Proper hepatic artery transection followed by blunt abdominal trauma: A case report and review of literature.

Abdominal vascular injuries, especially in the celiac trunk, are uncommon in blunt trauma, yet their life-threatening nature necessitates rapid surgical interventions to control possible massive bleedings. Damage control surgery principles may aid management. It is crucial to thoroughly assess all trauma patients, even in instances of initial normal physical examinations.

Introducing AEM-RADS: A novel reporting and data system for abdominal emergencies.

PURPOSE: The Reporting and Data System (RADS) has proven successful in various medical settings, but a standardized reporting system for abdominal emergencies is lacking. In this study, the Abdominal Emergency Reporting and Data System (AEM-RADS) for urgent findings on abdominal CT scans is introduced to address the need for consistency in emergency radiology. METHODS: In this prospective observational study, conducted over a six-month period, the urgency of abdominal CT scans was assessed using the proposed AEM-RADS scoring system. The committee developed a scale ranging from AEM-RADS 1 (normal) to AEM-RADS 5 (urgent disease). Interobserver agreement between two observers with different experience was evaluated, and robust AEM-RADS reference values were established by radiologists who were not observers. Statistical analysis used mean, standard deviations and Kendall's tau analysis for interobserver agreement. RESULTS: Among 2656 patients who underwent CT for abdominal emergencies, the AEM-RADS distribution was 17.50% AEM-RADS 1, 28.57% AEM-RADS 2, 7.22% AEM-RADS 3, 35.61% AEM-RADS 4, and 11.06% AEM-RADS 5. Interobserver agreement was high, especially for urgent and emergent cases (p < 0.0001). Notable discrepancies were observed in AEM-RADS categories 2C-D and 3B-C, emphasizing the influence of radiologists' experience on interpretation. However, the interobserver agreement for both AEM-RADS 2C-D and 3B-C were statistically significant (p < 0.001). CONCLUSIONS: AEM-RADS showed promising reliability, particularly in identifying urgent and emergent cases. Despite some inter-observer discrepancies, the system showed potential for standardized emergency workups. AEM-RADS could significantly enhance diagnostic accuracy in abdominal emergencies and provide a structured framework for shared decision-making between clinicians and radiologists.0.

Applying enhanced recovery principles to emergency laparotomy in penetrating abdominal trauma: a case-matched study.

PURPOSE: The implementation of enhanced recovery after surgery programs (ERPs) has significantly improved outcomes within various surgical specialties. However, the suitability of ERPs in trauma surgery remains unclear. This study aimed to (1) design and implement an ERP for trauma laparotomy patients; (2) assess its safety, feasibility, and efficacy; and (3) compare the outcomes of the proposed ERP with conventional practices. METHODS: This case-matched study prospectively enrolled hemodynamically stable patients undergoing emergency laparotomy after penetrating trauma. Patients receiving the proposed ERP were compared to historical controls who had received conventional treatment from two to eight years prior to protocol implementation. Cases were matched for age, sex, injury mechanism, extra-abdominal injuries, and trauma scores. Assessment of intervention effects were modelled using regression analysis for outcome measures, including length of hospital stay (LOS), postoperative complications, and functional recovery parameters. RESULTS: Thirty-six consecutive patients were enrolled in the proposed ERP and matched to their 36 historical counterparts, totaling 72 participants. A statistically significant decrease in LOS, representing a 39% improvement in average LOS was observed. There was no difference in the incidence of postoperative complications. Opioid consumption was considerably lower in the ERP group (p < 0.010). Time to resumption of oral liquid and solid intake, as well as to the removal of nasogastric tubes, urinary catheters, and abdominal drains was significantly earlier among ERP patients (p < 0.001). CONCLUSION: The implementation of a standardized ERP for the perioperative care of penetrating abdominal trauma patients yielded a significant reduction in LOS without increasing postoperative complications. These findings demonstrate that ERPs principles can be safely applied to selected trauma patients.

Does abdominal protrusion in pregnant women affect abdominal injury severity in motor vehicle collisions? A nationwide database study.

AIMS: Some pregnant women avoid vehicle driving owing to the risk of contact between their protruding abdomen and steering wheel. This study was performed to determine whether abdominal protrusion in late-term pregnant car users affects the occurrence and severity of abdominal injuries in motor vehicle collisions using a national crash database. METHODS: The National Automotive Sampling System/Crashworthiness Data System was used to analyse maternal background, collision characteristics, outcome and Abbreviated Injury Scale (AIS) scores for the body regions of all persons involved in the collision. RESULTS: Comparison of pregnant and non-pregnant women in the driver's seat showed no significant differences in the rate of AIS scores of ≥2 (2+) for abdominal injuries and female outcomes. Comparison of use of the driver's seat and front passenger's seat by pregnant women showed no significant difference in rate of AIS 2+ injuries or in maternal and fetal outcomes. Comparison of pregnant women with a gestational age of ≤27 and >27 weeks in the driver's seat showed no significant differences in rate of AIS 2+ injuries or in maternal and fetal outcomes. CONCLUSIONS: Based on the data from relatively low-speed frontal collisions, obstetrician/gynaecologists should advise pregnant women that they do not need to change their preferred car seat from the driver's seat to another seat because of fear of contact between their protruding abdomen and the vehicle interior.

