Academic literature on the topic 'ABDOMINAL TRAUMA, HEMOPERITONEUM, HAEMODYNAMIC STABILITY'

Objective: To diagnose the cases of hepatic injury due to blunt abdominal trauma in a shortest possible time and find out the way of efficient and planned management of hepatic injury in our present setting.
 Materials and methods: This study was done in the casualty department of Dhaka Medical College Hospital and 50 patients of hepatic injury following blunt abdominal trauma were selected over a period of January 2010 to December 2010. All 50 patients were admitted within 24 hours of incidence. The patients were diagnosed clinically by history and physical examination and relevant investigations. Immediately after admission patients were resuscitated by clearance of airway, maintenance of respiration, arrest of external bleeding and maintenance of normal circulation (ATLS Protocol). After resuscitation further management was planned depending upon the condition of the patient. Clinical presentation, overall management and outcome were evaluated by the available resources of casualty ward of DMCH.
 Results: Most patients were male (88%) and 68% of patients were belonged to age group of 21 to 40 years. Most of the patients (90%) were injured as a result of road traffic accidents. All patients had a history of trauma and most of them presented with abdominal pain, tenderness muscular rigidity of abdomen and shock (38%). Only 13 (26%) patients had isolated hepatic injury. Rest of the patients had associated other organ injuries. Majority patients (46%) had Grade-I hepatic injury. Out of 50 patients, 46 were operated and most of them had other intra abdominal organ injuries and 4 patients were given non-operative management. Suture hepatorrhaphy was done in 38 (76%) cases. Most common post operative complications were pulmonary in origin (24%) and three patients were died in this series.
 Conclusion: Simple technique of hemostasis such as suture hepatorrhaphy is sufficient in most cases with adequate drainage and non operative management can be tried based on haemodynamic stability.
 J Dhaka Medical College, Vol. 27, No.1, April, 2018, Page 57-61

Summary Introduction. Trauma is a leading cause of death, particularly among young patients. Spleen is the most commonly damaged organ in blunt abdominal trauma and liver injury is the main cause of death. Aim of the study. Review of the literature and recent clinical experience in the management of blunt liver injuries in the Riga East clinical university hospital. Materials and methods. Three-year experience in the management of liver traumatic rupture was retrospectively and prospectively analysed. The study included 64 patients over 15 years of age with blunt hepatic injuries. Exclusion criteria were patients with life-incompatible haemorrhagic shock. The Statistical analysis of the data was performed by median and mean of the Microsoft Excel 2010 and SPSS 22 version. Results. A total of 64 patients were treated in our institution during the period from November 2010 till November 2013. Isolated liver injuries were diagnosed in 49 cases, combined liver and spleen injuries in 15 cases. Most commonly mechanism ofinjury were road traffic accidents, falls and low energy blunt traumas (criminal beaten, sports injuries);19 patients underwent laparotomy for haemostasis while nonoperative management was used in 45 patients. Haemodynamic stability of the patient and CT confirmed liver injury were the main criteria for nonoperative management. One patient died atthe time of laparotomy from injuries not compatible with life – severe head injury with basal skull fracture, aortic arc rupture, flail chest and liver and spleen injury. Conclusions. Conservative management of liver trauma is justified in haemodynamically(HD) stable patients after thorough risk assessment and computed tomography (CT) based injury grading in centres with sufficient expertise and medical resources.

The diagnosis of diaphragmatic hernia (DH) in adults is rare and may be due to missed congenital DH or acquired DH from trauma or as a postoperative complication of certain thoracic and abdominal surgeries. We present a case of a patient with well-controlled chronic obstructive pulmonary disease who presented to the hospital with progressive dyspnoea, 6 months after laparoscopic nephrectomy. The patient was initially misdiagnosed and treated for empyema after plain radiographic images were reported as consolidation with gas locules. Multislice CT imaging undertaken before diagnostic thoracocentesis confirmed the presence of a right-sided DH, which was subsequently surgically repaired in the outpatient setting, given her haemodynamic stability. As patients with DH usually present in the emergency setting, requiring urgent inpatient surgical repair, there are currently no guidelines on the method and urgency of management of asymptomatic or mildly symptomatic, stable patients. Furthermore, while plain radiography is the usual first-line imaging modality used, misdiagnosis of DH as pleural effusion or empyema can lead to unnecessary and potentially harmful procedures such as diagnostic thoracocentesis. These risks can potentially be minimised with early utilisation of multislice CT imaging in patients with high clinical suspicion.

