Small Bowel Injury Research Articles

Safe access to laparoscopic cholecystectomy in patients with previous periumbilical incsions: new approach to avoid entry related bowel injury

BackgroundPatients with prior abdominal surgeries are at higher risk of intra-peritoneal adhesions near the trocar entry site, increasing the likelihood of organ injury during laparoscopic cholecystectomy (LC). This study evaluates a novel technique where the epigastric trocar is inserted first, after creating pneumoperitoneum, to allow safe dissection of adhesions under direct vision before placing the umbilical trocar.MethodsThis prospective study included 244 patients with symptomatic uncomplicated gallstone disease and a history of previous abdominal surgeries extending to the umbilicus. Patients were randomly assigned to two groups: Group I (n = 98) underwent traditional umbilical trocar-first LC using the Hasson technique, while Group II (n = 146) received LC using the epigastric trocar-first approach. Operative time, complications, and conversion rates were analyzed.ResultsThere was no significant difference in the demographics between both groups. The epigastric trocar-first approach significantly reduced total operative time (41.6 ± 7.7 min vs. 46.8 ± 8.8 min, p = 0.031) and small bowel injury rates (p = 0.006). Otherwise, intraoperative complications were comparable. Conversion to open surgery was lower in Group II (2.1% vs. 8.2%, p = 0.012). Postoperative pain at 6 h was significantly lower in Group II (p = 0.001).ConclusionsThe epigastric trocar-first approach, offers a safer alternative for patients with prior abdominal surgeries when undergoing LC. This approach is safe; minimizes bowel injury risk, reduces conversion rates, and enhances patient recovery. This approach may also be beneficial in other laparoscopic procedures requiring safe entry in patients with prior abdominal surgeries. Further studies are recommended to validate its broader clinical application.

Middle-grade led Expedited Gall bladder lists: Is it safe and feasible?

Gallstone-related acute admissions account for a significant percentage of acute general surgery admissions. Providing a dedicated expedited gall bladder list service to deal with these cases appears to be not only clinically effective but also cost-effective. There are various logistical reasons why hospitals are unable to provide such dedicated lists, inadequate surgical staff being one of them. We initiated a middle-grade-led expedited gall bladder list with indirect consultant oversight at our hospital as a consultant-led list was not feasible. This study evaluates the safety and efficacy of this service post-implementation. A retrospective analysis was conducted on prospectively collected data from February 2022 to September 2023. Patients were triaged using a dedicated questionnaire and operated on within 2-8 weeks of admission. The outcomes measured included complications, readmissions and the need for consultant opinion and assistance. Amongst 101 patients, the mean age was 50.59 ± 15.25 years, with a majority being female and having an American Society of Anaesthesiologists grade of 2. Consultant assistance was required in 14 cases, with 9 requiring active participation. Complications were comparable to national averages, with four cases of bile leaks and one small bowel injury. Six readmissions were recorded for various postoperative issues. The middle-grade led expedited gall bladder service demonstrated a safe and effective alternative to consultant-led lists, offering a pragmatic approach to addressing surgical demands within the constraints of staff and facility limitations.

Feasibility, safety, and clinical outcomes of modified laparoscopic cervicoisthmic cerclage for refractory cervical insufficiency: A single-arm clinical trial-Part 1.

