Impacto da introdução da angioembolização para o tratamento não operatório do trauma esplênico contuso grau III e IV no Hospital João XXIII, Belo Horizonte / Brasil / Impact of the introduction of angioembolization on nonoperative management of blunt splenic trauma grades III and IV at Hospital João XXIII - Belo Horizonte/Brazil

Objetivo: Comparar o sucesso do tratamento não operatório da lesão esplênica contusa graus III e IV, antes e após a introdução da angioembolização como método adjuvante. Métodos: Os dados foram coletados do prontuário eletrônico de pacientes com lesões esplênicas contusas graus III e IV (exceto hematoma subcapsular), segundo classificação da AAST (American Association for Surgery of Trauma), submetidos ao tratamento não operatório no Hospital João XXIII no período de janeiro/2014 a julho/2017. Os dados foram comparados a uma série de casos dessas mesmas lesões entre novembro/2004 e dezembro/2013 na mesma instituição, quando a angioembolização não era utilizada. O nível de significância do estudo foi 5% e seu desfecho foi a falha do tratamento não operatório. As análises foram feitas nos software R3.6.3 e MINITAB versão 14. Resultados: Entre novembro/2004 e dezembro/2013, foram estudados 389 pacientes em tratamento conservador, sendo 332 (82,8%) com lesão esplênica contusa grau III e 67 (17,2%) grau IV, havendo falha no tratamento (necessidade de esplenectomia) em 36 (11%) com lesão grau III e 22 (33%) com lesão grau IV. No período de janeiro/2014 a julho/2017, quando da disponibilidade da angioembolização, 195 pacientes foram submetidos a tratamento conservador, sendo 110 (56,4%) com lesão esplênica contusa grau III e 85 (43,6%) grau IV. Desses, houve falha no tratamento em 4 (3,6%) com lesão grau III e 6 (7%) com lesão grau IV. Conclusão: O tratamento não operatório do trauma esplênico contuso associado à angioembolização apresentou redução, com significância estatística, da necessidade de esplenectomia nas lesões esplênicas graus III e IV.

Objective: Compare the success of non-operative treatment of blunt splenic injury grades III and IV, before and after the introduction of angioembolization. Methods: Data collected from electronic medical reports of patients presenting blunt splenic injury (BSI) grades III and IV (subcapsular hematoma was not included), according to AAST (American Association for Surgery of Trauma) classification and undergoing nonoperative management at Hospital João XXII from January 2014 to July 2017. Data was compared to a case series of these nonoperative injuries from November 2004 to December 2013 at the same institution, when angioembolization was not used. The study level of significance was 5% and outcome was failure of non-operative treatment. Analyses were made using the software R3.6.3 and MINITAB version 14. Results: From November/2004 to December/2013, 389 patients undergoing conservative treatment were studied, 332 (82,8%) of which presented with blunt splenic injury grade III and 67 (17,2%) had lesions grade IV, treatment failure (need for splenectomy) occurred in 36 (11%) patients with injury grade III and 22 (33%) with grade IV. From January/2014 to July/2017, when angioembolization was available, 195 patients underwent conservative treatment, 110 (56,4%) with blunt splenic injury grade III and 85 (43,6%) with grade IV. In this group, treatment failed in 4 (3,6%) with injury grade III and 6 (7%) grade IV. Conclusion: Nonoperative management of blunt splenic trauma associated with angioembolization is associated with a reduction in splenectomy in splenic injuries grades III and IV.

