I-Ming Kuo

Blunt diaphragmatic rupture--a rare but challenging entity in thoracoabdominal trauma.

PURPOSE Delayed diagnosis of blunt traumatic diaphragmatic rupture (BDR) is not uncommon in the emergency department (ED) despite improvement in investigative techniques. We reviewed a large case series of patients diagnosed with blunt traumatic diaphragmatic rupture in order to report demographics, clinical features, and mechanisms of injury of this important but challenging entity. METHODS From January 2001 through December 2009, 43 patients were diagnosed with BDR at Linkou Chang Gung Memorial Hospital. Demographic data, including sex, age, initial hemodynamic parameters, laboratory data, diagnostic imaging, trauma mechanism, injury location, associated injuries, injury severity score (ISS), time to diagnosis, intensive care unit length of stay (ICU LOS), hospital length of stay (hospital LOS), and mortality, were extracted from hospital records. RESULTS A total of 43 patients (34 men; 9 women) with BDR were analyzed. Their median age was 37 years (15-82 yrs). Most of these injuries were related to traffic collision (76.8%). The anatomic location of injury to the diaphragm consisted of 24 left-sided (55.8%), 14 right-sided (32.6%),and 5 bilateral diaphragmatic injuries. (11.6%) Hemopneumothorax was the most common associated injury (37.2%). The median diagnostic time was 8 hours (range 2 to 366 hrs). The median ISS score was 18 (range 9 to 41). The median ICU LOS was 4 days (range 0 to 99 ds) and the median HLOS was 19 days (range 1 to 106ds). The total mortality rate was 9.3%. Initial high ISS, initial shock and bilateral diaphragmatic injury significantly increased mortality. CONCLUSION BDR constitutes a rare entity in thoracoabdominal trauma and most of these injuries were related to traffic collision. High index of suspicion was still the main factor to early diagnosis of this case. The mortality was related to initial shock , bilateral BDR and high ISS. Proper initial resuscitation and correction of other serious injuries may be more life-saving in patients with BDR.

The diminishing role of pelvic x-rays in the management of patients with major torso injuries

INTRODUCTION A pelvic x-ray (PXR) can be used as an effective screening tool to evaluate pelvic fractures and stability. However, associated intra-abdominal/retroperitoneal organ injuries and hemorrhage should also be considered and evaluated in patients with major torso injuries. An abdominal/pelvic computed tomographic (CT) scan may provide higher resolution and more information than a PXR. The role of conventional PXRs was delineated in the current study in the context of the development of the CT scan. MATERIALS AND METHODS We retrospectively reviewed patients with major torso injuries in our institution. The characteristics of the patients who received different diagnostic modalities (PXR only, CT scan only, or both) were investigated and compared. The characteristics of patients who underwent transcatheter arterial embolization (TAE) for the hemostasis of pelvic fracture-related retroperitoneal hemorrhage were also analyzed. RESULT There were 726 patients enrolled in current stud. Only 72.0% (523/726) of the patients who had major torso injuries were examined using PXRs, and 69.6% (505/726) of the patients underwent an abdominal/pelvic CT scan. For the patients who were examined using PXRs, there was no significant difference in the usage rate of an additional CT scan between the patients with positive (52.7%, 108/205) and negative (61.0%, 194/318) PXR examinations (P = .070). Four patients underwent TAE immediately following PXR examinations only, without a CT scan. These four patients had unstable pelvic fractures on the PXR examination and significantly a lower systolic blood pressure (61.0 ± 13.0 mmHg), a lower revised trauma score (3.560 ± 2.427), a greater requirement for blood transfusions (1750 ± 957.2 ml) than the patients who underwent TAE after a CT scan. CONCLUSION For the management of patients with major torso injuries, the role of PXR is diminishing due to the development of the CT scan. However, the PXR is still valuable for patients who are in critical condition and have an obviously high probability of retroperitoneal hemorrhaging.

Prospective study of computed tomography in patients with suspected acute appendicitis and low Alvarado score

BACKGROUND Computed tomography (CT) has been used in diagnosing acute appendicitis since late 1990s. Appropriate use of CT has not been studied prospectively in patients with suspected acute appendicitis and relative low Alvarado score. METHODS Sixty participants with suspected acute appendicitis and an Alvarado score of 4 to 7 points were enrolled for analysis. Clinical and laboratory differences were compared between patients with histologically proven acute appendicitis (AA group) and patients without evidence of acute appendicitis (non-AA group) in the first part of the analysis. In the second part of the analysis, participants were divided into 2 groups: leukocytosis (LK group) and nonleukocytosis (non-LK group). RESULTS In the first phase of the analysis, there were statistically significant differences in white blood cell count (13.5 K vs 10.9 K per μL), neutrophilia (81.5% vs 73.5%), and hospital stay (4.9 vs 3.5 days) between the 2 groups. Disease spectrum between LK and non-LK groups was obtained in second part of analysis. CONCLUSION Computed tomography scan is necessary for patients with relatively low Alvarado score when leukocytosis is noted. In female patients without leukocytosis, further large-scale prospective studies are necessary to change the current diagnostic strategy.

