Jen-Feng Fang

Aggressive resection is indicated for cecal diverticulitis

BACKGROUND Because of the difficulties in preoperative diagnosis and controversies in the management, cecal diverticulitis has received much discussion in the literature. There, however, are still many questions that remain unanswered. METHODS During a 5-year period, 112 patients with a clinical diagnosis of cecal diverticulitis were treated. Twenty-seven patients were excluded because of uncertainty in diagnosis or incomplete data collection, leaving 85 patients as the study group. The diagnosis of cecal diverticulitis was made by pathology, surgical findings, or image study. RESULTS Nonoperative management was applied to 18 patients initially. Three patients had recurrent diverticulitis during follow up. These patients responded satisfactorily to another course of medical treatment. Laparotomy was performed in 67 patients. Acute appendicitis was the preoperative diagnosis in 47 patients (70%). Of the other 20 patients, 6 received operation because of repeated attack of diverticulitis, 7 had preoperative computed tomography (CT) diagnosis of cecal diverticulitis with perforation, 5 had preoperative diagnosis of cecal tumor, and 2 had medical treatment failure. All these 20 patients received right hemicolectomy. In the 47 patients with a preoperative diagnosis of acute appendicitis, 24 received appendectomy, 9 received diverticulectomy, and 14 received right hemicolectomy. Overall, 34 patients received right hemicolectomy, 9 received diverticulectomy, and 24 received appendectomy only. In the right hemicolectomy group, there were 2 deaths with underlying diseases and 5 complications. In the appendectomy group, there was no postoperative mortality, but in 7 patients recurrent diverticulitis developed. Three of them required right hemicolectomy. CONCLUSIONS The natural history of cecal diverticulitis varies from benign and self-limiting to fulminant in the oriental population. Less than 40% (32 of 85) of patients were successfully treated with conservative methods initially and had no recurrence during the follow-up period. We recommend aggressive surgical resection for patients with a definite diagnosis. Adjuvant appendectomy without resection of the lesion should be considered only in uncomplicated patients whose diagnosis is in doubt.

Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury.

BackgroundPancreatic stents can be used to treat a variety of acute and chronic pancreatic lesions. Sporadic successful trials in trauma patients have been reported. To our knowledge, however, a series with long-term follow-up has not previously been reported. We treated six patients in a 6-year period and report the long-term results.MethodsFrom February 1999 to February 2005, six blunt-trauma patients with major pancreatic duct disruption were treated with pancreatic duct stent at a single trauma center. Assessment of injury severity and diagnosis were based on abdominal computed tomography (CT) and proved by endoscopic retrograde pancreatography (ERP), with chart review used to establish mechanism of injury, timing of ERP, and stent placement, as well as the long-term outcome.ResultsThree of the six injuries were classified AAST grade III and three were grade IV; the interval to ERP with stent placement ranged from 8 hours to 22 days after the injury. One patient developed sepsis and died. One patient’s stent could be removed early (52 days post-stenting) with mild ductal stricture, whereas the other four were complicated by severe ductal stricture that required repeated and prolonged stenting treatment. Removal of the stents was only possible in three of these four cases (at 12, 19, and 39 months, respectively), with stent dislodgment in the pancreatic duct occurring in another.ConclusionsStent therapy may avoid surgery in the acute trauma stage, and may be preserved as another choice for acute grade IV pancreatic injury. However, variant outcome and long-term ductal stricture reveal that the role of pancreatic duct stent is uncertain and may not be suitable for acute grade III pancreatic injury. However, it needs more clinical data to define the value in the acute blunt pancreatic duct injury.

Repeat transcatheter arterial embolization for the management of pelvic arterial hemorrhage.

BACKGROUND Most arterial hemorrhage associated with pelvic fracture can be adequately controlled by a single transcatheter arterial embolization (TAE). However, there is a small group of patients who remain hemodynamically unstable after TAE, have no other identifiable source of bleeding, and who benefit from repeat TAE of the pelvis. METHODS We conducted a retrospective study of patients with hemorrhage from pelvic fractures between January 2001 and June 2006. Clinical parameters and results were compared between patients requiring more than one pelvic TAE and those undergoing a single TAE. Risk factors for repeat TAE were identified by univariate and stepwise logistic regression analyses. RESULTS During the study period, 174 of 964 patients with pelvic fracture received pelvic angiography for suspected arterial hemorrhage. One hundred forty TAEs were performed. Thirty-four (24.3%) patients underwent more than one angiography for suspected recurrent arterial hemorrhage, and 26 (18.6%) underwent repeat TAE. Repeat angiography was performed 3 to 58 hours (mean, 21 hours) after initial TAE. Patients with repeat TAE had significantly more blood transfusions, higher mortality rate, and longer intensive care unit stay. Independent predictors for repeat TAE included initial hemoglobin level lower than 7.5 g/dL (OR, 6.22), superselective arterial embolization in initial TAE (OR, 3.22), and more than 6 units of blood transfusion after initial TAE (OR, 3.22). CONCLUSION Careful monitoring and prompt recognition of patients requiring repeat TAE is paramount. The arterial access sheath should remain in place for up to 72 hours after angiography. Initial hemoglobin level lower than 7.5 g/dL and more than 6 units of blood transfusion after initial angiography are predictors for repeat TAE. Superselective TAE is associated with a significantly higher risk of recurrent hemorrhage, and its use should be limited.