To assess the feasibility, safety, and outcomes of modified laparoscopic transabdominal cerclage in patients with refractory cervical insufficiency. This single-arm clinical trial examined women with refractory cervical insufficiency who underwent modified laparoscopic transabdominal cerclage at a specialized center in Japan between December 2017 and May 2022. Various parameters related to patient demographics, surgical techniques, outcomes, and complications were evaluated. The study enrolled 30 women with a median age of 36 years. The modified laparoscopic transabdominal cerclage was technically successful in all cases. The delivery rate and fetal survival rate at 28 days in the third trimester were both 93%. Surgical complication involving small bowel injury occurred in one case and was promptly repaired. No fetal complications or pregnancy losses occurred within 28 days of the procedure. Perinatal outcomes included a cesarean section rate of 93%, a neonatal intensive care unit admission rate of 30%, and an overall fetal survival rate of 93%. Additionally, no absence or reversal of end-diastolic flow in the uterine artery was identified at the time of cerclage in any of the cases. This study demonstrated the feasibility and safety of modified laparoscopic transabdominal cerclage for refractory cervical insufficiency. The procedure achieved a high delivery rate in the third trimester and a good overall fetal survival rate. The study findings highlight the importance of anatomical precision during thread placement in modified laparoscopic transabdominal cerclage. This technique is promising for treating refractory cervical insufficiency and potentially preventing second-trimester losses and extreme preterm births.

HPB SO61 - Benefits of Dual-surgeon On-call team on Emergency Laparoscopic Cholecystectomy – a Single Centre Experience

Abstract Background Since 2015, UK national guidance from National Institute for Health and Care Excellence (NICE) has been to offer laparoscopic cholecystectomy for patients presenting with acute cholecystitis within 7 days of admission. The aim of this study was to measure the benefits of a second team of surgeons doing emergency operations (first team dealt with emergency admissions and referrals) in terms of length of stay, conversion to open, morbidity, mortality, bile duct injury and rate of early cholecystectomy in a UK based district general hospital. Method Retrospective analysis of a prospectively maintained database was collected from electronic health records, admission and operative notes. Results were extracted in terms of index laparoscopic cholecystectomy, rate of conversion, intra-operative cholangiography, associated morbidity, mortality, bile duct injury, conversion to open, readmission rate and length of stay. The numbers and rates of cholecystectomy over the last six years duration was collected and compared year-on-year period, since early 2019 after the implementation of dual-surgeon on-call cover. Results Altogether, there was 944 cholecystectomy performed within 14 days, out of which 74% of cases was operated within the first week of presentation <8 days since admission. Majority of cholecystectomy was performed laparoscopically, there were twenty-three (2.43%) conversion to open, forty-six sub-total cholecystectomies (4.87%),intraoperative cholangiography was performed in 28.4% of cases and Indocyanine green (ICG) cholangiography was used in 50.5% of all cases. Average length-of-stay (LOS) was 2.2 days, there were eight cases (0.84%) of post-op bile leak, one bile-duct injury, one case of post-operative bleed, one case of small bowel injury and two deaths. Conclusion With the adoption of dual-surgeon on call, early laparoscopic cholecystectomy benefits both patient and hospital. It reduces time to surgery for patients, decreases overall length of stay, and reduces readmission rates and cost, with similar morbidity and mortality.

Novel homozygous nonsense mutation in glucagon‐like peptide‐2 receptor gene resulting in severe human illness

AbstractGlucagon‐like peptide‐2 (GLP2) acts on the GLP2 receptor (GLP2R) and plays a role in intestinal growth and adaptation. The endogenous actions of GLP2R do not have an established association with human disease, although mouse‐knockout models in a stressed state show enhanced susceptibility to small bowel injury, increased morbidity, mortality, and abnormal host–bacterial interactions. We report an 11‐month‐old female with multiple intensive care unit admissions for severe metabolic acidosis due to profuse nonbloody diarrhea in the context of various infections. She had normal growth, lab testing, and stooling patterns between illnesses. Trio‐whole genome sequencing revealed homozygous nonsense variants resulting in nonfunctional GLP2R. This is the first known human documented with a GLP2R‐deficient phenotype, resulting in clinical illness, which correlates with the findings in the GLP2R mouse knockout model and furthers our understanding of GLP2R and the action of teduglutide, a GLP2 analog used for the treatment of short bowel syndrome.

Comparison of Clinical Outcomes of Laparoscopic Totally Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) Techniques in Bilateral Inguinal Hernia Repair: A Retrospective Study.

