Ray Jade Chen

Classification and treatment of Pooling of contrast material on Computed tomographic scan of Blunt hepatic trauma

BACKGROUND Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management. METHODS During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material. RESULTS The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable. CONCLUSION With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.

Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury

BACKGROUND Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively. METHODS During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed. RESULTS Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy. CONCLUSION The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.

LABORATORY TESTS IN PATIENTS WITH ACUTE APPENDICITIS

Background:  Laboratory measurements such as leucocyte count, neutrophil percentage and C‐reactive protein (CRP) concentration are commonly used as diagnostic aids in patients with suspected acute appendicitis. The present study aimed to clarify the role of these laboratory tests in diagnosing acute appendicitis.

CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation.

PURPOSE The purpose of our study was to devise a CT grading scheme for blunt pancreatic injuries (BPIs) and to apply it to predict the presence or absence of ductal disruption. METHOD We retrospectively reviewed CT scans of 22 patients with proven BPIs. We graded these injuries on CT (A, BI, BII, CI, and CII) based on the (a) presence or absence of pancreatic lacerations, (b) site of lacerations, and (c) depth of lacerations. CT grading was correlated with surgical findings for glandular and ductal injuries. RESULTS Main pancreatic ducts were intact in 2 patients with normal CT scans and in all grade A injuries (n = 10). Distal pancreatic ducts were disrupted in all grade B injuries (BI, n = 1; BII, n = 4). Of five grade C injuries, three CII injuries had disruption of proximal pancreatic duct, one CII injury had disruption of minor duct, and one CI injury had an intact ductal system. CONCLUSION CT grading of BPIs was useful in predicting ductal integrity or disruption. Ductal disruption was likely present if the pancreas appeared to have a transection or deep laceration on CT scans. It was accurate in grade A and B injuries. Overestimation could occur in grade CI and CII injuries.

Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma

BACKGROUND Most blunt hepatic trauma patients can be managed nonoperatively. The current failure rate in adult blunt hepatic trauma is reportedly 0 to 19%. We wished to evaluate the applicability of laparoscopy and fibrin glue as a minimally invasive alternative to laparotomy in these unsuccessfully nonoperative cases. METHODS All adult patients with blunt hepatic trauma managed nonoperatively at Linkou, Chang Gung Memorial Hospital Medical Center, Taipei, Taiwan, over a 2-year period from July 1, 1994, to June 30, 1996, were eligible for the study. A laparoscopic examination was performed on those who failed conservative care before undertaking an exploratory laparotomy. Fibrin glue was sprayed over the wound surface if ongoing hemorrhage was evident from any liver laceration. The clinical data, operative and laparoscopic findings, operative methods, and outcomes of these patients were studied. RESULTS Of the 61 patients, 55 patients were successfully treated without operation. Of the six failures (10%) all were liver related. After the introduction of laparoscopy, the nontherapeutic laparotomy rate would have decreased from 100% (6 of 6) to 50% (3 of 6), and with the adjunctive use of fibrin glue, the laparotomy rate went down to 0% (0 of 6). There were no deaths among the six patients receiving laparoscopy and fibrin glues; and only one developed a liver abscess, for a morbidity rate of 17% (1 of 6). CONCLUSIONS The selective use of laparoscopy and fibrin glue can effectively reduce the nontherapeutic laparotomy rate among blunt hepatic trauma patients who fail nonoperative management.

BMP-2 increases migration of human chondrosarcoma cells via PI3K/Akt pathway†

Bone morphogenetic protein‐2 (BMP‐2), a member of transforming growth factor‐β superfamily, plays a crucial role in migration and metastasis of human cancer cells. Integrins are the major adhesive molecules in mammalian cells. Here we found that BMP‐2 directed the migration and increased cell surface and mRNA expression of β1 integrin in human chondrosarcoma cancer cells (JJ012). Pretreated of JJ012 cells with phosphatidylinositol 3‐kinase inhibitor (PI3K; Ly294002) or Akt inhibitor inhibited the BMP‐2‐mediated migration and integrin expression. BMP‐2 increased the phosphorylation of p85 subunit of PI3K and serine 473 of Akt. In addition, NF‐κB inhibitor (PDTC) or IκB protease inhibitor (TPCK) also inhibited BMP‐2‐mediated cells migration and integrin upregulation. Stimulation of JJ012 cells with BMP‐2 induced IκB kinase (IKKα/β) phosphorylation, IκB phosphorylation, p65 Ser536 phosphorylation, and κB‐luciferase activity. Furthermore, the BMP‐2‐mediated increasing of IKKα/β phosphorylation, IκB phosphorylation, and p65 Ser536 phosphorylation were inhibited by Ly294002 and Akt inhibitor. Co‐transfection with p85 and Akt mutants also reduced the BMP‐2‐induced κB‐luciferase activity. Taken together, these results suggest that the BMP‐2 acts through PI3K/Akt, which in turn activates IKKα/β and NF‐κB, resulting in the activations of β1 integrin and contributing the migration of human chondrosarcoma cells. J. Cell. Physiol. 217: 846–855, 2008.