Manejo conservador en diverticulitis aguda perforada con aire extraluminal / Conservative management of perforated diverticulitis with extraluminal air

Resumen Introducción: El tratamiento óptimo de la diverticulitis perforada con aire extraluminal (DPA) es materia de debate. El manejo conservador es controversial; en casos seleccionados puede ofrecer menor morbimortalidad y evitar una ostomía. Objetivo: Describir las características clínicas, imagenológicas, necesidad de intervención quirúrgica y morbimortalidad de pacientes con DPA tratados con manejo conservador. Materiales y Método: Estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de DPA hemodinámicamente estables sin evidencia de peritonitis entre los años 2009 y 2015. Resultados: Se hospitalizaron 162 pacientes con diagnóstico de diverticulitis aguda (DA), el 53,1% fueron diverticulitis agudas complicadas (DC), de las cuales el 43% (37 casos) eran DPA, la edad promedio fue 59,6 años, la mayoría eran mujeres (54,1%). Las manifestaciones clínicas más comunes fueron dolor abdominal (97,3%), signos peritoneales (59,5%) y fiebre (40,5%). La tomografía axial computada de abdomen y pelvis (TC AP) mostró burbujas extracolónicas en el 78,4% y neumoperitoneo en el 21,6%. El manejo conservador fue exitoso en el 87,8%. Durante el seguimiento de 71,2 meses la recurrencia fue 28,1% y el 31,3% se realizó sigmoidectomía electiva. La falla del tratamiento médico se presentó en 5 casos (12,2%), uno de los cuales fallece. Conclusión: el manejo conservador de la DPA es una alternativa válida de tratamiento con alto porcentaje de éxito en pacientes hospitalizados seleccionados. La decisión de cirugía de urgencia y de sigmoidectomía electiva posterior a una DPA tratada médicamente debe ser individualizada.

Background: The conservative management of perforated diverticulitis with extraluminal air (PDA) is controversial. In selected hospitalized patients may offer less morbidity and mortality and avoid an ostomy. Aim: To describe its clinical and imagenologic characteristics, the need for surgical procedure and morbimortality of patients with perforated diverticulitis with extraluminal air in conservative management. Materials and Methods: Retrospective descriptive study of hemodynamically stable hospitalized patients with a PDA diagnosis without evidence of peritonitis during the years 2009 and 2015. Results: 162 patients were admitted with the diagnosis of acute diverticulitis. 53.1% of cases were acute complicated diverticulitis, 43% (37 cases) were PDA. The average age was 59.6 years and most of them women (54.1%). The most common clinical manifestations were abdominal pain (97.3%), peritoneal signs (59.5%) and fever (40.5%). The abdomen and pelvic computerized axial tomography scan showed extra-colonic bubbles in 78.4% and pneumoperitoneum in 21.6%. The conservative management was successful in 87.8% of cases. After a 71.2-month follow-up, the recurrence was 28.1% and 31.3% had an elective sigmoidectomy. 5 cases did not respond to medical treatment, one of them resulting in death. Conclusion: The conservative management of PDA is a valid treatment option with a high degree of success in the selected sample of hospitalized patients. The decision of having emergency surgery and elective sigmoidectomy post DPA should be evaluated individually.

Are radiological modalities really necessary for the long-term follow-up of patients having blunt solid organ injuries? A single center study / 世界急诊医学杂志（英文）

@#During the past two decades, management of blunt solid organ injuries had shifted from conventional surgery to more conservative approach, namely nonoperative management (NOM).[1] The non-operative approach mainly depends on the trauma experience of surgeons and the institution, quality of radiographic imaging and its interpretation.[2-5] If the surgeon decides to observe the patients by NOM, close monitoring of vital signs and frequent physical examinations must be done accordingly with radiological evaluations if needed.

Hip fractures in the elderly: operative versus nonoperative management

<p><b>INTRODUCTION</b>Hip fractures are common in the elderly. Published studies have not shown significant differences in mortality rates between hip fracture patients who were managed nonoperatively and operatively. This retrospective study looked at 340 patients with hip fractures who were admitted to a local hospital over one year, and compared the long-term mortality between those treated operatively and nonoperatively.</p><p><b>METHODS</b>All patients with hip fractures were identified retrospectively from the hospital's hip registry. Mortality data was collected through nationwide electronic medical records and telephone interviews.</p><p><b>RESULTS</b>Overall mortality rates at one (14.4%) and two years (24.4%) were comparable to those of other studies. Hip fracture patients who were treated nonoperatively had a higher risk of mortality at both one (29.8%) and two years (45.6%) after fracture (p < 0.05). Their risk of mortality was four times higher at one year and three times higher at two years after fracture than the operative group. Patients with a higher American Society of Anesthesiologists (ASA) grade did not show an increased risk in mortality compared to patients with a lower ASA grade at both one year (p = 0.072) and two years (p = 0.360) after fracture.</p><p><b>CONCLUSION</b>Elderly patients with hip fractures should be managed surgically and counselled regarding the increased risk of mortality if treated nonoperatively.</p>

