Yu Pao Hsu

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.

Surgical management and outcome of blunt major liver injuries: Experience of damage control laparotomy with perihepatic packing in one trauma centre

INTRODUCTION This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries. MATERIALS AND METHODS From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearsons chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05. RESULTS Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005). CONCLUSIONS The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.

Increased susceptibility to oxidant injury in hepatocytes from rats with intra-abdominal hypertension.

BACKGROUND Intra-abdominal hypertension leads to visceral organ hypoperfusion, and subsequent decompression may cause ischemia-reperfusion, releasing toxic metabolites. This study focuses on the effect of intra-abdominal hypertension on hepatic antioxidant store and the susceptibility of hepatocytes to oxidant injury. METHODS Sprague-Dawley rats (150-180 g) were acclimatized to an environment for 3 days and then divided into two groups according to challenge based on intra-abdominal pressure (0 and 30 cm H2O for control and experimental groups, respectively). After a 90-minute challenge, the rats underwent immediate laparotomy for decompression; after a further 30 minutes, one fragment of liver from the lingual lobe (>0.1 g) was excised to measure glutathione (GSH) in vivo before portal vein perfusion. After hepatocyte isolation (viability rate > 85%), the cell density was set at 1 x 10/mL for each well. The samples were cultured in an incubator for 12 hours, after which varying concentrations of t-butyl hydroperoxide (TBHP) (0.0, 0.5, 1.0, and 2.0 mmol/L) were added into the wells. After another 5-hour incubation, the total store of intracellular GSH in vitro (GSHVT) and the hepatocyte survival rates were measured for different groups of TBHP challenge using GSH assay and MTT kits. RESULTS The control and experimental groups consisted of 10 and 8 rats, respectively, that successfully completed the entire experimental procedure. Compared with the control group, the in vivo GSH store was significantly reduced after the intra-abdominal pressure challenge (mean +/- SE, 968.1 +/- 63.5 vs. 1,581.0 +/- 115.3 nmol/g of protein; p = 0.001). After the hepatocyte isolation, the GSHVT stores at various TBHP concentrations in the experimental rats were also similarly and significantly decreased relative to the control animals (894.4 +/- 56.4, 804.2 +/- 118.4, 586.9 +/- 86.6, and 410.2 +/- 87.4 nmol/g of protein vs. 1,282.2 +/- 112.0, 1,156.6 +/- 91.0, 995.2 +/- 92.7, and 866.8 +/- 62.4 nmol/g of protein for TBHPs of 0.0, 0.5, 1.0, and 2.0 mmol/L, respectively; all p < 0.05). Moreover, from photocytometry, the hepatocyte survival rates were significantly reduced for the experimental rats compared with the control animals after challenge with various TBHP concentrations (survival was 100%, 91.1%, 81.3%, and 72.8% vs. 100%, 99.2%, 95.0%, and 88.2%, respectively, for TBHPs of 0.0, 0.5, 1.0, and 2.0 mmol/L; p < 0.05 for the last two). CONCLUSION This animal study demonstrated that intra-abdominal hypertension and subsequent decompression deplete the total in vivo GSH store in rat livers, probably via the mechanism of ischemia-reperfusion injury, and the GSHVT after hepatocyte isolation, which makes the isolated hepatocytes of rats more susceptible to oxidant challenge.

Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification

BackgroundTo evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD).MethodsBetween August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome.ResultsOf the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%.ConclusionBased on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries.

Surgeon‐performed ultrasonography in patients with traumatic cardiac tamponade

Blunt trauma to the chest can cause a spectrum of cardiac injuries, ranging from asymptomatic arrhythmias to rupture of the cardiac chambers. 1,2 Cardiac tamponade, an acute life-threatening cardiac injury, carries a high mortality rate even with aggressive management. 3,4 It is generally accepted that early recognition, prompt diagnosis and immediate treatment of cardiac tamponade are critical for improving prognosis. The high venous pressure, low arterial pressure and quiet heart classically associated with cardiac tamponade are not always present and can be unreliable indicators in trauma patients, which may contribute to the high mortality seen with this kind of injury. 4 Screening echocardiography, aiming to detect potential surgical emergencies, can be performed by the trauma surgeon in the emergency department and helps in making the diagnosis of cardiac tamponade. Two patients are described in whom early recognition of acute traumatic cardiac tamponade with screening echocardiography allowed for immediate surgical treatment and survival without complications.