Single-Incision Laparoscopic-Assisted Surgery for Small Bowel Obstruction

BACKGROUND Acute small bowel obstruction (SBO) is a common cause of emergency hospital admission, often requiring surgical intervention. Herein, we describe the single-incision laparoscopic surgery (SILS) procedure for the management of SBO in the acute care setting. PATIENTS AND METHODS Patients with intestinal obstruction who underwent SILS in Chang Gung Memorial Hospital, Linkou, Taiwan, from January 2010 to January 2012 were retrospectively analyzed. Informed consent was obtained from all patients. Demographic information, intraoperative findings, surgery duration, and conversion to multi-incision laparoscopic surgery (MILS) were recorded. Postoperative records included the recovery period after surgery, complications, length of hospital stay, and final prognosis. RESULTS Ten SILS procedures for the repair of SBO were performed (six women, four men; median age, 52 years [range, 28-89 years]). Only 1 patient (10%) required conversion to MILS. The median operative time was 140 minutes (range, 90-210 minutes), median time to resume oral intake was 3 days (range, 1-7 days), median time to ambulation was 3 days (range, 1-6 days), and median postoperative hospital stay was 7.5 days (range, 3-14 days). There was no mortality in this series. All patients were discharged uneventfully. The umbilical incision was nearly invisible at the 1-month follow-up. The median follow-up time was 13.5 months (range, 4-26 months). No incisional hernias or adhesions were observed. CONCLUSIONS SILS for SBO is a feasible, safe procedure that can be performed as initial treatment in select patients with bowel obstruction through resection and decompression of the small bowel using intra- or extracorporeal techniques, resulting in a nearly invisible scar.

Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers

INTRODUCTION Patients with pelvic fracture usually require transfers to trauma centers for additional advanced treatment. Patient safety during the transfer should always be a priority. The noninvasive pelvic circumferential compression device (PCCD) can reportedly provide a tamponade effect, which reduces hemorrhage. In the present study, we evaluated the feasibility and efficiency of PCCD in patients with pelvic fracture who required transfer to trauma centers. MATERIALS AND METHODS In the present study, we aimed to evaluate patients with pelvic fractures who were transferred from other hospitals. We investigated and compared the characteristics of these types of patients with and without pretransfer PCCD. We compared 2 groups (with and without pretransfer PCCD) of patients under different situations (unstable pelvic fracture, stable pelvic fracture, or indicated for transcatheter arterial embolization). We also analyzed the characteristics of patients with unstable pelvic fracture who were initially evaluated as having stable pelvic fracture primarily before being transferred. RESULTS During the 53-month period, we enrolled 585 patients in the study. The patients with unstable pelvic fractures who received pretransfer PCCDs required significantly fewer blood transfusions (398.4 ± 417.6 mL vs 1954.5 ± 249.0 mL, P < .001), shorter intensive care unit length of stay (LOS; 6.6 ± 5.2 days vs 11.8 ± 7.7 days, P = .024), and shorter hospital LOS (9.4 ± 7.0 days vs 19.5 ± 13.7 days, P = .006) compared with patients who did not receive the pretransfer PCCD. The stable patients who received pretransfer PCCDs required significantly fewer blood transfusions (120.2 ± 178.5 mL vs 231.8 ± 206.2 mL, P = .018) and had shorter intensive care unit LOS (1.7 ± 3.3 days vs 3.4 ± 2.9 days, P = .029) and shorter hospital LOS (6.8 ± 5.1 days vs 10.4 ± 7.6 days, P = .018) compared with patients who did not receive the pretransfer PCCD. CONCLUSION Pelvic circumferential compression devices benefit patients with pelvic fracture who need to be transferred to trauma centers. Pretransfer PCCDs appeared to be a feasible and safe procedure during the transfer. In discussions between the referring physicians and the receiving physicians, we recommend using pretransfer PCCDs.

The current status and management of blunt adrenal gland trauma.