Extension of Nonoperative Management on Spleen Injury with Judicious Selection and Embolization; 10 Years of Experience

PURPOSE: We describe clinical outcomes of NOM on spleen injuries with judicious selection and embolization during the past 10 years. METHODS: From March 2000 to November 2009, 151 patients with splenic injury were included. Eighteen patients were excluded because of incomplete data. Patients' medical records were reviewed to examine admission demographics, laboratory results, radiologic findings as well as transfusion requirement, hospital stay, and ultimate outcomes. RESULTS: Twenty patients were chosen for non-operative management (NOM) after splenic embolization and 1/20 (5%) patient failed. There were 32 patients more than 55 years old (range, 55~87 years). Of these patients, 26 (81%) patients were chosen for NOM and 3 (11.5%) patients failed. According to OIS, 51 patients were grade 3; 26 patients, grade 4; and 6 patients, grade 5. Among grade 3, 49 (96%) were chosen for NOM with or without embolization and 1 (2%) patient failed; grade 4, 19 (73%) with NOM, 2 (7.6%) patients failed. Of all 133 patients with NOM or failed NOM (FNOM), there was 0 mortality in grade 3; 2, in grade 4; 2, in grade 5, excluding other causes of death. The mean ISS was significantly higher in the failed NOM group compared with successful NOM group (P=0.01). The group of failed NOM had a significantly higher mean OIS (P=0.00). CONCLUSION: Aggressive but highly selective NOM on the base of clinicoradiologic parameters with the aid of angioembolization would result in a low failure rate and complication in the management of high grades (grade 3 or 4).

Twenty-year experience in the diagnosis and treatment of hepatic trauma / 国际外科学杂志

Objective To summarize the experience in the diagnosis and treatment of hepatic trauma. Methods The clinical data of 260 patients with hepatic trauma admitted from January 1988 to December 2007 were retrospectively reviewed with regard to degree of trauma, treatment methods, therapeutical effects, complications and SO on. Results One hundred and fifty-three eases were treated by operative management,1 07 cases by nonoperative management.236 cases were cured,24 cases died,and the case fatality rate was 10.2%.There were no death among 139 patients with hepatic trauma grades Ⅰ～Ⅱ,22 death among 119 grades Ⅲ～Ⅴ patients, all death of 2 in grade VI, which demonstrated the correlation between death and hepatic trauma grade was statistically significant. Complications appeared in 82 eases, mainly including Secondary hemorrhage, abdominal infection and so on. Conclusions Nonoperative management is suitable for hepatic trauma with stable hemodynamics. Operative management is rapidly selected when the hemodynamics aren't stable. The cooperation of many specialities can enlarge the application of nonoperative management and decrease complications.

Nonoperative Treatment of Thoracolumbar Fractures without Neurological Deficit / 中国康复理论与实践

@#Objective To evaluate the clinical effect of postural reduction and bracing on thoracolumbar fractures without neurological deficit.Methods21 patients with thoracolumbar fractures(T11～L2