Proteomic analysis of post-hemorrhagic shock mesenteric lymph.

Recent studies have documented the association of mesenteric lymphatic route with adult respiratory distress syndrome and multiple organ failure after hemorrhagic shock. However, the mediators and mechanisms of the toxic effects of mesenteric lymph remain unclear. This study aimed to identify mediators or biomarkers in the mesenteric lymph through comparative proteomic analysis. Fourteen mature male Sprague-Dawley rats were randomly divided and subjected to trauma (laparotomy) plus hemorrhagic shock or trauma plus sham shock. Mesenteric lymph samples were collected before shock and at 3 h after resuscitation from hemorrhagic shock (or sham shock). To investigate changes in proteome profiles between preshock and 3-h postshock (or 3-h post-sham shock) mesenteric lymph samples, two-dimensional gel electrophoresis and matrix-assisted laser desorption ionization time-of-flight mass spectrometry were performed. We found a more than 2-fold change in abundance of 31 protein spots in the lymph samples. Mass spectrometry analyses identified 12 distinct proteins. Four proteins were consistently upregulated in the 3-h postshock lymph samples, including serum albumin precursor, two isoforms of cytoplasmic actin, complement C3 precursor, and major urinary protein precursor. Two proteins, including haptoglobin and one unidentified protein, were consistently downregulated. The deregulation of these proteins was confirmed by Western blots. Most of these altered proteins are functionally implicated in tissue inflammation. The findings of this study provide a starting point for investigating the functions of these proteins in hemorrhagic shock-induced lung injury and hold great promise for the development of potential therapeutic interventions.

Surgical management of juxtahepatic venous injuries in blunt hepatic trauma.

The purpose of this analysis was to understand better the problems faced in the management of blunt juxtahepatic venous injuries and to try and simplify the controversies regarding the optimal surgical approach to these injuries. Charts of 92 blunt liver trauma patients treated between July 1, 1991 to June 30, 1993 were reviewed. Nineteen patients with blunt juxtahepatic venous injuries were identified. The isolated left hepatic vein injury group (five patients) were all treated using a nonshunting approach with no mortalities. Half of the isolated right hepatic vein injury group (ten patients) received an atriocaval shunt, and the other half did not. These two different approaches each produced one survivor, with a combined mortality rate of 80% (eight of ten patients). One of the combined injuries group (four patients) received a total hepatectomy followed by liver transplantation. Another received a shunt. The other two were treated without shunting, but all of them expired. The overall mortality rate was 63.2% (12 of 19 patients), with nine patients dying intraoperatively or immediately postoperatively from exsanguination. The other three died 10, 25, and 30 days postoperatively because of sepsis. Juxtahepatic venous injury should be suspected after failure of the Pringle maneuver to stop bleeding and the different venous injuries differentiated by palpation of the adjacent hepatic parenchymal injuries. If an isolated left hepatic vein injury is found and the liver parenchymal injury is limited to segments II, III, or IV, then a nonshunting approach will achieve the optimal outcome.

Spontaneous rupture of left external iliac vein: Case report and review of the literature

Iliac vein rupture is rare and primarily results from major trauma or occurs during pelvic surgery. Spontaneous nontraumatic rupture is even more unusual, with only 14 cases reported in the literature. We report an additional case, summarize all of the cases, and discuss the possible causes and treatment of iliac vein rupture and the role of anticoagulants in postoperative management.

Management of ongoing arterial haemorrhage after damage control laparotomy: Optimal timing and efficacy of transarterial embolisation

INTRODUCTION Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome. MATERIALS AND METHODS From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage=7, extra-hepatic haemorrhage=9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries. RESULTS There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery (n=6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury=1, lumbar artery injury=1). Of 16 patients overall, profound haemorrhagic shock (n=4) and multiple organ failure (n=4) resulted in eight deaths (hepatic injury=4, extra-hepatic injury=4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min). CONCLUSIONS TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.

