Partial Hepatectomy of a VA-ECMO Patient After Mechanical CPR by LUCAS Device Due to a Catastrophic Liver Laceration: A Case Report.

BACKGROUND Many patients experiencing acute coronary syndrome (ACS) present in cardiac arrest. Mechanical chest compressions are a common tool in cardiopulmonary resuscitation (CPR) and have their benefits as well as disadvantages and reported complications. In recent years, veno-arterial extracorporeal oxygenation membrane (VA-ECMO) has proven to be a promising tool in these circumstances and is now considered part of the treatment algorithm in emergent and refractory cases. The combination of mechanical compressions and the ECMO lead to "new" complicated situations in the patients. We discuss such a patient, who required emergent surgery due to complications from his resuscitation, while under ECMO. CASE REPORT A 56-year-old man, with medical history of cardiovascular risk factors, presented to our facility due to ST segment elevation myocardial infarction. During his catheterization, he went into cardiac arrest and needed cardiopulmonary resuscitation (CPR) using a LUCAS3™ device. Because no rhythm was restored, he was promptly placed on VA-ECMO support with immediate, albeit transient, stabilization. After transportation to our Intensive Care Unit (ICU), he quickly deteriorated again hemodynamically and after imaging workup it was discovered he had a major laceration to his liver and was rushed emergently to the operating room where he underwent partial hepatectomy, while on full anticoagulation due to the ECMO support. CONCLUSIONS Complications from mechanical CPR are common, including liver laceration. Patients who are placed on ECMO following such measures should be carefully evaluated for such complications as they might affect the treatment and prognosis.

Failure of observation and need for delayed tube thoracostomy in 197 unselected patients with occult pneumothorax: a retrospective study.

INTRODUCTION: Occult pneumothorax (OPTX) is defined as air in the pleural space that was not suspected on plain chest X-ray but detected on CT. Controversy exists in the management of OPTX, especially in patients who require positive pressure ventilation (PPV). In this study, we investigated the need for tube thoracostomy (TT) in blunt trauma patients with OPTX. MATERIALS AND METHODS: This is a retrospective study of blunt trauma patients of all ages with evidence of OPTX, treated in the Shamir Medical Center Trauma Unit between 2008 and 2017. Two groups were defined. Group I consisted of patients requiring PPV. Group II included patients who did not require PPV. We identified the indication for TT insertion (hemothorax, significant pneumothorax, and enlarging pneumothorax). Necessity for delayed TT insertion due to enlarging pneumothorax was analyzed. RESULTS: Overall 512 patients with traumatic pneumothorax were admitted. 197 (38.5%) had OPTX. Motor vehicle accidents and falls from height accounted for most of the injuries, 47.2 and 42.6%, respectively. Fifty-seven patients required PPV. TT was required in 31 (15.7%) patients. No differences were found between the overall rate of TT insertion between the groups (15.7 vs. 21.1%; p = 0.2) and for delayed insertion of a TT due to an enlarging pneumothorax (25.0 vs. 42.1%; p = 0.45). CONCLUSION: TT is not indicated in every patient with OPTX even in case of mechanical ventilation.

Angiography in patients with pelvic fractures and contrast extravasation on CT following high-energy trauma.

INTRODUCTION: Pelvic fracture may be accompanied by severe bleeding. Computed tomography (CT) is a gold standard diagnostic tool in stable trauma patients. Contrast extravasation detected on CT of pelvis is a sign of hemorrhage, but its significance is not clear. We aimed to evaluate the need for angiography in patients with pelvic fracture and CT revealed contrast extravasation. We tried to identify parameters that might help to choose patients who will benefit from therapeutic angiography. METHODS: Electronic medical records of patients with pelvic fracture admitted to Level II Trauma Center during 10 years were retrospectively reviewed. Patients who had contrast extravasation on CT were included. Data base consisted of demographics, injury severity, initial physiologic parameters, laboratory data, results of CT and angiography. RESULTS: Forty out of 396 patients had contrast extravasation detected by CT. Twelve patients underwent angiography and 4 of them benefited from embolization. The sensitivity of contrast extravasation in evaluating the need for embolization was 1.0 (95% CI 0.398, 1.0), positive predictive value was 0.1 (95% CI 0.028, 0.237), and the negative predictive value was 1.0 (95% CI 0.990, 1.0). CONCLUSION: The role of angiography in stable patients with pelvic fracture and CT identified contrast extravasation remains questionable. Most of these patients are not in need of angioembolization.

Frequency of intra-abdominal organ injury is higher in patients with concomitant stab wounds to other anatomical areas.

