Forat Swaid

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database.

INTRODUCTION Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. METHODS A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. RESULTS Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. CONCLUSIONS The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Rib fractures: comparison of associated injuries between pediatric and adult population

BACKGROUND Rib fractures are considered a marker of exposure to significant traumatic energy. In children, because of high elasticity of the chest wall, higher energy levels are necessary for ribs to fracture. The purpose of this study was to analyze patterns of associated injuries in children as compared with adults, all of whom presented with rib fractures. METHODS A retrospective cohort study involving blunt trauma patients with rib fractures registered in the National Trauma Registry was conducted. RESULTS Of 6,995 trauma victims who were found to suffer from rib fractures, 328 were children and 6,627 were adults. Isolated rib fractures without associated injuries occurred in 19 children (5.8%) and 731 adults (11%). More adults had 4 or more fractured ribs compared with children (P < .001). Children suffered from higher rates of associated brain injuries (P = .003), hemothorax/pneumothorax (P = .006), spleen, and liver injury (P < .001). Mortality rate was 5% in both groups. CONCLUSIONS The incidence of associated head, thoracic, and abdominal solid organ injuries in children was significantly higher than in adults suffering from rib fractures. In spite of a higher Injury Severity Score and incidence of associated injuries, mortality rate was similar. Mortality of rib fracture patients was mostly affected by the presence of extrathoracic injuries.

Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient’s Arrival to the Emergency Room

PurposeTo describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.MethodsWe briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.ResultsThree severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.ConclusionsThe interventional radiologist and the multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.

A comparison study of pelvic fractures and associated abdominal injuries between pediatric and adult blunt trauma patients

PURPOSE Pelvic fractures are a marker of severe injury, mandating a thorough investigation for the presence of associated injuries. Anatomical and physiological differences between adults and children may lead to a different impact of pelvic fractures on these populations. The purpose of this study is to compare pelvic fractures between pediatric and adult blunt trauma victims, mainly regarding their severity and associated intraabdominal injuries. METHODS A retrospective study involving blunt trauma patients suffering pelvic fractures, according to the records of the Israeli National Trauma Registry. Patients included children, aged 0-14years, and adults between 15 and 64years. The presence and severity of associated injuries were assessed. RESULTS Overall, 7621 patients aged 0-64years were identified with pelvic fractures following blunt trauma. The incidence of pelvic fractures in children was (0.8%), as compared to 4.3% in adults, p <0.0001. The most common mechanism of injury was motor vehicle accident (MVA) in adults, and pedestrian hit by car (PHBC) in children. About a quarter of the patients in both groups had an ISS >25. Adults sustained significantly more moderate to severe pelvic fractures (AIS≥3) than children (26.7% vs. 17.4%, p<0.0001). The overall mortality rate was similar among the two groups (5.4% in adults, 5.2% in children, p=0.7554). The only associated injury with statistically significant difference in incidence among the two groups was rectal injury (1.2% among children, 0.2% among adults, p<0.0001). Among adult patients, there was a clear correlation between the severity of pelvic fractures and the severity of concomitant splenic and hepatic injuries (p=0.026, p=0.0004, respectively). Among children, a similar correlation was not demonstrated. CONCLUSIONS Adults involved in blunt trauma are more likely to sustain pelvic fractures, and these are generally more severe fractures, as compared to children suffering from blunt trauma. Nonetheless, mortality rates were found similar in both groups. The only associated injury with statistically significant difference in incidence among the two groups was rectal injury. In adults, but not in children, higher grade pelvic fractures correlated with more severe concomitant splenic or hepatic injuries. LEVEL OF EVIDENCE The level of evidence for this study is III (3).

Does Severity of Pelvic Fractures Correlate with the Incidence of Associated Intra-Abdominal Injuries in Children?

Background Pelvic fractures are considered a marker of injury severity, especially in the pediatric population. However, the correlation between the severity of pelvic fractures and incidence of associated abdominal injuries is not clear. Methods A retrospective cohort study involving blunt trauma patients up to the age of 14 years, who suffered from pelvic fractures, with or without associated intra-abdominal injuries. Results A total of 812 trauma patients were included in this study. Overall, 671 of them suffered from pelvic fractures with abbreviated injury scale (AIS) of 2, 103 with AIS of 3, and 38 with AIS of 4 to 5. Overall mortality was found to be 5.2%, strongly correlating with the severity of the pelvic fractures (p value < 0.0001). There was no correlation between the incidence of most extrapelvic abdominal organ injuries (liver, spleen, small bowel, and pancreas) and the severity of pelvic fractures. A significant correlation was found with intrapelvic organ injuries (p value < 0.0001) and kidney injuries (p = 0.03). Conclusions Mortality of pediatric trauma patients with pelvic fractures is correlated with the severity of the fractures. An increase in the severity of pelvic fractures in this population is associated with an increased incidence of pelvic organ injury, but is not associated with the presence of extrapelvic abdominal injuries, except for kidney injuries.