Treatment of Endobronchial Hemorrhage After Blunt Chest Trauma With Extracorporeal Membrane Oxygenation (ECMO)

Blunt chest injury is common in trauma care. Motor vehicle crashes, pedestrian injuries, and falling from heights are leading causes of blunt chest injury. Pulmonary contusion occurs in some patients with severe blunt chest trauma. Pulmonary contusion complicated with endobronchial hemorrhage is life threatening. The overall mortality rate associated with pulmonary contusion is reportedly high (16%–42%). Severe airway bleeding can spoil the entire lung, leading to refractory hypoxemia. Currently, traumatic endobronchial hemorrhage is treated with lung isolation by a double lumen endotracheal tube and suction through the tube or bronchoscope to evacuate tracheal secretion and blood clotting. However, difficulty in hemostasis and progressive hypoxemia despite these aggressive treatments are frequently encountered. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy for severe respiratory failure, and has been shown to be life-saving in neonates and children with respiratory failure. ECMO was originally introduced with two main goals: to obtain a viable oxygenation in patients with severe hypoxia; and to buy time for lung healing. In 1972, Hill et al. first reported successful management with prolonged extracorporeal life support system in a trauma patient. Since then, only few studies have demonstrated that ECMO benefits individuals who suffer from blunt chest trauma or respiratory failure after trauma. This is attributed to disease physiology and the risk of bleeding associated with systemic heparinization, which is necessary during ECMO treatment. This report presents two patients with blunt chest trauma, active endobronchial hemorrhage, and a liver laceration or a subdural hematoma. Both patients received ECMO treatment for ventilatory support and survived what was considered a lethal injury.

Necrotic stercoral colitis: importance of computed tomography findings.

AIM To study the computed tomography (CT) signs in facilitating early diagnosis of necrotic stercoral colitis (NSC). METHODS Ten patients with surgically and pathologically confirmed NSC were recruited from the Clinico-Pathologic-Radiologic conference at Chang Gung Memorial Hospital, Taoyuan, Taiwan. Their CT images and medical records were reviewed retrospectively to correlate CT findings with clinical presentation. RESULTS All these ten elderly patients with a mean age of 77.1 years presented with acute abdomen at our Emergency Room. Nine of them were with systemic medical disease and 8 with chronic constipation. Seven were with leukocytosis, two with low-grade fever, two with peritoneal sign, and three with hypotensive shock. Only one patient was with radiographic detected abnormal gas. Except the crux of fecal impaction, the frequency of the CT signs of NSC were, proximal colon dilatation (20%), colon wall thickening (60%), dense mucosa (62.5%), mucosal sloughing (10%), perfusion defect (70%), pericolonic stranding (80%), abnormal gas (50%) with pneumo-mesocolon (40%) in them, pericolonic abscess (20%). The most sensitive signs in decreasing order were pericolonic stranding, perfusion defect, dense mucosal, detecting about 80%, 70%, and 62.5% of the cases, respectively. CONCLUSION Awareness of NSC and familiarity with the CT diagnostic signs enable the differential diagnosis between NSC and benign stool impaction.

Contrast-enhanced multiphasic computed tomography for identifying life-threatening mesenteric hemorrhage and transmural bowel injuries.

BACKGROUND Active mesenteric hemorrhage and bowel perforation after blunt abdominal trauma warrant immediate surgical intervention. We investigate whether findings on multiphasic computed tomography (CT) can identify life-threatening mesenteric hemorrhage and bowel injuries. METHODS Within 1-year period, 106 patients underwent multiphasic CT for evaluation of blunt abdominal injuries. Images obtained at arterial phase, portal phase, and equilibrium phase were retrospectively reviewed with special focus on mesentery and bowel injuries. We compared the recorded findings with surgically proven active mesenteric hemorrhage and transmural bowel injuries. The diagnostic values and positive likelihood ratios of individual CT signs were calculated. RESULTS Mesenteric contrast extravasation had 73.5 positive likelihood ratio and 75% sensitivity for active mesenteric hemorrhage. Hemorrhage first appeared at arterial phase and portal phase was active and life threatening, different from a contained hemorrhage appeared only at equilibrium phase. For transmural bowel injuries, positive likelihood ratio of full-thickness bowel wall abnormality and extraluminal air was large at 32.5 and 26.9, respectively. However, increased mesenteric fat density and peritoneal fluid had high negative predictive value at 98.9 and 97.8. Mean radiodensity of peritoneal fluid in transmural bowel injuries was significantly lower (30 vs. 44 Hounsfield unit, p = 0.008). CONCLUSIONS Multiphasic CT is accurate in identifying life-threatening mesenteric hemorrhage and transmural bowel injuries.