This study compared the clinical outcomes of two commonly used laparoscopic techniques, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair, in the treatment of bilateral inguinal hernias. This retrospective cohort study included 250 patients who underwent laparoscopic bilateral inguinal hernia repair using either the TEP or TAPP technique between May 2009 and May 2024. The patients were divided into two groups: 50 patients in the TEP group and 200 in the TAPP group. Data were collected from patient records, including demographics, type of hernia, surgical details, intraoperative and postoperative complications, conversion rates, and early hernia recurrence. Statistical analysis was performed to compare outcomes between the two groups. Among the 250 patients included in the study, the mean age was 51.62 ± 8.79 years, and 94% (n=235) were male. The mean operative time was significantly longer in the TEP group (93.2 ± 13.0 minutes) than in the TAPP group (57.95 ± 7.5 minutes) (p <.001). The mean hospital stay was also longer in the TEP group (1.36 ± 0.48 days) compared to the TAPP group (1.07 ± 0.25 days) (p <.001). The TEP group had a higher rate of conversion to open surgery 18%(n=9) and conversion to TAPP 10% (5) than the TAPP group, which had no conversions (p <.0001). Postoperative complications were more frequent in the TEP group, with urinary retention being significantly higher at 16%(n=8) than in the TAPP group at 2% (n=4) (p <.0004). Additionally, the TAPP group experienced two (1%) notable intraoperative complications that required reoperation: arterial injury and small bowel injury. The findings suggest that, while both TEP and TAPP effectively repair bilateral inguinal hernia, TAPP is associated with shorter operative times, shorter hospital stays, and fewer postoperative complications. However, the TAPP technique also presented notable intraoperative risks, including arterial and bowel injury. The choice between TEP and TAPP should be based on the surgeon's experience, patient characteristics, and the specific clinical context.

Oxymatrine alleviates NSAID-associated small bowel mucosal injury by regulating MIP-1/CCR1 signalling and gut microbiota

Oxymatrine (OMT) as a quinazine alkaloid extracted from matrine has been shown to exhibit anti-inflammatory and anti-tumour effects. However, the protective mechanism of OMT on NSAID-associated small bowel mucosal injury remains unreported. We found that OMT could improve the clinical symptoms and pathological inflammation scoring, reduce the secretion of proinflammatory cytokines IL-1β, IL-6 and TNF-α and cell apoptosis, promote cell proliferation and protect intestinal mucosal barrier as compared with the Diclofenac Sodium (DS) group. Further RNA-seq and KEGG analysis uncovered that the differentially expressed genes between DS and control groups were mainly enriched in immune regulation, of which MIP-1γ and its receptor CCR1 expression were validated to be repressed by OMTH. MAPK/NF-κB as the MIP-1 upstream signalling was also inactivated by OMT treatment. In this study, OMT regulated gut microbiota. Venn diagrams visualized and identified 1163 shared OTUs between DS group and OMTH group. The results showed that the α diversity index in the DS group was lower than that in the OMTH group, indicating that the complexity of the flora was reduced in the intestinal inflammatory state. β diversity mainly includes Principal Component Analysis (PCA) and Principal Co-ordinates Analysis (PCoA). The differences between groups can be observed through PCA. The more similar the composition of the flora, the closer the samples are. We found that the difference was smaller in the DS group than in the OMTH group. The results of PcoA showed that the sample similarity between OMTH groups was the highest. Moreover, gut microbiota analysis unveiled that the abundances of Ruminococcus 1, Oscillibacter and Prevotellaceae at the genus level as well as Lactobacillus SP-L-Yj at the species level were increased in OMTH group as compared with the DS group but the abundance of Allobaculum, Ruminococceos-UCG-005, Ruminococceos-NK4A214 and Clostridium associated with DS-induced small bowel mucosal injury could be decreased by OMTH. MIP-1α and CCR1 were upregulated in human small bowel injury samples as compared with the normal ileal mucosa tissues. In conclusion, our findings demonstrated that OMT could alleviate NSAID-associated small bowel mucosal injury by inhibiting MIP-1γ/CCR1 signalling and regulating gut microbiota.