Nonoperative Management Guideline of Liver Injury

Management of liver injury has significant evolved over the last two decades. Operative management is the standard treatment in liver trauma. One of the major reasons for operative management of liver injury is ongoing hemorrhage. However, the majority of the liver injuries stop bleeding spontaneously, and computed tomography (CT) has become increasingly affordable and valuable. As a consequence of these changes, nonoperative management of isolated liver injury in a hemodynamically stable patient is reasonable. Criteria for nonoperative management of liver injuries include hemodynamic stability, absence of a clear indication for laparotomy such as peritoneal signs, low grade liver injuries, and transfusion requirements of less than two units of blood. These criteria have been challenged, and more broad indications have since been used, followed by serial hematocrit and vital signs rather than physical examination. Injury grade, hemoperitoneal degree, neurologic status, and presence of associated injuries are not contraindications to nonoperative management of liver injury. Abdominal CT is the most reliable test used to identify and assess the severity of blunt liver injuries. More recently, arteriography with embolization is a useful adjunct for nonoperative management prior to exploration in the hemodynamically stable liver injury patient who continues to bleed. Advantages of nonoperative management are: avoidance of non-therapeutic celiotomies, fewer intra-abdominal complications, reduced need for blood transfusion, and decreased overall morbidity and mortality as compared with operative management. In conclusion, the nonoperative management strategy is an acceptable and safe treatment modality for the care of liver injury but remain hemodynamically stable, irrespective of the grade of injury or hemoperitoneal degree.

Blunt liver injuries in children: the role of nonoperative management

Background: Nonoperative management (NOM) is presently considered the treatment modality of choice for hemodynamically stable patients sustaining blunt liver trauma, especially in children. Objective: To evaluate role of NOM of blunt liver injuries (BLI) in children at National Hospital of Pediatrics. Subjects and method: Therecords ofallthe patientstreatedin National HospitalofPediatricswithfinaldiagnosisBLI betweenJanuary2000 and December 2006 were reviewed. The clinical signs,investigations,imagingstudies, methods oftreatmentandresultswereanalysed.Theliverinjuriesweregradedaccordingtothe American AsociationfortheSurgeryofTrauma(AAST).Results: There were15patients from one dayto 12 years of age with average BLI grade 2.5; 14 patients with precise diagnosis BLI were atempted NOM, 1 neonate was operated with diagnosis intraabdominal haemorrhage (BLI grade II found intraoperatively). Two patients (BLI grade II and V) from the atempted NOM group were operated thereafter because of hemodynamical instability or continuing bleeding, the remained 12recovered well with average hospital stay of 7.5 days. The rate of succesful NOM for BLI in our series was 12/14 (85.7%). Conclusions: NOM can be applied safely for BLI in children with high successful rate. Patients\ufffd?hemodynamic status may be more important for treatment decision-making than the injury grade according to the AAST based on ultrasound or CT.

Treatment and Prognostic Factors for Traumatic Liver Injury

PURPOSE: Due to its size and locatin, the liver is frequently injured in abdominal trauma. Recently, nonoperative management for liver injuries has been extended due to the development CT imaging, intensive care units, and their equipment and techniques. Herein, patients with traumatic liver injury were analyzed to evaluate its treatment and prognostic factors. METHODS: From 2001, January to 2003, July, 65 patients at our facility were confirmed to have traumatic liver injury. The operative or nonoperative managements were decided on the basis of the systolic blood pressure if no peritoneal irritation sign was noted. If the systolic blood pressure was stable, or recovered to within the normal range following hydration and transfusion at the emergency room, patients were managed nonoperatively. Hemodynamically unstable patients were managed operatively. The data were analysed using the SPSS program (Chi-squared tests and logistic regression analyses). RESULTS: 48 patients were treated nonoperatively, with 3 mortalities. The overall mortality rate was 15.8%, but only 6.4% in the nonoperative management group, compared to 67% in operative management group. In a Multivariate analysis the systolic blood pressure was found to be a reliable factor in traumatic liver injury and the mentality and ISS (injury severity score) reliable in finding complications in the nonoperative management group. The mentality was found statistically reliable for determining mortality in the operative management group, with the exception for the systolic blood pressure. CONCLUSION: The systolic blood pressure was an important indicator when considering the treatment plan in traumatic liver injury. An extensive study will be required that incorporates both nonoperative and operative management groups.