BACKGROUND: Management of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas. METHODS: We performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury. RESULTS: The study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1-1.6, p < 0.001). These patients also had a higher rate of injury to the solid organs than patients with an isolated abdominal stab wound. CONCLUSIONS: Patients with multi-regional stab wounds have an increased risk of intra-abdominal injury. Worldwide accepted "clinical follow up" protocol may not be appropriate in management of patients with multi-regional stab wounds.

Planned Re-Laparotomy in a Non-Trauma Setting: A Single Center Experience.

BACKGROUND: Damage control laparotomy (DCL) is the widely accepted procedure of choice in management of severely injured trauma patient. It has been implemented in non-trauma-related surgical pathology in the last decade. OBJECTIVES: To evaluate our experience with planned re-laparotomy (PRL) in non-trauma patients and compare it to other reports. METHODS: Charts of all patients admitted to Assaf Harofeh Medical Center who underwent PRL for non-trauma-related abdominal pathology during a 6 year period were reviewed. Data regarding demographics, vital signs, laboratory tests, indications for surgery, length of hospital stay, and mortality were obtained from medical charts. Indications for surgery, risk factors, and mortality were analyzed. RESULTS: The study was comprised of 181 patients. Primary abdominal sepsis (50), postoperative sepsis (49), mesenteric event (32), and intestinal obstruction (28) were the most common indications for PRL. Mortality rate was 48.6%. Factors correlating with increased mortality were advanced age, hypotension, hypothermia, metabolic acidosis, and renal failure. Bowel resection was performed on 122 patients (67%) and primary intestinal anastomosis constructed in 46.7%. Mortality rate was lower in patients who underwent PRL with primary anastomosis compared to patients with postponed bowel anastomosis (33.3% vs. 55.4%, P = 0.018). CONCLUSIONS: PRL in abdominal emergencies carries a high mortality rate. Primary anastomosis may be considered in non-trauma-related PRL.

[A COMPARATIVE STUDY OF THE PATHOLOGICAL CHARACTERISTICS OF RIGHT SIDED VERSUS LEFT SIDED COLON CANCER].

AIMS: This study aimed to investigate the pathologic differences between right and left sided colonic cancer. BACKGROUND: The incidence of right sided colon cancer during the past several decades is increasing as compared to left sided colon cancer. There are cumulative publications describing epidemiological, pathological and genetic differences between right and left sided colon cancer. A few studies have also shown a lower survival rate in patients with right sided colon cancer as compared to patients with left sided colon cancer. METHODS: A retrospective study based on the accumulated data on right and left sided colonic cancer. RESULTS: Data on 823 patients was collected; 426 patients (52.8%) had colon cancer located on the right side and in 397 patients (48.2%) it was located on the left side. There were no statistically significant differences between right and left colon cancer regarding sex, lymph node metastases and lymphovascular invasion. However, there was a significantly higher proportion of poorly differentiated adenocarcinomas (19%vs.8.7%; p<.001) and a trend to higher T stage (T3-4:87.7%vs.82.8%; p<.049) in right sided tumors as compared to left sided tumors. The incidence of mucinous tumors and mucinous components was also significantly higher in right sided tumors (7.3%vs.2%; p<.001, 13.1%vs.7%; p<.001). CONCLUSIONS: We found histopathological differences between right and left sided colon cancer. Tumors on the right colon were found to be more aggressive, as expressed by poorer differentiation, higher T stage and mucinous tumors. The reasons are unclear, either the existence of two distinct molecular pathways or simply a delay in the diagnosis of right sided colon cancer. Future studies are needed to better understand the true nature of these differences.

When Should Abdominal Computed Tomography Be Considered in Patients with Lower Rib Fractures?

BACKGROUND: Lower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the "gold standard" examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%-40%. OBJECTIVE: The purpose of this study was to evaluate the incidence of intra-abdominal organ injuries in blunt trauma patients with lower rib fractures. METHODS: Medical charts and radiology reports of patients with lower rib (from the 8th to 12th rib) fractures admitted to our center during a 6-year period were retrospectively reviewed. Patients were divided into two groups. Group I included patients with intra-abdominal injury (IAI) diagnosed either by CT or on urgent laparotomy, and Group II included those with normal abdominal CT scans. Data included demographics, mechanism of injury, laboratory tests, radiology results including number and location of fractured ribs, and incidence of IAI. RESULTS: Overall 318 patients were included in the study. Fifty-seven patients (17.9%) had 71 IAIs compared with 265 (82.1%) patients with no IAI. Logistic regression identified age younger than 55 years (relative risk [RR] = 7.2; 95% confidence interval [CI] 3.1-16.8; p = 0.001), bilateral rib fractures (RR = 3.9; 95% CI 1.1-13.5; p = 0.03) and decreased levels of hematocrit (RR = 2.4; 95% CI 1.2-4.8; p = 0.016) as independent risk factors for the presence of IAI. CONCLUSIONS: Abdominal CT should be considered in blunt trauma patients with lower rib fractures who are younger than 55 years of age and have bilateral rib fractures and decreased levels of hematocrit on admission.

