Management of liver trauma in RIPAS Hospital

Introduction: The management of blunt and penetrating liver trauma continues to pose a tremendous challenge to surgeons. This study reviews the pattern of liver trauma and its management, both operative and non-operative, in RIPAS Hospital, the only tertiary referral center in Brunei Darussalam. Material and Methods: A retrospective study of patients admitted with liver trauma, with and without other associated injuries between January 2002 and December 2006 to RIPAS Hospital was undertaken. The patients' case records were retrieved. Details on age, sex, mode of injury, pre-operative imaging, severity of liver injury based on the Liver Injury Scale (LIS, grades I to VI), presence of other associated injuries, overall management, complications and outcome were collected and analysed. Results: Twenty patients (male, n = 12) with a mean age of 36 years old (range 20 to 75) were treated for liver trauma (median LIS grade of III, range I to V) during the study period. Road traffic accidents accounted for 75% of the injuries. Thirteen (65%) had high grade injuries (≥ LIS grade III). Seventeen (85%) patients underwent surgical procedures for liver and other associated injuries. Four patients (20%) had non-operative management with one failure (5%). This patient subsequently required surgery. There were six post-operative deaths (mortality 30%). There were three major morbidities (15%): right hepatic artery aneurysm, a right hepatic duct bile leak and left hemiplegia secondary to cerebrovascular accident. Conclusions: In our local setting, blunt liver trauma is often due to road traffic accidents and is associated with a high mortality rate. A majority was of high grades and required urgent surgical interventions. Non-operative management is an option for those with low grade injuries and who are stable.

Evaluation of the RIPASA Score: a new appendicitis scoring system for the diagnosis of acute appendicitis

Introduction: We recently developed a scoring system for diagnosis of acute appendicitis. This study prospectively evaluates the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score for the diagnosis of acute appendicitis in patients presenting to the Accident & Emergency department or the Surgical wards with right iliac fossa pain. Materials and Methods: From November 2008 to April 2009, consecutive patients presenting to the Accident & Emergency department or the surgical wards with right iliac fossa pain were recruited for the study. The RIPASA score was applied but the decision for radiological investigations or emergency appendicectomy was made based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived. Ethical approval for the study was obtained from the Medical & Health Review Ethics Committee. Results: Within six months, 144 consecutive patients with a mean age of 29.5 ± 13.3 yrs were recruited to the study. Ninety-eight patients underwent emergency appendicectomy of which 79 were confirmed histologically for acute appendicitis. The observed negative appendicectomy rate was 19.4%. The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. The predicted negative appendicectomy rate was 13.5%, which is a 5.9% reduction from the observed rate of 19.4% (p=0.3). Conclusion: The RIPASA score is a more suitable appendicitis scoring system developed for our local settings with a population that is reflective of our region in South-east Asia and has high sensitivity, specificity and diagnostic accuracy.