ABSTRACT
Trauma is the leading cause of death among people aged 1-45 in the United States with the abdomen being the third most commonly injured anatomic region. The incidence of gallbladder trauma in the setting of abdominal injury ranges between 0.5 and 2.1 %. While gallbladder injuries secondary to penetrating abdominal wounds are found intra-operatively owing to the likely progression towards laparotomy, due to the paradigm shift of non-operative management of blunt liver injuries, the diagnosis of blunt gallbladder injuries are commonly delayed upwards of 1 to 6 weeks. 4 We present a case of a pre-emptive cholecystectomy less than 36 h after sustaining a grade V liver injury status post blunt abdominal trauma in effort emphasize the importance of critical review of diagnostic images, and support the utilization of diagnostic laparoscopy to definitively diagnose and manage traumatic blunt gallbladder injuries. When operative intervention is not performed, the nonspecific findings suggestive of gallbladder injuries can lead to delayed diagnosis and subsequent increased morbidity and mortality. Due to the lack of previous guidelines we propose a diagnostic algorithm for the approach of traumatic blunt gallbladder injuries.
ABSTRACT
INTRODUCTION: There is a stage migration for detection of kidney cancer, thus we aim to evaluate the distribution of metastatic renal cell carcinoma by presenting clinical T stage over time. MATERIALS AND METHODS: The National Cancer Database was evaluated for patients with metastatic kidney cancer from 2010 to 2016. The primary outcome was the temporal trend of presenting clinical T stage over time. The secondary outcome was overall survival. Kaplan-Meier and Cox regression analyses were performed. RESULTS: The incidence of metastatic kidney cancer has increased, from 3426 new cases in 2010 to 4510 in 2016. While diagnosis of metastasis has increased for all tumor stages over time, there has been a more rapid increase in metastasis of localized renal masses (cT1-T2) as compared to locally advanced disease (cT3-T4). In 2010, 46% of the new metastatic cases diagnosed were cT3-T4, while in 2016 this proportion decreased to 38.2%. Conversely, metastatic cases with cT1-T2 tumors increased from 54% in 2010 to 61.9% in 2016. Cox regression noted an increased risk of death correlating with higher clinical T stage. On Kaplan Meier analysis, the 2-year survival was 29.3%, 30.3%, 28.3%, and 16.0% for cT1, cT2, cT3, and cT4, respectively (logrank P < .001). CONCLUSION: Metastatic kidney cancer is increasingly diagnosed at a lower presenting cT stage. Survival outcomes worsen with increasing cT stage in the setting of metastasis.