Lymphocytic Infiltration as a Prognostic Factor in Patients With Colon Cancer.

Host-defense mechanisms may have an important role in predicting the outcome of colorectal cancer patients. We designed our study to evaluate the possible prognostic significance of the presence of lymphocytic infiltration (LI) and subgroups of lymphocytes (CD3 and CD20) in the primary tumors. We randomly selected 195 patients operated for colorectal carcinoma from a larger cohort of 1527 patients with colorectal cancer. Histological slides were blindly reevaluated for the presence of LI that was graded 0 to 3. Immunohistochemical phenotyping of the lymphocytes was performed only for tumors with LI score 3 and included antibodies CD3 and CD20. CD3 and CD20 immunostaining were graded in the same manner as LI. The mean duration of follow-up was 63.8 months. The distribution of patients with colorectal cancer according to LI scores was as follows: score 0, 20/195 (10.2%); score 1, 61/195 (31.3%); score 2, 78/195 (40%); and score 3, 36/195 (18.5%). There was no correlation between any clinicopathological pattern and LI. Score 3 staining for CD3 was more common than for CD20 (64.7% vs 8.8%, P < .0001). Prominent lymphocytic infiltration (score 3) was associated with better disease-free survival (P = .062). Recurrence was diagnosed among 2/22 (9.1%) patients with prominent CD3 staining versus 62/171 (36.2%) of all other patient groups (P = .054) and they correspondingly had better disease-free survival (P = .018). It seems we can identify a group of patients with colorectal cancer who have an excellent prognosis according to a single immunological test unrelated to other known prognostic factors.

Diagnostic Use of Endoscopic Retrograde Cholangiopancreatectography for Pancreatic Duct Injury in Trauma Patients.

BACKGROUND: Trauma patients diagnosed with pancreatic duct injury (PDI) have a high complication rate and prolonged hospital stay. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of PDI remains unclear. During the last decade, our trauma unit incorporated ERCP into the management protocol for suspected PDI cases. OBJECTIVES: To determine whether ERCP is a sensitive tool to detect PDI. METHODS: This retrospective trauma patient series study assessed the diagnostic yield of ERCP in trauma cases with suspected PDI on computed tomography (CT) or intraoperatively. Between 1 January 2004 and 31 December 2011, 13 patients admitted to our medical center underwent ERCP for suspected PDI. Patient demographics, mechanism of injury, Injury Severity Score (ISS), time from injury to ERCP, and ERCP-related complications were documented and assessed. RESULTS: Of the 13 patients included in the analysis, 8 stable patients with suspected PDI on CT had no leak from the main pancreatic duct on ERCP. Two of them underwent surgery for suspected pancreatic transection. ERCP confirmed a main pancreatic duct leak in three patients. Two patients underwent ERCP for suspected PDI after "damage control" surgery. No leak from the pancreatic ducts was diagnosed. No pancreas-related complications or ERCP-related complications were observed. CONCLUSIONS: ERCP is a sensitive and relatively safe tool for the diagnosis of PDI, and its use might prevent unnecessary surgical interventions in selected trauma cases.

Elevated white blood cell count, decreased hematocrit and presence of macrohematuria correlate with abdominal organ injury in pediatric blunt trauma patients: a retrospective study.

INTRODUCTION: Computerized tomography (CT) has become an important diagnostic modality in trauma patients. Pediatric patients are particularly susceptible to ionized radiation making liberal CT use in this age group unacceptable. We aimed to identify parameters that might predict abnormal findings on abdominal CT leading to patient management changes. METHODS: Data on blunt trauma patients up to 15 years of age admitted to Assaf Harofeh Medical Center from January 2007 to October 2014 was retrospectively collected. All patients with abdominal CT scan as part of initial assessment were included. Medical and surgical data were extracted from the medial charts. Patients were divided into two groups. Group I: patients whose management was changed solely based on abdominal CT findings and Group II: patients with normal abdominal CT. The groups were compared by all the data parameters. RESULTS: Overall, 182 patients were included in the study. The groups were comparable by age and mechanism of injury. Management changes based on CT findings were found in 68 (37.4 %) patients. White blood cell count >14000, abnormally low hematocrit level and macrohematuria were associated with a diagnosis of intra-abdominal injury requiring patient management changes (p < 0.05). Group I patients had longer LOS. Fifteen patients (22 %) required active intervention based solely on CT findings. Physical examination, arterial blood gases and initial radiology examinations results did not correlate with abdominal CT findings. CONCLUSIONS: Elevated WBC, decreased hematocrit and presence of macrohematuria strongly correlate with abdominal CT findings and lead to changes in patient management.