Nonoperative Management of Liver Injury in Children / 实用儿科临床杂志

Objective To study the feasibility and indication of liver injury in children treated nonoperatively.Methods Ninteen(cases) with liver injury who underwent nonoperative management(NOM) were analyzed retrospectively.Patients with obvious trauma were reviewed.The main cause of trauma was due to traffic accident.Eleven cases(57.9%) had subcapsular hematoma and 8 cases(42.1%)had intrapararenchymatous hematoma.The treatment procedure included blood transfusion,hemostasis and monitoring the hemodynamic parameters.Results Seventeen cases(89.5%)were cured nonoperatively;2 cases underwent the operation later.Followed up for 10-24 months,patients were well recovered.Conclusions Most of cases with liver injury in children can be cured by NOM due to the physicalogical and anatomic features of children.During treatment,it is very important for the doctors to observe the vital signs closely,and(mana)-ge the combined injuries effectively and take regular imaging measurement.

Clinical study on thoracolumbar fractures without neurologic deficit treated with nonoperative management / 中国康复理论与实践

@#ObjectiveTo study the clinical outcome and efficacy of closed management of theoracolumbar burst fractures without neurologic deficits.Methods 20 patients with a burst fracture of thoracolumbar vertebrae but without neurologic deficit were reviewed clinically and radiographically following nonoperative management.ResultsAfter treatment, the averaged Cobb angle (8°)was better than that (18.5°) before treatment (P<0.01), and the averaged anterior body height (87.18%) was also better than that (50.68%) before treatment (P<0.01). In 12 patients, averaged occupying area of vertebra in vertebral canal was 27% before treatment and lowered 16% after treatment (P<0.01). During treatment period, one patient developed neurologic deterioration that prompted surgery. All other patients remained neurologically intact. After follow-up (average 2.5 years), an overall outcome evaluation indicated that 70% of patients had excellent outcomes relative to pain and function, 25% had good and 5% had poor outcomes.Conclusions These findings suggest that nonoperative management as the preferred treatment can use in above circumstances.

A Comparison of Safety between the Operative and Nonoperative Management of Traumatic Liver Injury

PURPOSE: The aim of this study was to evaluate the safety of the nonoperative management of traumatic liver injuries. METHODS: The medical records of 67 patients, with traumatic liver injury, between January 1998 and December 2001, were reviewed retrospectively, with respect to the cause of injury, combined injury, hemodynamic stability, amount of transfusion, liver injury grade, length of hospital stay and complications. RESULTS: Of the 67 patients, 30 were treated operatively (Group A), and 37 nonoperatively (Group B). The initial systolic blood pressure in Group A was significantly lower than that in Group B (81.33+/-23.00 vs 108.10+/-20.66 mmHg, P<0.001). The amount of transfusion for hemodynamic stability were 2.83 and 0.89 units (P<0.01), and the mean total transfusion requirement and injury grade were 10.30 and 1.29 units (P<0.001). 3.63+/-0.99 and 2.48+/-1.12 (P<0.001) for Groups A and B. The duration of intensive care unit stay in Group A was significantly shorter than that of Group B (6.70+/-6.12 vs. 3.13+/-4.00 days, P<0.01), but there was no difference in total length of hospital stay. The complication rates in Groups A and B were 63.3 and 21.8%, respectively (P<0.01), and the most common complications were respiratory problems, such as pleural effusion, pneumonia, atelectasis and pulmonary edema. Five patients in Group A died, 2 from hypovolemic shock, and one each from disseminated intravascular coagulation, multiple organ failure, and respiratory failure, but no patients in Group B died. CONCLUSION: Nonoperative management is safe for hemodynamically stable patients with traumatic liver injury, regardless of the injury severity, but close observation and frequent physical examinations must be adhered to.

Nonoperative management of adult blunt hepatic injury / 中国普通外科杂志

ObjectiveTo evaluate nonoperative management of adult blunt hepatic injury. MethodThe outcome of 132 cases with adult blunt hepatic trauma admitted in this hospital between Oct 1982 and Oct 2002 was analyzed. Thirty-four cases (25.8%) were treated by nonoperative management. Before 1995, only a portion of patients underwent CT scan and after 1995, diagnosis of liver injury was established by CT scan in all cases. ResultThe nonoperative management rate before 1995 was 16.7% (14/84) and after 1995, it was 41.7% (20/48)(P0.05). ConclusionWith the progress of image monitoring and life support system, some patients of blunt hepatic injury could be managed by conservation therapy.