Edmundas Gaidamonis, Juozas Stanaitis, Sigitas Tamulis, Robertas Saltanavičius, Rytis Tutkus, Kazimieras Brazauskas, Aurelijus Grigaliūnas, Moisejus Racinas, Jonas Stasinas, Tomas Saladis, Raimundas LunevičiusVilniaus universiteto Bendrosios ir kraujagysliųchirurgijos klinikos Bendrosios chirurgijos centras,Vilniaus greitosios pagalbos universitetinė ligoninė,Šiltnamių g. 29, LT-2043, VilniusEl paštas: edmundas.gaidamonis@mf.vu.lt Įvadas / tikslas Teigiama, kad pooperacinių komplikacijų dažnis ir mirštamumas sužalojus plonąją žarną priklauso nuo traumos apimties ir gretutinių pilvo ertmės organų sužalojimų. Darbo tikslas – įvertinti ligonių, kuriems buvo atvirų plonosios žarnos sužalojimų, gydymo rezultatus, nustatyti veiksnius, lemiančius pooperacines komplikacijas ir mirštamumą. Metodai Darbo pobūdis – retrospektyvus. Nagrinėtos 1982–1991 metais VMUL ir 1991–1998 metais VGPUL nuo atviros plonųjų žarnų traumos operuotų 126 ligonių ligos istorijos. Duomenys rinkti pagal specialų traumą patyrusių ligonių duomenų registravimo protokolą. Vertinta: ligonių amžius, lytis, traumos mechanizmas, operacijos rizikos laipsnis, hemodinamikos būklė, instrumentiniai tyrimai, organo sužalojimo laipsnis, pilvo ertmės organų ir kombinuoti kitų sistemų sužalojimai, operacijos dydis, pooperacinės komplikacijos, baigtis. Rezultatai Pooperacinių komplikacijų radosi 32 ligoniams (25,4 %), iš jų 6 ligoniai mirė (mirštamumas 4,8 %). Ligonių, kuriems buvo I–III ir IV–V laipsnio plonosios žarnos sužalojimai, komplikacijų dažnio skirtumas (23,4 % ir 60 %) buvo statistiškai patikimas (p < 0,01). Pooperacinių komplikacijų buvo 11,9 % ligonių, pagal ASA klasifikaciją priklausančių I–III grupei, ir 52,9 % ligonių, priklausančių IV–V grupei (p < 0,01); mirštamumas I–III grupės ligonių buvo 1,8 %, IV–V grupės – 23,5 % (p < 0,005). Mirštamumas nestabilios hemodinamikos atveju buvo daugiau kaip 5 kartus didesnis (15 % ir 2,8 %) (p = 0,05). Įvertinus penetruojančios pilvo traumos indekso (PATI) ir pooperacinių komplikacijų bei mirštamumo priklausomybę paaiškėjo, kad komplikacijų dažnis buvo 3,6 karto didesnis ligonių, kurių PATI didesnis kaip 25 (p < 0,001), o mirštamumas – net 12,8 karto (p < 0,005). Išvados Atviri plonosios žarnos sužalojimai diagnozuoti 11,7 % ligonių, operuotų nuo atvirų pilvo ertmės organų trauminių sužalojimų. Plonosios žarnos sužalojimai sudaro 18 % atvirų pilvo sužalojimų. Lengvesnių sužalojimų (I–III laipsnio) komplikacijų dažnis 3 kartus mažesnis nei sunkesnių (IV–V laipsnio). Pooperacinių komplikacijų dažnį ir mirštamumą taip pat lemia gretutinių organų sužalojimai ir nestabili hemodinamika. Penetruojančios pilvo traumos indeksas (PATI) – statistiškai patikimas pooperacinių komplikacijų ir mirštamumo vertinimo rodiklis. Didesnis už 25 PATI rodo didelę pooperacinių komplikacijų ir mirštamumo riziką. Prasminiai žodžiai: atviros pilvo traumos, plonosios žarnos sužalojimai, pooperacinės komplikacijos, mirštamumas, pilvo traumos