Conservative approach in the management of isolated penetrating liver trauma

Damage to the liver is the most common cause of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma. In the case of penetrating injury, non-intervention management has not been adequately addressed. Selective non-operative management of stab wounds especially to the liver has been reported. This study was carried out from May 2006 to April 2011 at the Main Alexandria University Hospital, Faculty of Medicine, Alexandria, Egypt. This study consisted of 62 liver trauma patients and the following data were collected: demographics, mechanism of injury, pre-hospital care, hemodynamic status, grade of hepatic injury, associated injuries, failure of non-operative [NOP] management, hospital stay in intensive care unit [ICU] or in the ward and death. Patients were eligible for the study if they sustained isolated penetrating right hypochondrial injury. Assessment of hemodynamic stability was based on routine vital signs. Injury severity was determined from CT and classified by means of the Liver Injury Scale. This study was carried out for 62 consecutive patients with hepatic trauma in a five year period. Mean age was 33.6 years with a range of 16-54 years. The isolated penetrating liver injuries included knives, guns [gunshot and shotgun injuries] and other sharp objects. All patients were treated successfully via NOP management except five patients [8%] who failed NOP management. These five patients were hemodynamically unstable and were unresponsive to crystalloid and blood transfusion. The five patients underwent surgery [suturing, packing, and resectional debridement]. Two patients [3.2%] died because of high grade liver injury. The overall actuarial one-year survival in NOP management was 96.8%. Low grade penetrating hepatic injuries [G I-III] can be managed non-operatively with excellent results; even G IV penetrating liver injuries with hemodynamically stable patients can be managed safely non-operatively

Role of multi-slice CT angiography in the diagnosis of mesenteric vascular disorders

The diagnosis of mesenteric ischemia is a challenge to both clinicians and radiologists. Angiography is considered the standard of reference for the diagnosis of mesenteric ischemia; however, it is an invasive, time-consuming and may cause morbidity. Doppler ultrasonography is not useful in evaluating venous mesenteric ischemia. A detailed examination of the small bowel and mesenteric vessels is now possible to perform with the introduciion of multi-slice CT and three-dimensional [3D] imaging. This study was designed to evaluate the role of Multi-slice CT angiography [CTA] as an imaging tool in the diagnosis of the various mesenteric vascular disorders in patients with suspected mesenteric ischemia and its impact on management decision. A total of 43 consecutive patients who had been admitted to the Alexandria university hospital, emergency and general surgery departments from November 2005 through August 2006 who were presented with cither acute or chronic abdominal pain and were clinically suspicious for mesenteric ischemia were included in the study. All patients were subjected to thorough history taking and clinical examination, routine laboratory investigation, erect and supine plain abdominal radiographs and abdominal sonography. Multislice CT [MSCT] angiography was performed to all patients using 6 detector row scanner. Each patient received 120-140 mL of contrast material and multiplanar reconstruction [MRP], maximum intensity projection [MIP], Shaded surface display [SSD] and volume rendering [VRT] was obtained. Only 16 patients [12 males and 4 females] out of the studied 43 patients had an abnormal Multi-slice CT angiographic [CTA] findings diagnostic of mesenteric ischemia as the etiology of the pain and they constituted the material of this study. Their ages ranged from 52 -79 years [mean 65.5 years], 12 patients [75%] had chronic abdominal pains while only 4 patients [25%] were presented with an acute abdomen. Multislice CT angiography [CTA] showed arterial stenosis in 9 patients with stenosis of the main trunk of the superior mesenteric artery [SMA] in 8 patients and of the inferior mesenteric artery [IMA] in one patient. Complete arterial thrombotic occlusion was reported in 6 patients and involved the main trunk of the SMA in 2 patients, IMA in 2 patients, and the ileo-colic and jejunal branches of the SMA in 2 patients. Venous mesenteric thrombotic occlusion was detected in one patient with hepatic cirrhosis and portal hypertension. Surgical exploration was performed for 3 patients who presented with acute abdomen and CTA diagnosis of arterial thrombosis. At surgery there was occlusion of the main trunk of the SMA in two patients and the ileo-colic branch in the third patient. Resection of infracted small bowel loop was performed. Medical treatment with anticoagulant and vasodilators were the regimen applied to the rest of patients. Multislice CTA with 3D reformatting displayed vessels similar to traditional angiography and should be applied in the protocol of abdominal CT examination of patients with acute or chronic abdominal pains. The increased speed and narrower collimation of Multislice CT, coupled with timed I. V contrast and the use of water as an oral contrast agent, improved visualization of the mesenteric vasculature in all patients with suspected acute or chronic mesenteric ischemia