Nonoperative Management and Follow-up of Hepatic and Splenic Injuries after Blunt Trauma

PURPOSE: This study evaluates the effectiveness of nonoperative management of blunt hepatic and splenic injuries and the efficiency of follow-up. METHODS: The medical records of 49 patients with blunt hepatic and splenic injuries from January 1, 1993, to November 30, 1999, were reviewed. There were 35 patients with hepatic injuries and 14 patients with splenic injuries. The patients were divided into two groups, early and late, according to the year of injury. The severities of the injuries were determined by using the organ injury scale (OIS). We analyzed radiological findings and clinical parameters, including the cause of injury, combined injuries, symptoms, vital signs, amount of transfusion, reason for operation, operative findings, length of hospital stay, and complications. The results of treatment and follow-up were evaluated. RESULTS: Of the 49 patients, 34 patients (69.4%) were treated nonoperatively. There were no mortalities and treatment failures in patients with nonoperative treatment. Indications of operation during nonoperative treatment were hemodynamic instability and signs of aggravated peritoneal irritation. Major hepatic venous injury was suggestive of hemodynamic instability. There was a significant difference between patients with nonoperative management and those with operative management in transfusion requirements (1.2 units vs. 12.1 units, p<0.05). The rate of nonoperative management increased from 50.0% (12/24) in the early group to 88.0% (22/25) in the late group, and nontherapeutic operation decreased from 16.7% (2/12) in the early group to 0% (0/3) in the late group. All 34 patients with nonoperative management took CT scans as a follow-up. In patients with grade I or II on the OIS, the lesions had nearly disappeared at 2 weeks after injury. However, in patients with grade III or higher, resolusion of the lesion was minimal. A hepatic cyst developed in one patient with grade IV and a splenic cyst developed in another. CONCLUSION: Hemodynamic stability and findings on serial physical examinations are significant criteria for nonoperative management of blunt hepatic and splenic injuries. In patients with grade I or II injuries on the OIS, a follow-up CT is not necessary. In patients with grade III or higher, it is more efficient to delay a follow-up CT until 3 weeks or later after the injury if there are no symptom suggesting complications.

The Study of Operative Indications of Blunt Hepatic Trauma

PURPOSE: Nonoperative management is currently considered a treatment modality in 50 to 80% of patients with blunt liver injury. Nevertheless 10 to 50% of patients need operative management, and the criteria for operative management have not established. The purpose of this study is to find criteria for operative management of patients with blunt liver injury. METHODS: The records of 117 patients who experienced blunt hepatic injury from January 1992 to April 1999 were reviewed retrospectively with respect to hemodynamic stability, transfusion requirement, injury severity score, liver injury grade, amount of blood in the peritoneal cavity, and pooling of contrast material on computerized tomography (CT). RESULTS: Among the 117 patients, 29 patients (25%) were treated operatively (Group 1) and 88 patients (75%) were treated nonoperatively (Group 2). The initial systolic blood pressure in Group 1 was significantly lower than that of Group 2 (74.4+/-30.3 mmHg vs 107.1+/-27.2 mmHg, p<0.001). The amounts of transfusion for hemodynamic stability were 2.1 units in Group 1 and 0.4 units in Group 2 (p<0.001). The injury Severity score of Group 1 was significantly higher than that of Group 2 (20.8 +/- 11.0 vs 10.7+/-6.8, p=0.03). The mean injury grade was 3.7+/-0.1 for Group 1 and 2.4+/-1.0 for Group 2, which was a statistically significant difference was seen (p<0.001). The amount of hemoperitoneum in Group 1 was significantly higher than that of Group 2 (p<0.001). The pooling of contrast material on CT was detected in 3 cases in Group 1. CONCLUSION: We can establish the following criteria for operative management: operative management is necessary for hemodynamic instability during resusci tation, positive peritoneal irritation signs, and presence of pooling of contrast material on CT. In cases above grade IV, above 500 mL of hemoperitoneum on CT, or above 2 units of blood transfusion during resuscitation, close observation in an intensive care unit is necessary. If abnormality develops during observation, prompt operative management is mandatory.

