Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis.

Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I2 = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I2 = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.

Antiphospholipid syndrome with renal and splenic infarction after blunt trauma: A case report.

BACKGROUND: In trauma patients, bleeding is an immediate major concern. At the same time, there are few cases of acute vascular occlusion after blunt trauma, and it is unclear what assessment and diagnosis should be considered for these cases. Herein, we describe a patient diagnosed with antiphospholipid syndrome after a hypercoagulable workup for acute renal and splenic vascular occlusion due to blunt trauma. CASE SUMMARY: A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago. He had no medical history. Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney and occlusion of branches of the splenic artery with infarction of the central portion of the spleen. Attempted revascularization of the left renal artery occlusion through percutaneous transluminal angioplasty failed due to difficulty in passing the wire through the total occlusion. Considering the presence of acute multivascular occlusions in a young man with low cardiovascular risk, additional laboratory tests were performed to evaluate hypercoagulability. The results suggested a high possibility of antiphospholipid syndrome. Treatment with a subcutaneous injection of enoxaparin was started and changed to oral warfarin after two weeks. The diagnosis was confirmed, and he continued to visit the rheumatology outpatient clinic while taking warfarin. CONCLUSION: A hypercoagulable workup can be considered in trauma patients with acute multivascular occlusion, especially in young patients with low cardiovascular risk.

Time from Injury to Initial Operation May Be the Sole Risk Factor for Postoperative Leakage in AAST-OIS 2 and 3 Traumatic Duodenal Injury: A Retrospective Cohort Study.

Background and Objectives: Traumatic duodenal injury is a rare disease with limited evidence. We aimed to evaluate the risk factors for postoperative leakage and outcomes of pyloric exclusion after duodenal grade 2 and 3 injury. Materials and Methods: We reviewed a prospectively collected trauma database for the period January 2004-December 2020. Patients with grade 2 and 3 traumatic duodenal injury were included. To identify the risk factors for postoperative leakage, we used a stepwise multivariable logistic regression model and a least absolute shrinkage and selection operator (LASSO) logistic model. We constructed a receiver operator characteristic (ROC) curve to predict risk factors for postoperative leakage. Results: During the 17-year period, 179,887 trauma patients were admitted to a regional trauma center in Korea. Of these patients, 74 (0.04%) had duodenal injuries. A total of 49 consecutive patients had grade 2 and 3 traumatic duodenal injuries and underwent laparotomy. The incidence of postoperative leakage was 32.6% (16/49). Overall mortality was 18.4% (9/49). A stepwise multivariable logistic regression and LASSO logistic regression model showed that time from injury to initial operation was the sole statistically significant risk factor. The ROC curve at the optimal threshold of 15.77 h showed the following: area under ROC curve, 0.782; sensitivity, 68.8%; specificity, 87.9%; positive predictive value, 73.3%; and negative predictive value, 85.3%. There was no significant difference in outcomes between primary repair alone and pyloric exclusion. Conclusions: Time from injury to initial operation may be the sole significant risk factor for postoperative duodenal leakage. Pyloric exclusion may not be able to prevent postoperative leakage.

Efficacy and Safety of Laparoscopy for Mild and Moderate Pediatric Abdominal Trauma: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis, we aimed to investigate the efficacy and safety of laparoscopy for pediatric patients with abdominal trauma. Relevant articles were obtained by searching the MEDLINE PubMed, EMBASE, and Cochrane databases until 7 December 2021. Meta-analyses were performed using odds ratio (OR) for binary outcomes, standardized mean differences (SMDs) for continuous outcome measures, and overall proportion for single proportional outcomes. Nine studies examining 12,492 patients were included in our meta-analysis. Our meta-analysis showed younger age (SMD -0.47, 95% confidence interval (CI) -0.52 to -0.42), lower injury severity score (SMD -0.62, 95% CI -0.67 to -0.57), shorter hospital stay (SMD -0.55, 95% CI -0.60 to -0.50), less complications (OR 0.375, 95% CI 0.309 to 0.455), and lower mortality rate (OR 0.055, 95% CI 0.0.28 to 0.109) in the laparoscopy group compared to the laparotomy group. The majority of patients were able to avoid laparotomy (0.816, 95% CI 0.800 to 0.833). There were no missed injuries during the laparoscopic procedures in seven eligible studies. Laparoscopy for stable pediatric patients showed favorable outcomes in terms of morbidity and mortality. There were no missed injuries, and laparotomy could be avoided for the majority of patients.