indeksas. Penetrating small bowel injury Edmundas Gaidamonis, Juozas Stanaitis, Sigitas Tamulis, Robertas Saltanavičius, Rytis Tutkus, Kazimieras Brazauskas, Aurelijus Grigaliūnas, Moisejus Racinas, Jonas Stasinas, Tomas Saladis, Raimundas Lunevičius Background / objective To evaluate the results of treatment of patients with penetrating small bowel injuries and to determine the main factors affecting postoperative morbidity and mortality. Methods Medical records for 126 patients admitted with penetrating small bowel injuries between 1982 and 1998 were reviewed. The patients' age, ASA grade, presence of shock, method of diagnosis, injury grade according to OIS, penetrating abdominal trauma index, operative management, morbidity and mortality were taken into consideration. Results Isolated injuries were found in 47 cases (37.3%). Twenty patients (15.9%) had associated injuries of the organs of the other systems. Postoperative complications developed in 32 patients (25.4%), 6 patients died (mortality rate 4.8%). Postoperative complications were more frequent in patients with grade IV–V versus grade I–III of injury (60% versus 23.4%, p < 0.01). The complications were less in cases of a proximal part of small bowel injury (21.4%), versus a 36.5% complication rate in patients with injuries of the middle and distal parts of the small bowel (p = 0.05). The rate of postoperative complications was 3.6 times higher in patients with PATI over 25 than in patients with PATI from 2 to 25 (p < 0.001); the mortality rate was almost 12.8 times higher (p < 0.005). According to ASA, the rate of postoperative complications and mortality was 11.9% versus 52.9% (p < 0.01) and 1.8% versus 23.5% (p < 0.005) respectively in patients with ASA grade I–III and grades IV–V. Haemodynamical stability had no statistically reliable influence on the postoperative complication rate (40% in stable and 22.6% in unstable haemodynamic patients), but it had a statistically significant influence on mortality rate (15% with unstable and 2.8% with stable haemodynamics, p = 0.05). Conclusions Penetrating small bowel injuries were detected in 11.7% of patients operated on for abdominal trauma and in 18% of patients due to penetrating abdominal injuries. Isolated injuries were found in 37.3% of cases. Most of the patients were haemodynamically stable (84.2%), with grades I–III of injury (88.1%). The operation option was associated to the grade of the injury: primary repair was performed in 86% and resection in 13.5% of cases. The higher risk of complications and mortality rate was associated with a poor general condition (ASA grade IV–V), unstable haemodynamical status, grade of injury more than III, PATI more than 25, and injuries of the distal part of the small bowel. Tube enterodecompression had no influence on the suture insuffitiency rate. Keywords: penetrating abdominal trauma, small bowel injury, postoperative morbidity, mortality, abdominal trauma index.