Diagnosis and management of bladder injury by trauma surgeons

BACKGROUND Bladder injuries constitute one of the most common urological injuries involving the lower urinary tract. The methods of diagnosis and management of bladder trauma have been well established and accepted. However, bladder injuries are usually associated with other major injuries, and it is our concern here how bladder injuries have been managed as part of multiple trauma. METHODS From 1991 to 2000, a total of 51 cases of bladder injury were retrospectively reviewed. The mechanisms of trauma, types of bladder injury, time needed to diagnosis, methods of treatment, and patient outcome, were analyzed. Diagnosis time was defined as the time interval from patient arrival to the establishment of a diagnosis either by image studies or laparotomy. Management followed the general rule that bladder contusions or extraperitoneal ruptures were treated non-operatively, and that those with intraperitoneal rupture or combined rupture underwent operative repair. If bladder injury was noted after the patient left the emergency room (ER), it was defined as a delay diagnosis. The Injury Severity Score (ISS), length of hospital stay, and morbidity were used to evaluate patient outcome. RESULTS The mean age of all the patients was 31.4 years old, and most of them had sustained an injury from a motor vehicle accident (40 of 51). All but 3 patients had gross hematuria. Ten of the patients underwent emergency laparotomy, and 2 of them underwent emergency neurosurgical procedures, therefore no image studies were performed for these 12 patients. A total of 33 patients underwent abdominal computed tomography (CT), but only 20 were correctly diagnosed, yielding an accuracy rate of 60.6%. There were 3 delay diagnoses, due to either a lack of gross hematuria on presentation or the patient leaving the ER before any bladder injury study could be performed. A retrograde cystogram was performed in 24 patients, with an accuracy rate of 95.9% (23 of 24). The mean diagnosis time of the 48 bladder injuries presented in the ER was 3.2 hours and the time needed to reach a diagnosis was not related to the severity of bladder injury. Those patients who underwent operation immediately did not seem to have a quicker diagnosis. Those patients with a higher injury score (ISS >16), and those patients who suffered from pelvic fracture, stayed in the hospital longer. However, the severity of the bladder injury was not related to the length of hospital stay. There was no bladder-related mortality in our series. CONCLUSIONS We report our results of dealing with bladder injuries from the point of view of trauma surgeons who treat bladder injury as part of multiple injuries. Although known as a procedure of choice for diagnosis of bladder injury, the retrograde cystogram was performed in fewer than half of the patients (24 of 51), which means it is not feasible in many situations. The patient outcome was determined by the severity of injury of the patient but not by the severity of bladder injury.

Factors determining operative mortality of grade V blunt hepatic trauma

BACKGROUND Despite recent advances in the management of severe hepatic injuries, the operative mortality rate of grade V hepatic injuries still ranges from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blunt trauma. The purpose of this study is to understand the risk factors determining operative mortality in grade V blunt hepatic trauma, and to try to improve the surgical management of these injuries. METHODS A retrospective study was conducted at a medical center that offers services including primary, secondary, and tertiary care. Forty-four patients with grade V blunt hepatic injuries were treated during a 6-year period from January 1, 1991, to December 31, 1996. The operative mortality was compared by a multivariate analysis. RESULTS Forty-four patients with grade V blunt hepatic injuries were identified. Seven patients had only parenchymal injuries, and the others had vascular and associated parenchymal injuries. Venorrhaphy was used in 37 patients; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt. The overall mortality rate was 68% (30 of 44), and liver-related mortality was 50% (22 of 44). Univariate analysis revealed that the significant variables affecting operative mortality were initial systolic blood pressure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward stepping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative blood loss of 5,000 mL or more (relative risk = 23.5) would, significantly, encounter a worsening prognosis. CONCLUSIONS Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V blunt hepatic trauma. We suggest that prompt resuscitation and expeditious and appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepatic trauma.