Stent Graft Placement in the Top-Down Direction for Treating Traumatic Intra-Abdominal Suprahepatic Inferior Vena Cava Rupture: A Case Report.

PURPOSE: The treatment of suprahepatic inferior vena cava (IVC) ruptures results in high mortality rates due to difficulty in performing the surgical procedure. Here, we present a case of successful endovascular management of a life-threatening suprahepatic IVC rupture with top-down placement of a stent graft. CASE REPORT: A 33-year-old woman was involved in a traffic accident and presented to our emergency department due to unstable hemodynamics after blunt abdominal wall trauma. Computed tomography (CT) revealed massive extravasation of contrast agent from the suprahepatic IVC, which suggested traumatic suprahepatic IVC rupture. To seal the IVC, to salvage major hepatic veins, and to prevent migration of the stent graft into the right side of the heart after placement, an aortic cuff with a proximal hook was introduced in a top-down direction via the right internal jugular vein. After closure of the injured IVC, the patient's hemodynamics improved, and additional laparotomy was performed. After 3 months of trauma care, the patient recovered and was discharged. Follow-up CT after 58 months showed a patent stent graft within the IVC. CONCLUSION: Endovascular management with top-down placement of a stent graft is a viable option for emergent damage control in patients with life-threatening hemorrhage from IVC rupture.

The Efficacy and Safety of Laparoscopy for Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis.

The efficacy and safety of laparoscopy for blunt trauma remain controversial. This systemic review and meta-analysis aimed to evaluate the usefulness of laparoscopy in blunt trauma. The PubMed, EMBASE, and Cochrane databases were searched up to 23 February 2021. Meta-analyses were performed using odds ratios (ORs), standardized mean differences (SMDs), and overall proportions. Overall, 19 studies with a total of 1520 patients were included. All patients were hemodynamically stable. In the laparoscopy group, meta-analysis showed lesser blood loss (SMD -0.28, 95% confidence interval (CI) -0.51 to -0.05, I2 = 62%) and shorter hospital stay (SMD -0.67, 95% CI -0.90 to -0.43, I2 = 47%) compared with the laparotomy group. Pooled prevalence of missed injury (0.003 (95% CI 0 to 0.023), I2 = 0%), nontherapeutic laparotomy (0.004 (95% CI 0.001 to 0.026), I2 = 0%), and mortality (0.021 (95% CI 0.010 to 0.043), I2 = 0%) were very low in blunt trauma. In subgroup analysis, recently published studies (2011-present) showed lesser conversion rate (0.115 (95% CI 0.067 to 0.190) vs. 0.391 (95% CI 0.247 to 0.556), test for subgroup difference: p < 0.01). This meta-analysis suggests that laparoscopy is a safe and feasible option in hemodynamic stable patients with blunt abdominal trauma.

Failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of subclavian vein during catheter insertion.

In this study, we report a case of failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of the subclavian vein during catheter insertion. A 30-year-old woman experienced blunt trauma upon falling from her bed. Laceration of a seemingly preexisting hepatic hemangioma was diagnosed. No other injury was detected during a preoperative diagnostic workup. Subclavian vein catheterization was performed, followed by angioembolization to control bleeding due to the ruptured hemangioma. After angioembolization, the patient's systolic blood pressure and hemoglobin levels were 70 mmHg and 5.3 g/dL, respectively. She underwent emergency laparotomy. During the surgery, a large volume of blood in the abdominal cavity due to profuse bleeding from the ruptured hemangioma was observed. Because of a hemothorax found on chest radiography, we performed thoracoscopy, which revealed a large volume of blood in the right thoracic cavity and perforation of the subclavian vein by the catheter. After the damage-control surgery, the patient recovered safely. In this case, ruptured liver hemangioma complicated by subclavian vein catheter-related injury was treated safely using damage-control surgery. The catheter-related injury could be identified and treated using thoracoscopy.