BACKGROUND Blunt adrenal gland trauma (BAGT) is a potentially devastating event if unrecognized during the treatment course of patients with trauma. Because of its rarity, no current algorithm or consensus exists for BAGT. In the present study, we demonstrated the feasibility and safety of transcatheter angiographic embolization (TAE) in BAGT and analyzed the clinical presentation and outcome of BAGT. METHODS We conducted a prospective collection and retrospective review at a level I trauma center in Taiwan. This study included all of the patients that sustained BAGT from May 2004 to May 2013. We retrieved and analyzed the patient demographic data, clinical presentation, BAGT grade, injury severity score, management, hospital stay, and mortality. RESULTS The cohort consisted of 77 patients: 59 men and 18 women. The mean age was 34.3 ± 15.5 years. The right side was the predominant site of injury (59/77; 76.6%). Six patients underwent operation; 18 patients underwent angiography, including four TAEs, and the remaining patients underwent conservative management. The mortality rate was 9.1% (7/77), and a high injury severity score was an independent factor to predict mortality. CONCLUSION In conclusion, BAGT is a rare injury with a benign prognosis. Most patients can be treated conservatively. Furthermore, this study demonstrates that both TAE and operation can be used to achieve hemostasis. The mortality of BAGT was related to severe associated injuries. BAGT is an indicator of severe multiple trauma; however, it does not increase mortality or prolong hospital stay.

Gasless laparoscopic assisted surgery for abdominal trauma.

BACKGROUND Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma. MATERIALS AND METHODS This was a retrospective, 1:2 matched case-control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed. RESULTS A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9min, and the mean operative time was 109.7, SD 33.5min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6min; p=0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p=0.030). CONCLUSION GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.

Impact of Deferred Surgical Intervention on the Outcome of External Laryngeal Trauma

BACKGROUND External laryngeal trauma (ELT) can be a fatal injury. Proper management of ELT significantly affects patient survival and quality of life. The optimal timing of surgical intervention is controversial. In this study, we review the incidence, management, and outcome of ELT and attempt to analyze the risk factors and prognosis of this injury. METHODS We conducted retrospective review using prospective data collection from patients with ELT in a level I trauma center from May 2008 to May 2013. We retrieved data regarding the severity of ELT, Injury Severity Score (ISS), New Injury Severity Score (NISS), Reverse Trauma Score (RTS), surgical timing, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), long-term outcome, and mortality. We analyzed the risk of prolonged hospitalization, adverse outcome, and mortality. RESULTS The 48 patients in this cohort had a mean age of 40.8±19.6 years. Twenty-four patients underwent operation within 48 hours, 10 patients underwent operation after 48 hours, and the other 14 patients did not require surgical intervention. A high NISS and the necessity for operation prolonged the ICU LOS and the HLOS. A high ISS and a low RTS predicted mortality. Initial phonatory impairment and the necessity of surgical intervention increased adverse outcomes. CONCLUSIONS In conclusion, ELT leads to high mortality and morbidity. The mortality in our series was related to severe associated injuries and to initial physical decompensation. Proper resuscitation and aggressively physiologic compensation were more important in the initial phase. Deferred treatment was acceptable until the patients were ready for operation.

Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures.

INTRODUCTION Transcatheter arterial embolization (TAE) is usually necessary in the management of hemodynamically unstable patients with concomitant pelvic fractures. Given the critical conditions of such patients, TAE is at times performed only according to the results of a primary evaluation without computed tomographic (CT) imaging. Therefore, the evaluation of associated intra-abdominal injuries (IAIs) might be insufficient. Clinically, some patients have required post-TAE laparotomy due to further deterioration. In this study, we attempted to determine a feasible protocol for post-TAE observation. MATERIALS AND METHODS This study focused on patients who received TAE to achieve hemostasis of retroperitoneal hemorrhage and who did not undergo CT imaging due to their unstable hemodynamics. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. We also analyzed the effects of the timing of post-TAE CT imaging on patients with IAIs requiring surgery. RESULTS A total of 41 patients were enrolled in the study. Of these patients, all of whom underwent primary TAE without preprocedure CT imaging; 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Comparisons between the 2 patient groups revealed no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P=.480), loss of consciousness (66.7% vs 73.1%, P=.730), or abdominal symptoms (20.0% vs 23.1%, P=1.000). CONCLUSION In the management of hemodynamically unstable patients with concomitant pelvic fractures, greater attention should be paid to associated IAIs. Early CT imaging is encouraged after the patients hemodynamic status is stabilized with TAE.