Shih-Ching Kang

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.

Hypotension does not always make computed tomography scans unfeasible in the management of blunt abdominal trauma patients

INTRODUCTION Computed tomography (CT) scans have been used worldwide to evaluate patients with blunt abdominal trauma (BAT). However, CT scans have traditionally been considered to be a part of a secondary survey that can only be performed after the patients haemodynamics have stabilised. In this study, we attempted to evaluate the role of the CT scan in managing BAT patients with hypotension. MATERIAL AND METHODS Patients who fulfilled the criteria for a major torso injury in our institution were treated according to the Advanced Trauma Life Support guidelines. The selection of diagnostic modalities for patients with stable and unstable haemodynamics was discussed. Furthermore, patients with hypotension after resuscitation who were administered haemostasis procedures were the focus of our analysis. We also delineated the influence of CT scans on the time interval between arrival and definitive treatment for these patients. RESULTS During the study period, 909 patients were enrolled in this study. Ninety-one patients (10.0%, 91/909) had a systolic blood pressure (SBP) <90mmHg after resuscitation. Fifty-eight of the patients (63.7%) received CT scans before they received definitive treatment. There was no significant difference in the CT scan application rate between the patients with and without hypotension after resuscitation (63.7% vs. 68.8%, p=0.382). Among the 79 patients with hypotension after resuscitation who underwent a haemostasis procedure (surgery or angioembolisation), there was no significant difference in the time between arrival and definitive haemostasis between the patients who received CT scans and those who did not (surgery: 57.8 (standard deviation (SD) 6.4) vs. 61.6 (SD 14.5)min, p=0.218; angioembolisation: [147.0 (SD 33.4) vs. 139.3 (SD 16.7)min, p=0.093). CONCLUSION The traditional priority of diagnostic modalities used to manage BAT patients should be reconsidered because of advancements in facilities and understanding of BAT. With shorter scanning times and transportation distances, hypotension does not always make performing a CT scan unfeasible.

Screening and management of major bile leak after blunt liver trauma: a retrospective single center study

BackgroundMajor bile leak after blunt liver trauma is rare but challenging. It usually requires endoscopic retrograde cholangiography (ERC) for management. However, there is still lack of specific indications. The aim of this study is to elucidate risk factors for major bile leak and indications for early ERC after blunt liver trauma.MethodsThe trauma registry of a level I trauma center in Taiwan was queried, and all blunt liver trauma patients from June, 2008 to June, 2011 were selected for retrospective review. Data collected included demographic data, laboratory data, Injury Severity Score (ISS), liver injury grade and location, management of liver trauma, length of ICU, hospital stay and treatment result. ERC was used to confirm major bile leak.Results288 blunt liver trauma patients were selected from 2,475 torso trauma patients. There were 214 (74.5%) male and 74 (25.7%) female patients. The mean ISS was 24.2. Most patients received conservative treatment. Transcatheter artery embolization (TAE) and operation were 15.6% and 10.8% respectively. Major bile leak occurred in 14 (4.9%) patients. Risk factors for bile leak include high-grade liver injury, centrally-located liver trauma and use of TAE. A bilirubin level greater than 43.6 μmol/L provides a sensitivity of 100% and specificity of 85.1% for predicting major bile leak.ConclusionsHigh injury grade; centrally-located liver trauma; and use of TAE are risk factors for major bile leak after blunt liver trauma. ERC should be arranged early if the patient has risk factors and their plasma bilirubin level is greater than 43.6μmol/L during admission.

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.

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.

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.

Factors associated with ED length of stay during a mass casualty incident

BACKGROUND The aim of this study was to examine the factors associated with emergency department (ED) length of stay (LOS) using the patient registry data from a medical burns center during a burn injury mass casualty incident (MCI) after a dust explosion in New Taipei City, Taiwan. METHODS This was a retrospective cohort study conducted at an urban, tertiary care teaching hospital during an MCI event that occurred on June 27, 2015. A celebratory party was held at the Formosa Fun Water Park in New Taipei City, Taiwan. At 20:32, the was an explosion caused by an overheated spotlight accidentally igniting colored cornstarch powder that had been sprayed on the stage. Factors associated with ED LOS were compared. RESULTS In total, 48 burn injury patients were enrolled for study analysis. The median total body surface area of second- to third-degree burns was 35.0% (interquartile range [IQR], 15.8%-55.0%). The median ED LOS was 121.5 minutes (IQR, 38.3-209.8 minutes). The output time interval accounted for the longest interval with a median time of 56.0 minutes (IQR, 15.3-117.3 minutes). In multivariate analysis of the variables, triage level (level III; hazard ratio, 0.06; 95% confidence interval, 0.01-0.52) and output time (hazard ratio, 0.97; 95% confidence interval, 0.96-0.98) were significant influential factors. CONCLUSIONS The triage level and output time intervals were significantly associated with ED LOS in a burn-related MCI. Time effectiveness analyses, using a patient flow model, might serve as an important indicator during a hospital MCI response.

