffic accident is reported. A motorcycle rider, while trying to avoid a car, lost control and skidded into a drain. Upon arrival to the Emergency Department, he was complaining of upper abdominal pain evident by abrasion and bruising of his bilateral hypochondriacs. FAST scan showed free fluid at Morrison’s pouch and a formal abdominal ultrasound confirmed minimal free fluid at Morrison’s pouch. A plain CT abdomen was done and did not show any evidence of solid organ injury but demonstrated pneumoperitoneum. In view of the persistent abdominal tenderness, open fracture of left femur, radius and ulna, and radiological findings, a laparotomy was performed which revealed an isolated 1x1cm small bowel perforation, 60cm from DJ junction with localized faecal contamination. Small bowel repair was done and patient recovered well afterward. Although challenging, due to its detrimental infectious potential, early recognition of small bowel injury is crucial. Isolated small bowel perforation, rarely without associated intra-abdominal injury, requires more investigations, delaying diagnosis to treatment period. CT abdomen has proven to be both specific and sensitive in diagnosing small bowel injuries. Even when physical examination and radiological examinations are minimal, a suspicion of small bowel perforation should be considered as delay in diagnosis eventually increases morbidity and mortality.

A study of role of non-operative management in blunt abdominal trauma with solid organ injury

Background: The present study of role of non-operative management in blunt abdominal trauma with solid organ injury was done to assess the feasibility and safety of non-operative management in hemodynamically stable patients and identify the causes, predictive factors to delineate the rate of non-operative management failure.Methods: A longitudinal observational study was carried out from September 2013 to November 2015. All cases of blunt trauma abdomen with ultrasonological e/o solid organ injury and were hemodynamically stable were included in study.Results: Total 138 cases presented with a history of blunt trauma abdomen of which 56 cases had ultrasonological evidence of solid organ injury. 8 cases were excluded as 6 of these were hemodynamically unstable at presentation while 1 had bowel perforation and another had severe head injury all requiring operative management. Maximum cases were of age group 21-30 years (41.66%) and 31-40 years (31.25%). 42 (87.5%) cases were male and 6 (12.5%) cases of 48 were females. 28 (66.67%) cases presented as Road Traffic Accident. 28 (66.67%) cases had abdominal pain as the commonest symptom while tenderness in 38 (79.17%) cases and tachycardia in 30 (75%) cases was the predominant sign. Most injuries were seen in spleen 23 (47.92%) cases f/b Liver with 14 (29.12%). Conservative management was successful in 40 (83.33%) cases and failed in 8 (16.67%) cases. Mortality of the study was 1 (2.08%) case.Conclusions: Non-operative strategy is a successful approach in patients who are hemodynamically stable and authors strongly recommend it.

Clinical Outcomes of Pediatric Patients With Acute Abdominal Pain and Incidental Findings of Free Intraperitoneal Fluid on Diagnostic Imaging

The presence of free intraperitoneal fluid on diagnostic imaging (sonography or computed tomography [CT]) may indicate an acute inflammatory process in children with abdominal pain in a nontraumatic setting. Although clinical outcomes of pediatric trauma patients with free fluid on diagnostic examinations without evidence of solid-organ injury have been studied, similar studies in the absence of trauma are rare. Our objective was to study clinical outcomes of children with acute abdominal pain of nontraumatic etiology and free intraperitoneal fluid on diagnostic imaging (abdominal/pelvic sonography, CT, or both). We conducted a retrospective review of medical records of children aged 0 to 18 years presenting to a pediatric emergency department with acute abdominal pain (nontraumatic) between April 2008 and March 2009. Patients with intraperitoneal free fluid on imaging were divided into 2 groups: group I, imaging suggestive of an intra-abdominal surgical condition such as appendicitis; and group II, no evidence of an acute surgical condition on imaging, including patients with equivocal studies. Computed tomograms and sonograms were reviewed by a board-certified radiologist, and the free fluid volume was quantitated. Of 1613 patients who underwent diagnostic imaging, 407 were eligible for the study; 134 (33%) had free fluid detected on diagnostic imaging. In patients with both sonography and CT, there was a significant correlation in the free fluid volume (r = 0.79; P < .0005). A significantly greater number of male patients with free fluid had a surgical condition identified on imaging (57.4% versus 25%; P < .001). Children with free fluid and an associated condition on imaging were more likely to have surgery (94.4% versus 6.3%; P < .001). We found clinical outcomes (surgical versus nonsurgical) to be most correlated with a surgical diagnosis on diagnostic imaging and not with the amount of fluid present.