Selective nonoperative versus operative management of liver gunshot injuries: a retrospective cohort study.

INTRODUCTION: Experience accumulated over the last decades suggests nonoperative management (NOM) of civilian gunshot liver injuries can be safely applied in selected cases. This study aims to compare the outcomes of selective NOM versus operative management (OM) of patients sustaining gunshot wounds (GSW) to the liver. METHODS: A registry-based retrospective cohort analysis was performed for the period of 2008 to 2016 in a Brazilian trauma referral. Patients aged 16-80 years sustaining civilian GSW to right-sided abdominal quadrants and liver injury were included. Baseline data, vital signs, grade of liver injury, associated injuries, injury severity scores, blood transfusion requirements, liver- and non-liver-related complications, length-of-stay (LOS), and mortality were retrieved from individual registries. RESULTS: A total of 54 patients were eligible for analysis, of which 37 underwent NOM and 17 underwent OM. The median age was 25 years and all were male. No statistically significant differences were observed between groups regarding patients' demographics, injury scores, grade of liver injury and associated lesions. NOM patients tended to sustain higher-grade injuries (86.5% vs 64.7%; p = 0.08), and failure of conservative management was recorded in two (5.4%) cases. The rate of complications was 48% with no between-group statistically significant difference. Blood transfusion requirements were significantly higher in the OM group (58.8% vs 21.6%; p = 0.012). The median LOS was seven days. No deaths were recorded. CONCLUSION: Patients with liver GSW who are haemodynamically stable and without peritonitis are candidates for NOM. In this study, NOM was safe and effective even in high-grade injuries.

Outcomes of Nonoperative Management of Penetrating Abdominal Trauma Injury: A Retrospective Study.

BACKGROUND: The treatment of penetrating abdominal injuries has changed in recent years with more focus on "nonoperative management" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting. METHODS: A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure. RESULTS: During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05). CONCLUSION: Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.

Mortality and its predictors in abdominal injury across sub-Saharan Africa: systematic review and meta-analysis.

BACKGROUND: Abdominal injuries exert a significant impact on global morbidity and mortality. The aggregation of mortality data and its determinants across different regions holds immense importance for designing informed healthcare strategies. Hence, this study assessed the pooled mortality rate and its predictors across sub-Saharan Africa. METHOD: This meta-analysis employed a comprehensive search across multiple electronic databases including PubMed, Africa Index Medicus, Science Direct, and Hinari, complemented by a search of Google Scholar. Subsequently, data were extracted into an Excel format. The compiled dataset was then exported to STATA 17 statistical software for analysis. Utilizing the Dersimonian-Laird method, a random-effect model was employed to estimate the pooled mortality rate and its associated predictors. Heterogeneity was evaluated via the I2 test, while publication bias was assessed using a funnel plot along with Egger's, and Begg's tests. RESULT: This meta-analysis, which includes 33 full-text studies, revealed a pooled mortality rate of 9.67% (95% CI; 7.81, 11.52) in patients with abdominal injuries across sub-Saharan Africa with substantial heterogeneity (I2 = 87.21%). This review also identified significant predictors of mortality. As a result, the presence of shock upon presentation demonstrated 6.19 times (95% CI; 3.70-10.38) higher odds of mortality, followed by ICU admission (AOR: 5.20, 95% CI; 2.38-11.38), blunt abdominal injury (AOR: 8.18, 95% CI; 4.97-13.45), post-operative complications (AOR: 8.17, 95% CI; 4.97-13.44), and the performance of damage control surgery (AOR: 4.62, 95% CI; 1.85-11.52). CONCLUSION: Abdominal injury mortality is notably high in sub-Saharan Africa. Shock at presentation, ICU admission, blunt abdominal injury, postoperative complications, and use of damage control surgery predict mortality. Tailored strategies to address these predictors could significantly reduce deaths in the region.

Liver impalement with an antique African iron barbed spear. A case report.

Impalement injuries happen when an object penetrates a body cavity or organ and remains in situ. We present a case of a 35-year-old fisherman whose act of violence resulted in the lodging of an antique iron spear in segment V of the liver, which was then referred to our institution on the day after the accident. Despite the challenges posed by patient transfer, diagnosis, resuscitation, and, most importantly, handling in the operating room, the object was successfully removed via hepatotomy, and the patient is now in good health. Impalement by an ancient African iron spear, repurposed as a fishing tool in modern times, remains undocumented in the literature, necessitating reporting and a call for further research by the medical community into managing impalement injuries of varying severity.

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.

Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership.