Effect of Transcatheter Arterial Embolization Nonoperative management of blunt splenic trauma

BACKGROUND: This study was to access the hemostatic effectiveness of transcatheter arterial embolization (TAE) in a blunt splenic injury. We evaluated the efficacy of using detailed angiographic examnination and embolization for the nonsurgical management of patients with spleen injury. METHODS: Blunt splenic injuries diagnosed by Computed tomography (CT) between January 1997 and December 1997 were prospectively studied according to our management algorithm. The first group (G1) consisted of patients who were observed only, the second grourp (G2) with consisted of patients receving a TAE, and the third group (G3) consisted of those receving a laparotomy. The criteria for a TAE were: 1) Type III or IV injury and 2) extravasation of contrast material revealed by CT. RESULTS: Of the total 46 patients with blunt splenic injury, 17 underwent emergency laparotomies because of associated injuries or unstable vital signs after resuscitation. Fourteen of the 17 had splenectomies and the other three had splenorrhaphies. The remaining 29 patients were considered for nonoperative management (63%), and 13 of them were selected for a TAE. Splenic angiography showed active bleeding in 12 and minor bleeding in one. The bleeding was successfully controlled by TAE in all 13 patients. Abdominal CT and scintigraphy taken after TAE disclosed well functioning spleens. The total splenic salvage rate was 63% in our patients. CONCLUSION: We could reduce the laparotomy rate and could preserve more spleens after application of TAE. Our success rate for splenic salvage should encourage more extensive use of a TAE for splenic injury.

Nonoperative Management of Blunt Abdominal Trauma with Hemoperitoneum

Because of the two merits of nonoperative management of blunt abdominal trauma, 1) avoidance of operative morbidity and 2) better treatment of associated injuries, the use of nonoperative management has been extended, but the indications for such treatment have not been sufficiently found. One hundred two(102) cases admitted due to hemoperitoneum, 44 involving surgery and 58 conservative managment, were analyzed for age, sex, cause of injury, injured organ, injury grade, transfusion amount, and shock on admission. The major causes of injury in the nonoperative and the operative groups are as follows : 23 cases of auto-pedestrian accidents and 15 cases of in-car accidents in the nonoperative group and 19 cases of auto-pedestrian accidents in the operative group. In terms of the injured organ, liver trauma was the most frequent, and spleen trauma was next. The difference in the transfusion amount between the two groups was statistically significant; 8.1 units in the nonoperative group and 13 units in the operative group. In conclusion, 1) nonoperative management can be considered as a first choice in children with blunt abdominal trauma and stable vital signs; 2) patients with hemodynamically stable liver injury with AAST OIS grade 4 and isolated splenic injury AAST OIS grade 4 are candidates for nonoperative management; and 3) nonoperative management through emergency care without transfusion can be considered in cases with stable vital signs.

Management of Liver Injuries Following Blunt Abdominal Trauma in Children

A clinical review was done in 31 children with blunt liver injury admitted to the Department of Surgery, Kyungpook National University hospital between 1981 and 1990. 17 of the 31 children with injured liver required laparotomy. (11 hepatorrhaphy, 4 lobectomy, 2 segmentectomy) There were two deaths after laparotomy, one from associated severe head injury and one from multi organ failure and the remaining 14 children, who were hemodynamically stable after initial resuscitation and without signs of other associated intraabdominal injuries, were managed by nonoperative treatment. Patients were observed in a pediatric intensive care unit for at least 48 hours with repeated abdominal physical examination, laboratory studies, vital sign check and bed rest. The hospital courses in all cases were uneventful and there were no late complication. A follow-up computed tomography was obtained in 7 patients, showing resolution of the injury in all. The authors believe that, for children with blunt liver injuries, nonoperative management is safe and appropriate if carried out under careful continuous surgical observation in a pediatric intensive care unit.