Drugs Effective for Nonsteroidal Anti-inflammatory Drugs or Aspirin-induced Small Bowel Injuries: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The frequency of small bowel (SB) injuries has increased due to the increased use of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin. This study was a systematic review and meta-analysis to compare drugs effective for SB injuries caused by NSAIDs or aspirin use. We searched MEDLINE, Embase, and Cochrane registries for randomized controlled trials through February 2023. The extracted data included changes in the number of erosions or ulcers in the jejunum or ileum observed through capsule endoscopy in patients taking NSAIDs or aspirin and administration of various mucoprotectants. We investigated the therapeutic or preventive efficacy of these drugs. The methodological bias was evaluated using Risk of Bias 2.0. Eighteen randomized controlled trials of drugs effective for NSAIDs or aspirin-induced SB injuries were included and analyzed. The agents used to treat or prevent SB injuries were rebamipide, misoprostol, geranylgeranylacetone, and probiotics. In the meta-analysis, the mucoprotectants that showed a significant effect in treating NSAID users, who developed SB injuries, were misoprostol (mean difference: -9.88; 95% CI: -13.26 to -6.50). Meanwhile, the mucoprotectant that can prevent SB injuries caused by NSAIDs or aspirin in the general population was rebamipide (mean difference: -1.85; 95% CI: -2.74 to -0.96). Misoprostol was effective in treating SB injuries caused by NSAIDs or aspirin (CRD42023410946).

Critical Illness Corticosteroid Insufficiency after Blunt Abdominal Trauma: A Case Report

A 60-year-old man with a history of a previous colon resection presented after a motor vehicle collision. He was hypotensive in the field. A systolic pressure of 58 was noted on admission to the trauma bay. The remaining vital signs revealed a pulse of 99 and respirations 18. The temperature was 98 degrees. The patient was alert with a GCS of 15. He was given 2 liters of crystalloids and his systolic pressure increased to 100. His initial hemoglobin was 12.3 with hematocrit of 37. The initial base deficit was -12 and a venous lactate was 3.3. Work up revealed a left femur fracture, a right tibial plateau fracture and right radius and ulna fractures. An abdominal CT revealed a possible small bowel injury and the patient was taken to the operating room for exploration. The operative findings included small bowel injury and blunt colon injuries requiring jejunal resection and a primary anastomosis along with a segmental colon resection and end-colostomy. The left femur fracture was fixed along with the radius and ulna fractures at a separate operative intervention.

A decade long overview of damage control laparotomy for abdominal gunshot wounds.

Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.

Safety of ultrasound-guided percutaneous suprapubic catheter insertion in spinal cord injury patients.

Retrospective chart audit. To evaluate the safety of ultrasound-guided percutaneous suprapubic catheter (SPC) insertion in patients with spinal cord injury/disease (SCI/D) and to attempt to identify risk factors for complications. Specialized German centre for spinal cord injuries. This retrospective chart analysis evaluated demographic, neurologic, and neuro-urologic data and the incidence and type of complications within the first 30 days after suprapubic bladder catheter insertion in SCI/D patients in the period between January 1st, 2013, and December 31st, 2022. The data of 721 SCI/D patients (244 women and 477 men, 386 tetraplegics and 355 paraplegics) were analysed. There were 44 complications (6.5%), of which 11 (1.5%) were major complications according to Clavien-Dindo ≥ 3. Among these were one small bowel injury and one peritoneal injury each, but no fatal complications. Regarding major complications (according to Clavien-Dindo ≥3), only patient age was identified as a risk factor (p = 0.0145). Gender, SCI/D level, neurological completeness, and severity of SCI/D or type of neurogenic lower urinary tract dysfunction (Odds ratio [95% CI] 1.6423 [0.4961;5.4361], 1.0421 [0.3152;3.4459], 0.3453 [0.0741;1.6101], 2.8379 [0.8567;9.4004] and 2.8095 [0.8097;9.7481] respectively) did not show any association with the frequency of major complications. Mild complications, especially temporary hematuria or infectious complications, are not uncommon after SPC insertion in SCI/D patients. Major complications occur only rarely, and no risk factor other than age could be detected. On this basis, pre-intervention education on informed consent for SCI/D patients can be provided on an evidence-based approach.