Surgical drains: what is still unlearned in everyday practice?

A 14-year-old male patient presented in the emergency room with right lower quadrant (RLQ) abdominal pain. His physical examination elicited tenderness on the RLQ. His laboratory tests showed 14 000 white blood cells. An abdominal sonography could not identify the appendix. An abdominal computerized tomography scan demonstrated a thickened appendix with a diameter of 2.5 cm, surrounding fat stranding, and free peritoneal fluid around the caecum. A diagnosis of acute appendicitis was made, and the patient was taken to the operating room. On surgery, perforated appendicitis was found, and an open appendectomy through a McBurney’s incision was performed. After irrigation of the abdominal cavity, a 7-Fr silicone Jackson Pratt (JP) drain (Cardinal Health, Waukegan, IL, USA) was left in the right lower abdomen. On post-operative day 2 (POD 2) the patient started to complain of abdominal pain, and his abdomen was diffusely tender. An abdominal X-ray showed several distended loops of small bowel, and a radiopaque shadow interpreted by senior radiologists as ‘a strange foreign body’ (Fig. 1). It was not clear whether it is a retained surgical sponge (gossypiboma) in the abdominal cavity or a foreign body inside the gastrointestinal lumen. A decision to re-operate the patient was made. On surgery, small bowel obstruction caused by early adhesions was found, and was released by adhesiolysis. The JP drain was found folded several times on itself. After removal of the drain, an on-table fluoroscopy did not identify any suspicious shadows. The patient was uneventfully discharged home at POD 6. Jackson Pratt drains are commonly used in abdominal operations. Their radiologic appearance should be familiar. Misidentification of the drain as a foreign body may lead to the wrong impression of a foreign body accidentally forgotten in the abdominal cavity, and thus may alter patient management. Small bowel obstruction (SBO) is rare after appendectomy. In a study on 871 children, Ahlberg et al. found the incidence of SBO following open appendectomy as 0% in cases of simple appendicitis, and 3.4% in children who suffered from perforated appendicitis. However, Kaselas et al. reported that the overall incidence of postappendectomy bowel obstruction is not related to the severity of the disease but only to the initial operative approach. Although the most common cause of mechanical postoperative SBO is adhesions, other reasons should also be considered. Accidentally leaving foreign bodies after surgery is still an existing phenomenon. The true incidence of gossypibomas is unclear and most probably underestimated, because such cases are rarely reported. However, in a systematic review by Wan et al., 244 cases of gossypiboma were reported, 147 of them were in the years 1963– 2008. Yildirim et al. reported on 14 cases of retained surgical sponge after intra-abdominal or retroperitoneal surgery during a 5-year period in a single centre. Intestinal obstruction was found as the most common clinical presentation in these cases. In our case, the presence of an ‘unidentified foreign body’ on the abdominal X-ray has led us to conclude that cause of intestinal obstruction was gossypiboma. This simple case demonstrates how a wrong interpretation of an imaging finding can confuse senior physicians and raise false clinical suspicions. Several experienced surgeons and radiologists could not correctly interpret the appearance of a folded JP drain. After obtaining the post-operative X-rays, the main clinical suspicion was intestinal obstruction secondary to an accidentally left-behind foreign body in the abdomen. However, the intestinal obstruction proved to be secondary to abdominal adhesions. According to the JP product sheet line, these drains feature a radiopaque stripe running the entire length of the drain tubing for X-ray detection. It is the weird radiologic appearance of the folded JP drain that generated the confusion. To further understand the radiologic appearance of JP drains, we performed an ex vivo X-ray of JP drains of two different sizes (Fig. 2): 7-Fr (black arrow) and 10-Fr (white arrow). The 10-Fr drain was easy to diagnose as it has two parallel radiopaque stripes and the known appearance and contour of the drain can easily be recognized. However, the 7-Fr drain has only one radiopaque stripe, and its radiologic appearance is less familiar. Fig. 1. Abdominal X-ray showing small bowel obstruction and the radiopaque object in the right lower quadrant (black arrow). IMAGES FOR SURGEONS