Laparotomy following cardiopulmonary resuscitation after traumatic cardiac arrest: is it futile?

PURPOSE: The outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest is very poor. Moreover, some consider laparotomy for abdominal trauma after CPR futile. This study aimed to investigate the outcomes of trauma patients who were pulseless and received CPR followed by laparotomy. METHOD: We conducted a retrospective review of 28,255 trauma patients from our hospital from January 2009 to November 2017. Patient demographics, injury severity scores, duration of CPR, operative data, and mortality of patients with laparotomy after CPR were collected and analyzed. RESULT: We identified 120 trauma patients (0.42%) who underwent CPR at admission. Twenty-three patients (0.08%) underwent laparotomy following CPR. Of these, 19 patients (82.6%) died after laparotomy. Of four survivors after laparotomy, three (13.0%) survived with a good neurologic outcome. One survivor required rehabilitation due to poor neurologic outcome. All patients had suffered a blunt injury. CONCLUSION: The survival rate for laparotomy following CPR after traumatic cardiac arrest was very poor. However, laparotomy following CPR is not always futile.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center.

BACKGROUND: Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. METHOD: The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. RESULT: Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. CONCLUSION: After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center.

PURPOSE: Pancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation. METHODS: We reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses. RESULTS: Data from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%. CONCLUSION: The pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.

Early postoperative small bowel obstruction after laparotomy for trauma: incidence and risk factors.

PURPOSE: This study aimed to investigate the incidence and risk factors of early postoperative small bowel obstruction (EPSBO) after laparotomy for trauma patients. METHODS: From 2009 to 2016, consecutive patients who had undergone laparotomy for trauma were retrospectively evaluated. EPSBO was defined as the presence of signs and symptoms of obstruction between postoperative days 7 and 30, or obstruction occurring anytime within 30 days and lasting more 7 days. RESULTS: Among 297 patients who met the inclusion criteria, 72 (24.2%) developed EPSBO. The length of hospital stay was significantly longer in patients with EPSBO than in those without EPSBO (median [interquartile range], 34 [21-48] days 24 [14-38] days, P < 0.001). Multivariate logistic analysis identified male sex (adjusted odds ratio [AOR], 3.026; P = 0.008), intraoperative crystalloid (AOR, 1.130; P = 0.031), and Abbreviated Injury Scale (AIS) score for mesenteric injury (AOR, 1.397; P < 0.001) as independent risk factors for EPSBO. The incidence of adhesive small bowel adhesion after 30 days postoperatively did not significantly differ between the 2 groups (with EPSBO, 5.6% without EPSBO, 5.3%; P = 0.571). Most of the patients with EPSBO were recovered by conservative treatment (95.8%). CONCLUSION: After laparotomy for trauma patients, the incidence of EPSBO was 24.2% in our study. EPSBO was associated with a longer hospital stay. Male sex, use of intraoperative crystalloid, and AIS score for mesenteric injury were significant independent risk factors for EPSBO. Patients with these risk factors should be followed-up more carefully.

Role of interventional radiology in trauma care: retrospective study from single trauma center experience.

PURPOSE: Although interventional management is now regarded as essential in trauma care, the effect on clinical result remains uncertain. We conducted this retrospective study to figure out the role of interventional management in trauma care. MATERIALS AND METHODS: Medical records of patients enrolled in the trauma database of our trauma center were reviewed for the period of January 2009 to December 2012. During this period, we have evaluated how many interventional procedures were conducted and the clinical effect of interventional procedure on trauma care. RESULTS: Based on our institutional trauma database, medical records of 2017 patients were reviewed (male/female, 1475:542; mean age, 50.03 years). Their mean injury severity score was approximately 26.28. Among them, 111 patients have been treated with interventional procedure. The number of interventional procedures increased significantly over time, up to 15% (P < .005). During the same period, the overall survival rate did not show significant change. The survival rate of the patients, who have been treated with interventional procedures for traumatic vascular injury, was higher than possibility of survival from trauma injury severity score (86.4% vs 65.59%). CONCLUSION: The need for interventional procedure in trauma care is increasing. Although interventional procedure could not affect the overall survival rate in trauma care, it can improve survival rate remarkably in patients with traumatic vascular injury.