Nonsteroidal anti-inflammatory drug-induced small bowel strictures (diaphragm disease) – an under-recognized cause of small bowel obstruction

BackgroundSmall bowel obstruction is a major source of morbidity and mortality that carries a significant economic burden. Recurrent small bowel obstruction may be secondary to circumferential strictures (small bowel diaphragm disease), an under-recognized entity secondary to long-term NSAID use. We aim to describe the sensitivity of preoperative CT enterography in patients with surgically treated small bowel diaphragm disease. MethodsWe retrospectively reviewed adult patients who underwent elective small bowel resection for small bowel obstruction performed by a single minimally-invasive surgeon between 2010-2023. Patient history, radiographic, endoscopic, operative, and pathology reports were reviewed for reference to NSAID use, small bowel strictures, diaphragms, and enteropathy. Exclusion criteria were prior radiation, inflammatory bowel disease, malignancy, adhesive disease, and anastomotic strictures. ResultsA total of 225 patients were identified; of those, 22 patients (10%) met inclusion criteria. The mean age was 60.7 years (range 29-78), with 15 women (68%). All patients underwent minimally invasive small bowel resection for obstruction with histopathologic evidence of stricture without evidence of transmural inflammation, granuloma, or dysplasia and confirmed NSAID use (n=22; 100%). Anemia was present in 36% (n=8). Preoperative CT or MR enterography was performed in 18 patients (82%) and stricturing was reported in 13 patients (72%). Intraoperatively, palpation identified strictures in all patients. ConclusionNSAID-induced small bowel injury is an under-recognized condition that, in severe cases, can present as small bowel obstruction. Surgeons should consider diaphragm disease in patients with obstruction and NSAID use, in which preoperative CT or MR enterography may be useful but cannot rule out disease.

An evaluation of the “Obesity Paradox” in isolated blunt abdominal trauma in the United States

BackgroundThe obesity paradox theorizes a survival benefit in trauma patients secondary to the cushioning effect of adiposity. We aim to evaluate the impact of body mass index (BMI) on abdominal injury severity, morbidity, and mortality in adults with isolated, blunt abdominal trauma in the United States. MethodsWe reviewed the National Trauma Data Bank (2013–2021) for adults sustaining isolated, blunt abdominal trauma stratified by BMI. We performed a doubly robust, augmented inverse-propensity weighted multivariable logistic regression to estimate the average treatment effect (ATE) of BMI on mortality and the presence of abdominal organ injury. Results36,350 patients met the inclusion criteria. In our study, 41.4 % of patients were normal-weight (BMI 18.5–24.9), 20.6 % were obese (BMI 30–39.9), and 4.7 % were severely obese (BMI≥40). In these cohorts, the abdominal abbreviated injury scale (AIS) was 2 (2 -3). Obese and severely obese patients had significantly reduced presence of pancreas, spleen, liver, kidney, and small bowel injuries. The predicted probability of abdominal AIS severity decreased significantly with increasing BMI. Crude mortality was significantly higher in obese (1.3 %) and severely obese patients (1.3 %) compared to normal-weight patients (0.7 %). Obese and severely obese patients demonstrated non-statistically significant changes in the mortality of +26.4 % (ATE 0.264, 95 %CI -0.108–0.637, p = 0.164) and +55.5 % (ATE 0.555, 95 %CI -0.284–1.394, p = 0.195) respectively, compared to normal weight patients. ConclusionBMI may protect against abdominal injury in adults with isolated, blunt abdominal trauma. Mortality did not decrease in association with increasing BMI, as this may be offset by the increase in co-morbidities in this population.