Introduction: Medical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian centers to maintain clinical readiness. It is unclear what impact this strategy may have on patient outcomes in these centers. We sought to compare emergent trauma laparotomy (ETL) outcomes between active-duty Air Force Special Operations Surgical Team (SOST) general surgeons and civilian faculty at an American College of Surgeons verified level 1 trauma center with a well-established military-civilian partnership. Methods: Retrospective review of a prospectively maintained, single-center database of ETL from 2019 to 2022 was performed. ETL was defined as laparotomy from trauma bay within 90 min of patient arrival. The primary outcome was to assess for all-cause mortality differences at multiple time points. Results: 514 ETL were performed during the study period. 22% (113 of 514) of patients were hypotensive (systolic blood pressure ≤90 mm Hg) on arrival. Six SOST surgeons performed 43 ETL compared with 471 ETL by civilian faculty. There were no differences in median ED length of stay (27 min vs 22 min; p=0.21), but operative duration was significantly longer for SOST surgeons (129 min vs 110 min; p=0.01). There were no differences in intraoperative (5% vs 2%; p=0.30), 6-hour (3% vs 5%; p=0.64), 24-hour (5% vs 5%; p=1.0), or in-hospital mortality rates (5% vs 8%; p=0.56) between SOST and civilian surgeons. SOST surgeons did not significantly impact the odds of 24-hour mortality on multivariable analysis (OR 0.78; 95% CI 0.10, 6.09). Conclusion: Trauma-related mortality for patients undergoing ETL was not impacted by SOST surgeons when compared with their civilian counterparts. Military surgeons may benefit from the valuable clinical experience and mentorship of experienced civilian trauma surgeons at high volume trauma centers without creating a deficit in the quality of care provided. Level of evidence: Level IV, therapeutic/care management.

A pregnant woman with long-standing, retained intraabdominal glass shards who gave birth to a live infant with no complications: a case report.

BACKGROUND: Most cases of traumatic injury during pregnancy involve blunt trauma, with penetrating trauma being uncommonly rare. In glass shard injuries, fragments often penetrate deeply, and multiple injuries may occur simultaneously; attention must be paid to the possibility of organ injury from the residual fragments. However, no case of this occurring during pregnancy has been reported yet. CASE PRESENTATION: We present the case of a 34-year-old pregnant Cameroonian woman who retained intraabdominal glass shards following a penetrating injury at 13 weeks gestation and not diagnosed until 22 weeks gestation. Notably, this patient continued the pregnancy without complications and gave birth via cesarean section at 36 weeks gestation. CONCLUSION: In pregnant women sustaining a penetrating glass trauma during pregnancy, careful attention should be paid to the fragments; in that case, computed tomography is a useful modality for accurately visualizing any remaining fragments in the body. Essentially, the foreign bodies in glass shard injuries during pregnancy should be removed immediately, but conservative management for term delivery is an important choice for patients at risk for preterm delivery.

Isolated pancreatic injury following blunt trauma in a seven-year-old girl: A case report.

INTRODUCTION AND IMPORTANCE: Isolated pancreatic injury following blunt abdominal trauma is rare, and the absence of definite clinical signs and symptoms may delay diagnosis and management. CASE PRESENTATION: We present the case of a seven-year-old girl with a history of progressive, periumbilical abdominal pain and multiple episodes of non-bilious, non-blood mixed vomiting following a road traffic accident. Computed tomography (CT) imaging revealed an isolated grade three pancreatic injury managed conservatively. CLINICAL DISCUSSION: The patient usually presents with epigastric tenderness with or without a rise in pancreatic enzyme levels. CT grading of injury correlates with and guides the management approach, and CT abdomen with contrast is the preferred investigation for diagnosis. Management depends on the grade of injury, the hemodynamic status of the children, and the co-existence of other injuries. CONCLUSION: Isolated pancreatic injury, although rare, can go undiagnosed due to a lack of suspicion from the treating surgeon and may have dire consequences. Conservative management can be a suitable strategy for children with stable hemodynamic status.

Small Intestinal Perforation after 360-Degree Liposuction: A Case Report.

OBJECTIVE: As one of the most commonly performed cosmetic procedures, liposuction is relatively safe. Bowel injury following liposuction is a rare but devastating complication, which necessitates hospital admission and surgical intervention. The authors highlight a case report describing the presentation, diagnosis, and management of a patient with bowel injury following liposuction. CASE: A 58-year-old woman presented with abdominal pain, erythema, and discharge three days after 360-degree abdominal liposuction with concomitant fat grafting to bilateral buttocks at an outpatient surgery center. Bowel perforation was suspected after CT-scan revealed extraluminal gas in the abdomen and communication that traversed the peritoneum. Exploratory laparotomy was performed which demonstrated at least one site of distinct perforation of the small bowel and an area omentum noted to be inflamed, thickened and with a purulent rind. The patient underwent 20-cm small bowel resection and partial omentectomy temporarily closed with negative pressure wound therapy. After subsequent abdominal wall debridements the patient received ventral hernia repair with bridging mesh and abdominal closure. CONCLUSIONS: While safe, elective cosmetic procedures are not without risk of serious and even fatal complications. Providers must be familiar with the presentation of bowel injury following abdominal liposuction to prevent delays in appropriate surgical and medical care. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.