Intra-abdominal pressure monitoring as a guideline in the nonoperative management of blunt hepatic trauma.

BACKGROUND Nonoperative management has been validated as a standard of care for patients with blunt hepatic trauma. We herein study the correlation of intra-abdominal pressure (IAP) and other clinical parameters to predict the failure of nonoperative management, and attempt to use IAP to determine further therapeutic options. METHODS During a 9-month period, 25 hemodynamically stable patients sustaining grades III to V blunt hepatic injuries were prospectively studied. They were admitted to the intensive care unit for clinical reevaluation, and hemodynamic and IAP monitoring. If the patient developed an IAP greater than 25 cm H(2)O, then an emergent laparotomy or laparoscopy was performed to achieve hemostasis and decompression of intra-abdominal hypertension (IAH). On the basis of an IAP of 25 cm H(2)O, the correlation between the IAP and an estimated amount of liver-related transfusion, the Pao(2)/Fio(2) ratio and peritoneal signs were analyzed. RESULTS Of the 25 patients being studied, 20 (80%) had an IAP below 25 cm H(2)O, 1 of whom was found to have a pelvic abscess from an amputated segment of liver. On the other hand, five other patients with an IAP greater than 25 cm H(2)O received decompression and laparoscopic examinations, and one needed an open hepatorrhaphy. In general, though, 19 patients (76%) were successfully treated without operation. All recovered well after different therapeutic regimens; however, two developed liver abscesses, for a morbidity rate of 8% (2 of 25). This analysis revealed a strong association between the IAP value and the presence of peritoneal signs (Phi coefficient = 0.890, p < 0.001), but not in the estimated amount of liver-related transfusion and Pao(2)/Fio(2) ratio. CONCLUSION This preliminary investigation suggests that IAH or abdominal compartment syndrome can develop while patients receive nonoperative management for grade III to V blunt hepatic injuries. There were no parameters that precisely reflected ongoing hepatic hemorrhage or predicted hemodynamic instability. Although the amount of hepatic hemorrhage was not accurately measured by the IAP, it could be reflected by an increased IAP. During nonoperative management, IAP monitoring may be a simple and objective guideline to suggest further intervention for patients with blunt hepatic trauma. Laparoscopic hepatic evaluation and abdominal decompression may be helpful in this situation.

Multidetector-row computed tomography (CT) of blunt pancreatic injuries: can contrast-enhanced multiphasic CT detect pancreatic duct injuries?

BACKGROUND We examined patients of blunt trauma with contrast-enhanced multiphasic computed tomography (CT) and determined if it could detect pancreatic duct injuries. METHODS During a 17-month period, 95 patients of blunt abdominal trauma underwent multiphasic CT examinations. The CT grading scales of pancreatic injuries at parenchymal phase, portal venous phase, and equilibrium phase were recorded and compared with surgery, endoscopic retrograde cholangiopancreatography, or discharged diagnosis. The diagnostic values of multiphasic CT and interobserver agreements at different phases were computed. RESULTS Of the 95 patients, nine (9.5%) had pancreatic injuries (six with main duct injuries, three without main duct injuries). The interobserver agreement presented in kappa values between two radiologists regarding the integrity or disruption of the main duct were good at parenchymal phase (K = 0.73), portal venous phase (K = 0.64), and equilibrium phase (K = 0.68). The overall accuracies of multiphasic CT in detecting main duct injuries were 97.9% (parenchymal phase), 100.0% (portal venous phase), and 96.8% (equilibrium phase), respectively. The sensitivity (50.0%) and negative predictive value (96.7%) of equilibrium phase CT were the lowest among the three phases of CT scans. CONCLUSION The portal venous phase CT was the most accurate scan to detect pancreatic duct injuries. However, equilibrium phase CT might underestimate major pancreatic injuries. Multiphasic CT shows early promise in this clinical application and further multi-institutional studies to verify its accuracy and reveal the optimal CT methodology are needed.