Endovascular treatment of traumatic pseudoaneurysm of the ileal branch of the superior mesenteric artery in a 9-year-old girl: Case report and literature review.

Visceral artery aneurysm is a rare and potentially fatal vascular condition that typically affects the superior mesenteric or inferior mesenteric arteries, the splenic, hepatic, and celiac arteries, as well as their branches. Visceral artery aneurysms can usually be treated using endovascular intervention, open surgery, or percutaneous thrombin injection. A 9-year-old girl was admitted to our trauma center with abdominal and bilateral leg pain after a car accident involving a head-on collision. Abdominal computed tomography (CT) showed bowel herniation through a muscle defect in the left lateral abdominal wall. There was a small amount of fluid around the liver and spleen, mild thickening of the small bowel wall, and infiltration in the small bowel mesentery, indicating the possibility of small bowel injury. Emergent exploratory laparotomy was performed. After resection of the ischemic parts of the terminal ileum and sigmoid colon, intestinal continuity was reestablished. Primary repair was performed on a traumatic left lateral abdominal wall hernia. She recovered well postoperatively without any complications. A follow-up abdominal CT scan after 2 months showed a pseudoaneurysm of the ileal branch of the superior mesenteric artery. Despite the absence of any gastrointestinal symptoms, the pseudoaneurysm was treated by endovascular intervention using numerous coils because of the significant risk of delayed rupture or massive bleeding. Follow-up abdominal CT scan after 6 months showed complete occlusion and resorption of the pseudoaneurysm. Although it is technically challenging, endovascular coil embolization may be a feasible technique in children with traumatic visceral artery pseudoaneurysms without complications.

The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.

Serum lactate normalization time associated with prolonged postoperative ileus after surgical management of the small bowel and/or mesenteric injuries

Back ground: Determining the optimal timing of postoperative oral feeding in trauma patients who have undergone abdominal surgery with small bowel and/or mesenteric injuries is challenging. The aim of this study is to investigate serum lactate as a factor that can predict oral feeding tolerance and prolonged postoperative ileus (PPOI) in patients who underwent surgery for small bowel and/or mesenteric injury due to trauma.Methods: The single center retrospective observational study was conducted on 367 patients who underwent surgery for small bowel and/or mesenteric injury between January 2013 and July 2021. The patient group was divided into two groups based on whether the peak serum lactate was over 2mmol/L (18 mg/dL). In the group of lactate > 2mmol/L, it was divided into prolonged postoperative ileus (PPOI) groups and groups rather than PPOI.Results: Patients in the peak serum lactate > 2 group had tendency to use vasopressors, lower initial systolic blood pressure, larger number of packed red blood cells for 24 h, higher injury severity score, higher PPOI incidence, and a tendency for delayed oral intake tolerance. In peak serum lactate greater than 2 mmol/L group, the lactate normalization time (OR 1.699, p = 0.04), quantity of FFP transfusion for 24 h (OR 1.145, p = 0.012), and creatine kinase (OR 1.001, p = 0.023) were related to PPOI. The lactate normalization time had the highest correlation.Conclusion: In patients undergoing surgical management for small bowel and/or mesenteric injury after trauma, serum lactate normalization time affects oral intake tolerance and prolongs postoperative ileus.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury

PurposeBlunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI.MethodsWe conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI.ResultsOne hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67–0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64–0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75–0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55).ConclusionRadiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist’s impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Moving toward point-of-care surgery in Ukraine: testing an ultra-portable operating room in an active war zone.