Abdominal trauma is relatively uncommon in children but can leads to a significant morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children. We are reporting a case of a child with multiple solid organ injury that was successfully treated non-operatively at our center. We presented a previously healthy 9-month-old girl, presented with fluctuating GCS secondary to motor vehicle accident with borderline hemodynamic stability. She was intubated, blood transfusion commenced and a single inotrope support started. She subsequently diagnosed with grade III liver injury, grade II splenic injury, right grade IV renal injury with large perinephric and retroperitoneal hematoma and moderate hemoperitoneum, a non-displaced left superior pubic rami fracture and cerebral edema on computed tomography (CT). She was admitted to pediatric intensive care unit (PICU). Her intra-abdominal injury injuries were successfully treated conservatively. She required a right chest tube on post trauma day 2, for right hemothorax. The chest tube was removed 3 days later following adequate drainage. She eventually was weaned off from ventilator on post trauma day 11. Feeding was commenced on day 7 of post trauma. She was discharge home well after 3 weeks post trauma with periodical follow up. Conclusion: Pediatric intra-abdominal solid organ injury is relatively uncommon, but a potential source of significant morbidity. Non-operative management is the standard of care for the majority of these injuries, which have shown successful rate more than 95%, although continued hemodynamic instability mandates operative intervention.

Abstract Introduction Laparoscopy is the gold-standard approach to elective abdominal surgery. Nevertheless, its application to abdominal trauma, including the treatment of haemoperitoneum, has been historically challenged by links to missed injuries. The European Association for Endoscopic Surgery does not clearly recommend therapeutic laparoscopy in trauma, despite the recognised potential benefits, in light of the scarcity and poor standardisation of available evidence. Case description A 68-year old male, presented with worsening shortness of breath and ascites. He was in type-2 respiratory and renal failure on a background of decompensated heart failure. He was admitted to the ITU for circulatory and ventilatory support and underwent ascitic drainage, removed on day 2. On day 3, the patient became peritonitic, exhibited a haemoglobin drop and went into class 2 haemorrhagic shock. A CT-abdomen showed moderate haemorrhagic ascites. An emergency laparoscopy was undertaken, which revealed active bleeding from the left lower abdominal wall. Haemostasis was achieved with ligation and electrocautery of the deep inferior epigastric perforators. Post-operatively, the patient showed a sustained clinical improvement. On day 4 he was stepped down to the ward and on day 10 discharged without further complications. Discussion Therapeutic laparoscopy is efficacious and safe in selected cases of intra-abdominal trauma, as revealed by emerging literature. The haemodynamic stability of the patient is not always a pre-requisite, and the patient's preoperative comorbidities can be key in deciding in favour of laparoscopy. We underline the following important conditions for success: an experienced surgeon, a systematic approach, suitable equipment and short time to surgery.

Abstract Endovascular management of splenic blunt trauma is widely accepted as a safe and effective alternative to open surgery in carefully selected patients. Following a radiologically successful intervention, patients are normally discharged with no follow up after 48-72 hours of haemodynamic stability and satisfactory serial haemoglobin levels. We present a case of a fit and well 24-year-old male patient who presented with abdominal pain, syncope and haemodynamic instability 14 days post successful splenic artery coil-embolization for splenic artery aneurysm rupture secondary to blunt trauma. After initial resuscitation, computed tomography angiography was performed and demonstrated active bleeding from the splenic artery aneurysm which was deemed likely to be a consequence of retrograde filling. The patient underwent successful emergency re-embolization using a combination of embolization coils and Onyx via a trans-splenic approach to eliminate retrograde flow. On further review of the imaging, it was incidentally noted there was evidence suggesting a diagnosis of median arcuate ligament syndrome, which may have predisposed the patient to splanchnic artery aneurysm formation. This case report highlights a potential limitation of endovascular management compared to open surgery and summarises the literature surrounding splenic artery anatomical variations and the implications of median arcuate ligament syndrome. A re-bleed following embolization is a hostile prospect with potentially catastrophic outcomes for patients if not recognised quickly. The authors propose that interval re-imaging should be considered following endovascular management of blunt splenic trauma.

Abstract Introduction The liver is the most commonly injured intra-abdominal organ and occurs in 30% of patients undergoing laparotomy for penetrating injuries and in 15–20% of laparotomies for blunt injuries. CT scan is the investigation of choice for accurate diagnosis and categorization of hepatic injury. Management of isolated liver trauma can be by operative or non-operative management, guided mainly by haemodynamic stability of the patient irrespective to category of injury. Close observation of patients undergoing non-operative management is important; they may develop early complications that require operative intervention, including bleeding, bile leak and peritonitis. Methods A questionnaire will be sent to the General Surgery consultants and registrars within the North East of England, a region with eleven hospitals taking General Surgical admissions, two of which are regional trauma centres. This is to assess the understanding of liver trauma classification and management and their familiarity with and adherence to the regional liver trauma guidelines. Following this, the guidelines will be distributed throughout the region with accompanying teaching sessions. A follow up questionnaire will determine the improvement of regional knowledge and use of the guidelines. In parallel, the outcome of liver trauma patients within the region will be sought to look for correlation between the education and the patient’s outcome. Results Regional distribution of the results will demonstrate the change in the education of liver trauma management and the subsequent change in patient’s outcome. Results will be recorded using Excel and analysed using SPSS statistical software.