D1 versus D2 Gastrectomy for Gastric Adenocarcinoma.

BACKGROUND: Despite the ongoing decrease in the incidence of gastric cancer, this disease is still a major cause of death. It is still debatable whether D2 lymphadenectomy improves survival and whether this procedure should be performed routinely or selectively. OBJECTIVES: To compare the pathological and short-term results following radical D2-type gastric resection and lymphadenectomy versus the more limited D1 type resection and lymphadenectomy. METHODS: We conducted a retrospective study on 4 years experience treating 164 patients suffering from gastric cancer. We compared the results between the group of patients who underwent a radical D2 type gastric resection and lymphadenectomy (n = 100) and those of a relatively small group of patients who intentionally underwent the more limited D1 type (n = 34). RESULTS: The overall number of harvested lymph nodes was 9 ± 4 in the D1 group compared to 30 ± 12 (range 16-69) in the D2 group (P = 0.001). Of the 100 patients undergoing a D2 lymphadenectomy, 57% had positive nodes compared to 38% of the 34 patients in the D1 group (P = 0.045). CONCLUSIONS: We showed statistically significant differences between D1 and D2 procedures in the overall number of harvested lymph nodes and the proportion of positive nodes to the overall number. Our results support the fact that D2 resection should be recommended as the standard approach of treatment for gastric cancer patients, ensuring a larger number of retrieved lymph nodes and a comparable rate of complications and mortality.

A comparative study on two different pathological methods to retrieve lymph nodes following gastrectomy.

BACKGROUND: The number of lymph nodes harvested during gastrectomy depends on the extension of lymphadenectomy and the method of lymph node retrieval. AIM: The objective of this study was to evaluate two methods of lymph node retrieval in specimens of gastric cancer. METHODS: The number of lymph nodes was compared using two different techniques. The technique used in the first group was manual dissection following formalin fixation, and the techniques used in the second group was fat-clearing by acetone. RESULTS: Both groups were comparable for demographic and pathological variables. The average number of harvested nodes was 19.3 ± 10 for the manual group as compared to 26.1 ± 14 in the acetone group (P = 0.003). The differences in the average number of positive nodes did not reach statistical significance (4.6 compared to 6.9 nodes). CONCLUSION: The acetone clearing technique enables the evaluation of a larger number of nodes. An increase, but statistically non significant, number of positive nodes was noted in the acetone group.

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury.

OBJECTIVE: Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury. METHODS: Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation. RESULTS: Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention. CONCLUSION: The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified.

Tumor differentiation as related to sentinel lymph node status in gastric cancer.

AIM: To investigate the influence of tumor grade on sentinel lymph node (SLN) status in patients with gastric cancer (GC). METHODS: We retrospectively studied 71 patients with GC who underwent SLN mapping during gastric surgery to evaluate the relationship between SLN status and tumor grade. RESULTS: Poorly differentiated tumors were detected in 50/71 patients, while the other 21 patients had moderately differentiated tumors. SLNs were identified in 58/71 patients (82%). In 41 of the 58 patients that were found to have stained nodes (70.7%), the tumor was of the poorly differentiated type (group I), while in the remaining patients with stained nodes 17/58 (29.3%), the tumor was of the moderately differentiated type (group II). Positive SLNs were found in 22/41 patients in group I (53.7%) and in 7/17 patients in group II (41.2%) (P = 0.325). The rate of positivity for the SLNs in the two groups (53.7% vs 41.2%) was not statistically significant (P = 0.514). CONCLUSION: Most of our patients were found to have poorly differentiated adenocarcinoma of the stomach and there was no correlation between tumor grade and SLN involvement.

The role of diagnostic laparoscopy in detecting minimal peritoneal metastatic deposits in patients with pancreatic cancer scheduled for curative resection.