Free abdominal fluid without obvious solid organ injury upon CT imaging: an actual problem or simply over-diagnosing?

Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the abdomen without evidence of solid organ injury not only presents a challenge for the treating emergency physician but also for the surgeon in charge. Despite recent advances in imaging modalities, with multi-detector computed tomography (CT) (with or without contrast agent) usually the imaging method of choice, diagnosis and interpretation of the results remains difficult. While some studies conclude that CT is highly accurate and relatively specific at diagnosing mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences may in part be due to the experience and the interpretation of the radiologist and/or the treating physician or surgeon.A search of the literature has made it apparent that there is no straightforward answer to the question what to do with patients with free intraabdominal fluid on CT scanning but without signs of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence of solid organ injury usually mandates immediate surgical intervention. For patients with blunt abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach - should be low. Based on the available information, we aim to provide the reader with an overview of the current literature with specific emphasis on diagnostic and therapeutic approaches to this problem and suggest a possible algorithm, which might help with the adequate treatment of such patients.

Spontaneous hemoperitoneum from a ruptured mesenteric branch arterial aneurysm: Report of a case

We report a case of spontaneous intraperitoneal hemorrhage from a ruptured mesenteric branch artery aneurysm in a patient presenting with syncope. A 54-year-old woman was brought to our emergency department as a medical code, following two syncopal episodes. Computed tomography, carried out to rule out aortic aneurysmal disease, revealed hemoperitoneum without evidence of solid organ injury. Emergency exploratory laparotomy revealed a large jejunal mesenteric hematoma accompanying a ruptured mesenteric branch artery aneurysm with active extravasation. We ligated and excised the lesion and diagnosis was confirmed on final pathologic examination. We report this case because general surgeons should be aware of these vascular lesions and the basic guidelines for treatment.

The Management of Blunt Abdominal Trauma Patients with Computed Tomography Scan Findings of Free Peritoneal Fluid and No Evidence of Solid Organ Injury

Modalities available for the diagnosis of blunt abdominal traumatic (BAT) injuries include focused abdominal sonography for trauma, diagnostic peritoneal lavage, and computed tomography (CT) of the abdomen/pelvis. Hollow viscous and/or mesenteric injury (HVI/MI) can still be challenging to diagnose. Specifically, there is debate as to the proper management of BAT when CT findings include free peritoneal fluid but no evidence of solid organ injury (SOI). Our objective was to determine the incidence of HVI/MI and to evaluate the management of BAT patients with CT findings of peritoneal fluid without evidence of SOI. An Institutional Review Board-approved retrospective chart review was conducted of all BAT patients with peritoneal fluid on CT admitted to Kern Medical Center from January 1, 2003 to July 31, 2004. A total of 2651 trauma admissions yielded 79 patients. Fourteen of these had no evidence of SOI. Nonoperative management was successful in only 2 of these 14, whereas 12 required an operation, with 11 being therapeutic. Trigger to operate and time from presentation to laparotomy was hypotension in three patients (164 minutes), signs of HVI/MI on CT in two patients (235 minutes), diaphragm injury on CT in one patient (95 minutes), and for peritoneal signs in six patients (508 minutes). In BAT patients with peritoneal fluid on CT without evidence of SOI, there should be a high suspicion of HVI/MI. Relying on increasing abdominal tenderness to trigger laparotomy can result in delayed treatment.

Abdominal pain in a child after blunt abdominal trauma: an unusual injury

We report a case of perforation of a walled off appendiceal abscess in a 5-year-old boy who sustained blunt abdominal trauma. The past medical history was significant only for a 4-day episode of abdominal pain 1 month prior to this presentation. Initial laboratory studies were unremarkable, and radiographic studies showed free fluid in the pelvis with no evidence of solid organ injury, but inflammation of the right colon. The final diagnosis was made at laparotomy. We emphasize this unique presentation and review the literature on traumatic appendicitis in children.

Does Free Fluid on Abdominal Computed Tomographic Scan After Blunt Trauma Require Laparotomy?

Background: Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy. Methods: Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings. Results: Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus. Conclusion: Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.

Does Free Fluid on Abdominal Computed Tomographic Scan after Blunt Trauma Require Laparotomy

Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy. Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings. Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus. Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.