Abstract Aim Pancreatic injury, a rare consequence of blunt abdominal trauma, is associated with significant morbidity and mortality when the appropriate management is delayed. Due to the rarity of the injury, there is currently a lack of evidence to establish a treatment pathway for adults. The aim of this review was to compare outcomes following non-operative and operative management of adults who suffered blunt pancreatic trauma injuries. Method An electronic literature search was performed from 2008 to 2020. Studies pertaining to adults sustaining blunt pancreatic injuries, of all grades (I-V) of severity, according to the American Association for the Surgery of Trauma, were included. The primary outcome was mortality, whilst secondary outcomes were components of pancreas specific morbidity. 1501 studies were initially identified and screened, and 11 studies were included in the review. Results Qualitative analysis showed an increase risk of mortality with increased severity of injury, and in the operative group compared to non-operative group. All patients who were haemodynamically unstable underwent immediate operative management, whereas the management strategy for patients with haemodynamic stability differed between the studies and depended on either the grade of injury, presence of other organ injury, or failure of initial management strategy. Conclusions This systematic review largely reaffirmed accepted practice in determining operative versus non-operative treatment for blunt pancreatic injury. Larger institutional analyses are required to add strength to the evidence supporting non-operative management for grade III or IV injuries with appropriate monitoring and subsequent intervention if required.

The spleen is an organ commonly injured in abdominal trauma of the upper left quadrant and until just under two decades the first choice was always splenectomy; however, based on new research and clinical experience, there is a tendency to preserve the spleen as much as possible, precisely because of its immune function and risk of infection. On the basis of the trauma and of the patient’s anamnesis, after an objective examination, the primary ABCDE evaluation, the Eco-FAST, and if necessary also the CT scan (with contrast), it is possible to choose between surgical (OM) and non-surgical (NOM) management: in the first hypothesis are included total or partial splenectomy surgery, raffia, direct hemostasis through drugs or devices with hemostatic-adhesive action, and laparoscopy; in the second hypothesis are included treatments such as controlled nutrition, rest, anticoagulant drug therapy (and antibiotic, if necessary), and angioembolization (exclusive or accessory to a NOM). In particular, in the last few years, a dual interpretation has emerged on the findings necessary to favour splenectomy (total or partial) over angioembolization. From the best clinical practice emerges therefore the answer to the question at hand, namely that the patient is a candidate for angioembolization if 1) is hemodynamically stable (with systolic blood pressure > 90 mmHg, heart rate < 100 bpm, and transfusion of < 3 units of blood in 24 hours) or stabilizable (positive response to rapid infusion of 1000-2000 cc of crystalloids-Ringer Lactate-with restoration of blood pressure and heart rate values in the range of hemodynamic stability); 3) there is no open trauma to the abdomen or evidence of vasoconstriction (cold, sweaty skin, decreased capillary refill) or obvious intestinal lesions or perforative peritonitis or high-grade lesions to the spleen or peritoneal irritation or signs of exsanguination or contrast blush or effusion (exceeding 300ml) detected by Eco-FAST. This preference is optimal concerning both the risks of postoperative infection and immunological risks; finally, age and head trauma, compared to the past, seem to be no longer discriminating conditions to favour splenectomy regardless. Splenic immune function is thought to be preserved after embolization, with no guidelines for prophylactic vaccination against encapsulated bacteria. Other clinical signs finally, however, might argue for discontinuation of NOM treatment in favour of a surgical approach: 1) need to transfuse more than 3 units of blood or simply the need for transfusion in 24 hours to maintain a maximum systolic blood pressure greater than 90 mmHg, correct anaemia less than 9 g/100 ml, or a hematocrit less than 30%; 2) persistence of paralytic ileus or gastric distension beyond 48 hours (despite a nasogastric aspiration); 3) increased hemoperitoneum (on ultrasound or CT); 4) aggravation of the lesion evidenced by ultrasound and/or CT (so-called “expansive” lesions); and 5) subsequent appearance of signs of peritoneal irritation. A complete understanding of post-embolization immune changes remains an area in need of further investigation, as do the psychological and mental health profiles of the surgical patient.

L emoperitoneo è la presenza di sangue libero in peritoneo. Può essere classificato in: a) traumatico,b)iatrogeno, c) spontaneo. I traumi addominali sono la causa più frequente di emoperitoneo, con un incidenza del 20% è più frequente nei traumi chiusi dell addome (70-80% dei casi); a carico di organi parenchimatosi, milza (55%), fegato (35%), rene e vie urinarie (15%), mesentere (10%), piccolo intestino (8%).La presenza di sangue libero in cavità addominale, pone al chirurgo non pochi problemi sia gestionali che terapeutici.