Biliovascuar complications: a price to pay for non-operative management of major liver trauma.

BACKGROUND: With non-operative management of major liver trauma, there has been an increased incidence of biliovascular complications which are reported variably. METHODS: Fifty-six patients with age of 29.79±11.40 years and M:F 8.3:1, with grade III or more liver trauma were evaluated after stabilization for the development of liver related complications. Patients with active contrast extravasation at admission were managed with immediate angioembolization. Patients with prolonged hospital stay underwent repeat CT prior to discharge. Radiological, endoscopic and surgical interventions were carried out as appropriate. RESULTS: Ninety-eight percent had blunt abdominal injury. Mean injury severity score was 25.68±10.389. Four (7%) required damage control laparotomy. CECT showed grade III injuries in 52%, grade IV in 30.4%, and grade V in 18%. 11% had laceration extending to porta. Seventeen patients had 21 liver-related complications: 4 biliary, 12 vascular and 1 combined biliary and vascular. Liver related complications were- 3.5% in grade III, 52% in grade IV and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization while other arterial pseudoaneurysms were detected 7.23±5.14 days after trauma. Angioembolization was successful in 83% patients. On univariate and multivariate analysis, PRBC requirement and injury grade were the predictors of bilivascular complications. Laceration extending to porta was a predictor for biliary complications and not vascular. Repeat CT picked up 13 complications in 10 patients. CONCLUSIONS: Biliovascular complications are managed by multidisciplinary approach. Lacerations extending to porta and grade IV/V injuries have a higher chance of developing biliovascular complications and should be observed closely.

Radio-pathological Correlation of 18F-FDG PET in Characterizing Gallbladder Wall Thickening.

AIM: Thick-walled gallbladder is difficult to characterize on conventional imaging. 18F-FDG PET was used to differentiate benign and malignant wall thickness and compared with histopathology. METHODS: Thirty patients with gallbladder (GB) wall thickening (focal > 4 mm and diffuse > 7 mm), underwents uspected on  ultrasound, or CT scan, and underwent 18F-FDG PET. Histopathology of the specimen was compared with imaging findings. RESULTS: The mean age was 48.22 ± 31.33 years with a M:F 1:4 ratio. Twenty patients had diffuse and 10 had focal thickening. On 18F-FDG PET, lesion was benign in 12, malignant in 13, and indeterminate in 5. Histopathology was malignancy in 12; benign in 18-chronic cholecystitis in 11, xanthogranulomatous in 4, IgG4 related in 2, and polyp in 1. The mean GB wall thickness was 7.79 ± 3.59 mm (10.34 malignant and 6.10 in benign, p = 0.001). At a cutoff of 8.5 mm, the sensitivity and specificity of detecting malignancy was 94% and 67%. The mean SUV uptake was 7.46 (benign 4.51, malignant 14.26, p = 0.0102). At a cutoff of 5.95, the sensitivity and specificity of detecting malignancy was 92% and 79%. For 18F-FDG PET, overall sensitivity was 91%, specificity 79%, PPV 77%, NPV 92%, and diagnostic accuracy was 84%. CONCLUSION: 18F-FDG PET is a reliable method of differentiation between benign and malignant thickening of the gallbladder particularly when wall thickness and SUV value is taken into account.