In conflict zones, providers may have to decide between delaying time-sensitive surgeries or performing operative interventions in the field, potentially subjecting patients to significant infection risks. We conducted a single-arm crossover study to assess the feasibility of using an ultraportable operating room (U-OR) for surgical procedures on a porcine cadaver abdominal traumatic injury model in an active war zone. We enrolled participants from an ASSET-type course designed to train Ukrainian surgeons before deployment to active conflict zones. They performed three standardized consecutive abdominal surgical procedures (liver, kidney, and small bowel injury repair) with and without the U-OR. Primary outcomes included surgical procedurecompletion rate, procedure time, and airborne particle count at the start of surgery. Secondary survey-based outcomes assessed surgery task load index (SURG-TLX) and perceived operative factors. Fourteen surgeons performed 76 surgical procedures (38 with the U-OR, 38 without the U-OR). The completion rate for each surgical procedure was 100% in both groups. While the procedure time for the liver injury repair did not differ significantly between the two groups, the use of the U-OR was associated with a longer time for kidney (155 vs. 56s, p = 0.002), and small bowel (220 vs. 103s, p = 0.004) injury repair. The average airborne particle count within the U-OR was substantially lower compared to outside the U-OR (6,753,852 vs. 232,282 n/m3, p < 0.001). There was no statistically significant difference in SURG-TLX for procedures performed with and without the U-OR. The use of the U-OR did not affect the procedure completion rate or SURG-TLX. However, there was a marked difference in airborne particle counts between inside and outside the U-OR during surgery. These preliminary findings indicate the potential feasibility of using a U-OR to perform abdominal damage-control surgical procedures in austere settings.

Management of 52 small bowel perforations following gunshot injury: A case report

Abstract Small bowel injury is one of the most common abdominal injuries following penetrating injuries and is usually secondary to gunshot, stab, or impalement injuries to the abdomen. We report a case of shotgun injury to the abdomen in a hemodynamically stable man. He had an emergency exploratory laparotomy, during which 52 small bowel perforations and 1 transverse colon perforation were found. He was managed by damage control surgery involving a temporary nonclosure of the anterior abdominal wall with resuscitation and a second look laparotomy after 48 h.

Index CT-Based Scoring Systems in Operative Blunt Bowel and Mesenteric Injury Identification

IntroductionDetermining the need for surgical management of blunt bowel and mesenteric injury (BBMI) remains a clinical challenge. The Faget score and Bowel Injury Prediction Score (BIPS) have been suggested to address this issue. Their efficacy in determining the need for surgery was examined. MethodsA retrospective review of all adult blunt trauma patients hospitalized at a level 1 trauma center between January 2009 and August 2019 who had small bowel, colon, and/or mesenteric injury was conducted. We further analyzed those who underwent preoperative computed tomography (CT) scanning at our institution. Final index CT reports were retrospectively reviewed to calculate the Faget and BIPS CT scores. All images were also independently reviewed by an attending radiologist to determine the BIPS CT score. ResultsDuring the study period, 14,897 blunt trauma patients were hospitalized, of which 91 had BBMI. Of these, 62 met inclusion criteria. Among patients previously identified as having BBMI in the registry, the retrospectively applied Faget score had a sensitivity of 39.1%, specificity of 81.2%, positive predictive value (PPV) of 85.7%, and negative predictive value (NPV) of 31.7% in identifying patients with operative BBMI. The retrospectively applied BIPS score had a sensitivity of 47.8%, specificity of 87.5%, PPV of 91.7%, and NPV of 36.8% in this cohort. When CT images were reviewed by an attending radiologist using the BIPS criteria, sensitivity was 56.5%, specificity 93.7%, PPV 96.3%, and NPV 42.8%. ConclusionsExisting BBMI scoring systems had limited sensitivity but excellent PPV in predicting the need for operative intervention for BBMI. Attending radiologist review of CT images using the BIPS scoring system demonstrated improved accuracy as opposed to retrospective application of the BIPS score to radiology reports.