The impact of preoperative etiology on emergent pancreaticoduodenectomy for non-traumatic patients

BackgroundEmergent pancreaticoduodenectomy is a life-saving procedure in certain clinical scenarios when all the conservative treatment fails. The indications can be limited into perforation and bleeding. To clarify the impact of etiology on surgical outcomes of emergent pancreaticoduodenectomy for non-trauma, we analyzed our patients and performed a literature review.MethodsWe reviewed 931 consecutive pancreaticoduodenectomies performed at our institute between January 2001 and July 2015. Patients with emergent pancreaticoduodenectomy for non-trauma etiologies were enrolled, whereas those who suffered from caustic injuries were excluded. The keywords “emergent/emergency” and “pancreaticoduodenectomy/pancreatoduodenectomy” were applied in a literature search. The universally available data for all the enrolled patients including etiology, surgical complications, outcomes, and hospital stays were analyzed. Univariate and multivariate logistic analysis for the contributing factors to surgical mortality were performed.ResultsSix out of 931 (0.6%) registered pancreaticoduodenectomies matched our criteria of inclusion. The literature review obtained 4 series and 7 case reports, which when combined with our patients yielded a cohort of 31 emergent pancreaticoduodenectomies with 13 cases of perforation and 18 of bleeding. The rate of emergent pancreaticoduodenectomy for non-traumatic etiologies is similar between the present study and the other 3 series, ranging from 0.3 to 3%. The overall surgical complication rate was 83.9%. The rate of surgical mortality is significantly higher than in elective pancreaticoduodenectomy by propensity score matching with age and gender (19.4 versus 3.2%, P = 0.015). Univariate and multivariate logistic regression disclosed that etiology is the only preoperative risk factor for surgical mortality (perforation versus bleeding; odds ratio = 39.494, P = 0.031).ConclusionsEmergent pancreaticoduodenectomy remains a rare operation. Surgical morbidity and mortality are higher than with elective pancreaticoduodenectomy among different reported series. By sorting the preoperative etiologies into two groups, perforation carries a higher risk of surgical mortality than bleeding.

Three-year and five-year outcomes of surgical resection for pancreatic ductal adenocarcinoma: Long-term experiences in one medical center

OBJECTIVE Pancreatic ductal adenocarcinoma is one of the most malignant types of cancer. This study evaluated the 3-year and 5-year surgical outcomes associated with the cancer and determined whether statistically identified factors can be used to predict survival. METHODS This retrospective review was conducted from 1995 to 2010. Patients who had resectable pancreatic ductal adenocarcinoma and received surgical treatment were included. Cases of hospital mortality were excluded. The relationships between several clinicopathological factors and the survival rate were analyzed. RESULTS A total of 223 patients were included in this study. The 3-year and 5-year survival rates were 21.4% and 10.1%, respectively, and the median survival was 16.1 months. Tumor size, N status, and resection margins were independent predictive factors for 3-year survival. Tumor size independently predicted 5-year survival. CONCLUSION Tumor size is the most important independent prognostic factor for 3-year and 5-year survival. Lymph node status and the resection margins also independently affected the 3-year survival. These patient outcomes might be improved by early diagnosis and radical resection. Future studies should focus on the tumor biology of this aggressive cancer.

The risk factors of concomitant intraperitoneal and retroperitoneal hemorrhage in the patients with blunt abdominal trauma

IntroductionIntraperitoneal and retroperitoneal hemorrhages may occur simultaneously in blunt abdominal trauma (BAT) patients. These patients undergo emergency laparotomies because of concomitant unstable hemodynamics and positive sonographic examination results. However, if the associated retroperitoneal hemorrhage is found intraoperatively and cannot be controlled surgically, then the patients require post-laparotomy transcatheter arterial embolization (TAE). In the current study, we attempted to determine the risk factors for post-laparotomy TAE.Materials and methodsPatients with concomitant BAT and unstable hemodynamic were retrospectively analyzed. The characteristics of the patients who underwent laparotomy or who required post-laparotomy TAE were investigated and compared. The Tile classification system was used to evaluate the pelvic fracture patterns.ResultsSeventy-four patients were enrolled in the study. Fifty-nine (79.7%) patients underwent laparotomy to treat intra-abdominal hemorrhage, and fifteen (20.3%) patients underwent additional post-laparotomy TAE because of concomitant retroperitoneal hemorrhage. Pelvic fracture was present in 80.0% of the post-laparotomy TAE patients. This percentage was significantly greater than that of the laparotomy only patients (80.0% vs. 30.5%, p < 0.001). Furthermore, 30 patients (40.5%, 30/74) had concomitant pelvic fracture diagnoses. Of these patients, eighteen (60%, 18/30) underwent laparotomy only, while the other twelve patients (40%, 12/30) required post-laparotomy TAE. Compared with the patients who underwent laparotomy only, more patients with Tile B1-type pelvic fractures (58.3% vs. 11.1%, p = 0.013) required post-laparotomy TAE.ConclusionRegarding BAT patient management, the likelihood of post-laparotomy TAE should be considered in patients with concomitant pelvic fractures. Furthermore, more attention should be directed toward patients with Tile B1-type pelvic fractures because of the specific fracture pattern and impaction force.