Rectal arterio-venous malformation (AVM) with bleeding of an internal hemorrhoid.

A 38-year-old male with no past history of illnesses visited the out-patient clinic of Nerima Hikarigaoka Hospital complaining of dizziness and persistent anal bleeding. There was a significant anemia on a blood test and colonoscopy showed a thrombus in a markedly swollen internal hemorrhoid. Contrast-enhanced computed tomography (CT) showed a poorly demarcated area with early face enhancement on the right side of the rectum and anal canal. Based on these findings, an arterio-venous malformation (AVM) of the rectum was suspected. Abdominal angiography showed abnormal vessels receiving a blood supply from the bilateral superior rectal arteries. We suspected that the AVM in the rectum was the cause of the hemorrhage from the internal hemorrhoid, and therefore performed embolization of the AVM. Thereafter, the hemorrhage from the internal hemorrhoid stopped completely and the anemia improved to the normal level, without the need for treatment for the internal hemorrhoid. Colonoscopy performed 6 months after embolization showed shrinkage of the internal hemorrhoid. To the best of our knowledge, there are no reports stating a relationship between rectal AVM and internal hemorrhoids. However, we consider that contrast-enhanced CT can be used to detect vessel abnormalities related to severe bleeding of the internal hermorrhoids in patients with internal hemorrhoids and severe anemia.

[Clinical analysis of delayed hemothorax due to diaphragmatic injury treated by emergent video-assisted thoracic surgery].

We encountered 5 cases of delayed massive hemothorax due to diaphragmatic injury. Delayed hemothorax presented 2∼11 days after injury, with lower rib fractures seen all cases. We performed emergent video-assisted thoracic surgery with mini-thoracotomy for all patients. Lacerations could be clearly visualized in the diaphragm after evacuation of blood clots, which were then sutured. In four cases, the sharp edges of the broken ribs were thought to have caused the diaphragmatic lacerations. The mean blood loss volume was 2,905 ml, and all patients required blood transfusions. However, homeostasis was achieved after surgery, and all patients had an uneventful postoperative course. Although, delayed hemothorax is relatively uncommon, it needs to be considered a lethal condition.

Non-operative management of blunt liver injury: a new protocol for selected hemodynamically unstable patients under hypotensive resuscitation.

BACKGROUND: The objective of this study was to evaluate our new protocol for performing non-operative management for selected unstable patients under hypotensive resuscitation using improved diagnostic imaging techniques. METHODS: This retrospective study included 77 consecutive patients with blunt liver injury. They were divided into two groups: those treated before and those treated after the revision. Under the new protocol, we attempted to manage the patients non-operatively, usually with angioembolization, including those whose shock improved with fluid resuscitation and continuous loading, permitting the maintenance of a target systolic blood pressure of 80 mmHg. The outcomes of the two groups were evaluated and compared. RESULTS: While comparing the groups, although there was no change in the liver-related morbidity and mortality rates, the urgent and overall laparotomy rates and transfusion requirements in 24 h significantly decreased after the protocol revision. While comparing the subgroups of high-grade injury (AAST Grades 3-5), the overall laparotomy rates and transfusion requirements in 24 h significantly decreased after the protocol revision. CONCLUSIONS: All the selected unstable patients were successfully managed non-operatively after the protocol revision. The decrease in laparotomy rates and transfusion requirements confirmed the feasibility of our new protocol for these selected patients.

Protocol for splenic salvage procedures in this era of non-operative management.

AIM: The increased prevalence of non-operative management of splenic injuries contributes to the infrequent use of salvage procedures. Nevertheless, salvage procedures are sometimes required. The study aimed to evaluate the safety and feasibility of our salvage procedure protocol for selected patients. METHODS: This retrospective study included 27 splenic injury patients divided into two groups: those treated by salvage procedures (splenorrhaphy or partial resection) and those who underwent splenectomy. Our salvage procedure protocol was applied in the following situations: if hemodynamics were stable during laparotomy or bleeding was fully controlled by manual or incisional mobilization of the organ, when no more than two other organs required repair, and if no clinical coagulopathy existed. RESULTS: The splenic abbreviated injury scale, intraoperative bleeding, and transfusion requirements of packed red blood cells and fresh frozen plasma requirements in 24 h were significantly lower in the salvage procedure group. There was no difference in the injury severity score, initial amount of bleeding, length of intensive care unit stay, or morbidity and mortality rates between the groups. Patients who underwent salvage procedures were managed without major complication, except one pseudoaneurysm case. CONCLUSION: We confirmed the feasibility of our salvage procedure protocol for selected patients, particularly for those with simple or lower grade injuries.

[High-age thoracic impalement injury treated by conservative therapy].

Thoracic impalement injury is uncommon mechanism of injury. We describe a case treated successfully by non-surgical management. An 87-year-old male got impalement injury in his room by a part of stepladder on right anterior chest wall. He was found to be alert and hemodynamically stable, so computed tomography (CT) scan was performed. Chest CT showed right-sided hemopneumothorax and pulmonary contusion, but no cardiac and great vessels injury. We discussed about performing video-assisted thoracic surgery (VATS), but selected non-surgical treatment including chest drainage at that time, because of low possibilities of massive bleeding and apprehension of postoperative complication resulting from patient's high age. He had uneventful recovery and was discharged on foot 13 days after admission.