BACKGROUND: Pancreatic cancer (PC) is an aggressive disease usually diagnosed at an advanced stage. Modern computed tomography can define the subgroup of operable patients. However, minimal peritoneal deposits can be undetected even by modern computed tomography protocols. AIM: To diagnose those patients who are not operable because of a peritoneal spread using diagnostic laparoscopy (DL), thus avoiding unnecessary laparotomies. METHODS: A retrospective study was conducted on 52 consecutive patients with PC scheduled for curative pancreatic surgery. RESULTS: Out of 52 patients who underwent DL, peritoneal spread was diagnosed in 5 patients and these patients were denied surgery. Laparoscopy did not detect 2 other patients with peritoneal spread. CONCLUSIONS: Although the added value of DL in patients with PC is small (around 10% in our series), considering the minimal morbidity and costs attributed to this procedure, we believe that it should be adopted as a routine approach.

Indication for relumpectomy--a useful scoring system in cases of invasive breast cancer.

BACKGROUND AND OBJECTIVES: In two-thirds of breast cancer patients undergoing reoperation no residual tumor will be found. A scoring system for selection of patients who might benefit from relumpectomy is proposed. METHODS: This study is based on 293 patients with invasive breast cancer undergoing reoperation due to margins of <2 mm. Eighteen parameters were evaluated by univariate and multivariate stepwise logistic regression. RESULTS: Univariate analysis identified nine parameters associated with a residual invasive tumor: surgical margins; lobular histological type; grade 3; multifocality; positive lymph modes; non-fine needle localization (FNL) versus FNL lumpectomy; vascular/lymphatic invasion; age <50 years; and tumor size ≥3 cm. Multivariate stepwise logistic regression study identified six out of nine parameters associated with a higher probability of finding a residual invasive tumor: margins <1 mm, multifocality, tumor size ≥3 cm, positive lymph nodes, age <50 years, and lumpectomy without previous FNL. Odds of these factors were used for scoring. CONCLUSIONS: For patients with surgical margins <2 mm and a score of <4, the probability of finding a residual invasive tumor is 0%, while the probability of finding a microfocus of <2 mm of invasive carcinoma is 3.2% and of finding residual DCIS is up to 10%.

Bowel preparation: comparing metabolic and electrolyte changes when using sodium phosphate/polyethylene glycol.

BACKGROUND: Many patients with various types of colonic pathology undergo invasive procedures that require mechanical bowel preparation. The most commonly used medications for bowel preparation include phosphate-containing drugs which are low cost and enable this procedure to be performed in an outpatient setting, as opposed to other medications, such as polyethylene glycol. Recent studies have suggested that freely using phosphate-containing drugs might lead to renal function impairment in a small group of patients. Despite this, many surgeons still use these drugs to prepare their patients. We conducted a comparative study to check the side effects of phosphate-containing drugs compared to polyethylene glycol when used for bowel cleansing. METHODS: We conducted a double blind prospective randomized study that included 40 patients undergoing surgery for colonic pathology, all of whom underwent bowel cleansing (20 with sodium phosphate and 20 with polyethylene glycol). During the perioperative course, electrolyte parameters were collected from serum and urine and compared between the two groups of patients. RESULTS: Changes in electrolyte and metabolic parameters were shown in both groups, but more prominently in patients prepared with sodium phosphate. In addition, early signs of renal function impairment appeared in this group. The differences in metabolic and electrolyte changes between the two groups were statistically significant. CONCLUSIONS: On the basis of this study, we propose that the wide use of phosphate-containing drugs for colonic preparation might be dangerous for the specific group of patients that is prone to develop renal failure or electrolyte abnormalities.

The role of diagnostic laparoscopy in the management of patients with gastric cancer.

BACKGROUND: Gastric cancer continues to be a leading cause of cancer death. The treatment approach varies, and preoperative staging is therefore crucial since an exploratory laparotomy for unresectable gastric cancer will be followed by an unacceptably high morbidity and mortality rate. OBJECTIVES: To assess the added value of diagnostic laparoscopy to conventional methods of diagnosis such as computed tomography in avoiding unnecessary laparotomies. METHODS: We conducted a retrospective study on 78 patients scheduled for curative gastrectomy based on CT staging. DL was performed prior to exploratory laparotomy. RESULTS: In 23 of 78 patients (29.5%) unexpected peritoneal spread not detected on preoperative CT was found. Fifty-five patients underwent radical gastrectomy, 15 patients were referred for downstaging and 8 patients underwent a palliative procedure. CONCLUSIONS: Based on our results, DL should be considered in all gastric cancer patients scheduled for curative gastrectomy.