T.B and pyogenic neck infection: different patterns in CT examination

The aim of this work was to illustrate the different CT patterns of neck infections. This study included 28 patients with suspected neck infection were referred to the Radiodiagnosis Department. They were subjected to history taking, clinical examination and multislices computed tomography [CT] evaluation with contrast. 28 patients were included in this study, 19 males and 9 females, their age ranged from 2-73 years. The different affected neck spaces were as follows: 12 peritonsillar, 7 submandibular, 7 parapharyngeal, 4 retropharyngeal, 2 sublingual, 4anterior cervical, 1 posterior cervical, and 1 parotid space. Lymph nodal abnormalities were identified in 9 patients. Nine patients with chest involvement as mediastinal extension in 6 patients, lung parenchymal lesions 2, one with mediastinal lymph nodes. CT is sufficient in detection of the extension of various neck infections. CT chest in the same sitting with CT neck may add information about the extension of the disease or can give a due to the diagnosis

Gastroenterology surgical unit experience in hepatic resection for liver tumors

Hepato-cellular carcinoma [HCC] is the fourth most common malignant tumor in the world and is responsible for an estimated one million deaths annually. This study was carried out on 35 patients with hepatic tumors. The aim was to study the impact of the underlying liver disease, tumor pathology, and extent of resection on the outcome of hepatic resection for liver tumors. All patients were subjected to complete history taking, thorough clinical examination, laboratory and imaging studies followed by hepatic resection based on the preoperative data. Follow up of patients was done to determine the perioperative complications, disease-free period, overall survival, tumor recurrence and tumor-related deaths in cases of malignant liver tumors. The indications for hepatic resection were haemangioma [in 2 patients], HCC [in 27 patients] and secondary malignancy [in 6 patients]. Hepatic resections were hemi-hepatectomy in 16, extended hepatectomy in 4 and left lateral lobectomy in 7. The remaining 8 cases included resections of one to three segments or consisted of non-anatomical wedge resections. 23 patients had no perioperative complications. Minor morbidity occurred in 8 patients and major morbidity in 4 patients. There were 2 perioperative deaths. The median survival in patients who underwent hepatic resection for HCC was 30.6 months [15.07-46.17] and the survival rates at 1, 3 and 5 years were 83.3, 63.6 and 34.1% respectively. There is now ample evidence that surgical resection, if possible, remains the best option for treating malignant liver tumors as it offers the best hope of cure in such patients

Evaluation of plasma elastase, D-dimer and fibrin degradation products in comparison to doppler ultrasonography in the diagnosis of patients with deep vein thrombosis

The present work aimed at evaluating the usefulness of plasma elastase, D-dimer and fibrin [ogen] degradation products [FDPs] in comparison with doppler ultrasonography for the diagnosis of deep vein thrombosis [DVT] among 20 adult patients who were admitted to the emergency unit of Alexandria main University hospital with symptoms and signs suggestive of DVT. 10 healthy age and sex matched controls were also enrolled in this study. Plasma elastase, D-dimer were estimated by ELISA technique while FDPs by semiquantitative latex agglutination. They were done at presentation and 10 days after heparin therapy while they performed once in control group. It was found that the mean values of plasma D-dimer elastase and FDPs were significantly higher than those in control group both before [P[1]< 0.0001] and after therapy [P[2]< 0.0001] respectively. Post heparin therapy, the mean values of same parameters were significantly decreased when compared with pretreatment mean values using paired t-test [p= 0.000] for D dimer, elastase and FDPs respectively. As regards the extent of thrombus diagnosed by doppler ultrasonography, there was a significant increase in the mean values of D-dimer in proximal and all DVT than those in distal DVT while there was no significant difference between plasma elastase and FDPs and the extent of thrombus. A significant positive correlation was found between plasma D-dimer and elastase both before [r=0.845, p=/< 0.0001] and after heparin therapy [r= 0.764, p= 0.000]. No significant correlation was found between FDPs and the previous two parameters neither before nor after treatment. Doppler ultrasonography is a definitive test for diagnosis and localization of thrombus in DVT. Plasma D-dimer, elastase and FDPs can be used for initial evaluation of DVT suggestive patients in the emergency unit and further studies are needed to clarify their role in predicting the recurrence of DVT