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Symptomatic Isolated Celiac Artery Dissection following Blunt Trauma

Sang Bong LEE ; Hyuk Jae JUNG ; Jae Hun KIM

Journal of Acute Care Surgery.2019;9(2):76-79. doi:10.17479/jacs.2019.9.2.76

An isolated splanchnic artery injury due to blunt trauma occurs rarely because abdominal vascular injuries are typically associated with injuries to the surrounding abdominal structures, including solid organs or hollow viscus. Of the major abdominal vessels, the celiac artery is the least commonly injured by penetrating or blunt abdominal trauma. Furthermore, a celiac artery dissection due to blunt trauma is rarely reported and there is no clearly defined treatment method, even though endovascular and conservative treatments are accepted widely. On the other hand, endovascular treatment can be challenging if the celiac artery dissection involves its main branch, including the proper hepatic artery, left gastric artery, and splenic artery. This case study presents the treatment experience of a celiac artery dissection involving its main branch following dorsal blunt trauma. Furthermore, conservative treatment is proposed as a treatment option for this rare injury.
Arteries ; Celiac Artery ; Hand ; Hepatic Artery ; Methods ; Splenic Artery ; Vascular System Injuries

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Spontaneous Retroperitoneal Hemorrhage Caused by Idiopathic Acquired Hemophilia A Misdiagnosed as a Delayed Traumatic Hematoma: A Case Report

Seon Hee KIM ; Sung Jin PARK ; Chan Ik PARK ; Seon Uoo CHOI ; Jae Hun KIM

Journal of Acute Care Surgery.2019;9(2):72-75. doi:10.17479/jacs.2019.9.2.72

Acquired hemophilia A (AHA) is a rare disease where typically coagulation factor VIII is inhibited by autoantibodies. It occurs in patients with no personal or familial history of bleeding. In this case study a 61-year-old male presented with a huge psoas hematoma. He had no history of bleeding disorders. He was initially diagnosed with delayed traumatic hematoma. Despite conservative and surgical treatments, coagulopathy was not resolved and postoperative bleeding continued. Consequently, coagulation factor tests were performed and showed reduced activity of factor VIII (2.7%). In addition, factor VIII inhibitor was detected. The patient was diagnosed with AHA and administered recombinant factor VIII for 3 days which resulted in the cessation of bleeding. AHA can lead to a life-threatening hemorrhage, and needs to be considered in differential diagnoses in any patients presenting with unexplained and repeated bleeding, where there is no personal or familial history of bleeding disorders.
Autoantibodies ; Blood Coagulation Disorders ; Blood Coagulation Factors ; Diagnosis, Differential ; Factor VIII ; Hematoma ; Hemophilia A ; Hemorrhage ; Humans ; Male ; Middle Aged ; Rare Diseases

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Nontraumatic Splenic Rupture due to Infectious Mononucleosis

Elliot A FRANK ; James R LAFLEUR ; Stanley OKOSUN

Journal of Acute Care Surgery.2019;9(2):69-71. doi:10.17479/jacs.2019.9.2.69

A 19-year-old otherwise healthy male presented to the Emergency Department with left upper quadrant abdominal pain having felt a “pop” in his abdomen which was followed by nausea and lightheadedness. There was no evidence of trauma but 3 weeks earlier he began with symptoms of a sore throat and nasal congestion without cough. On subsequent investigation, given the patient's acute abdominal pain, abnormal vitals and a non-diagnostic computed tomography scan, an emergent exploratory laparotomy was performed. There was 600 mL of blood evacuated from the abdomen. A 643-gram inflamed and ruptured spleen was identified and removed, and follow-up lab work was positive for heterophile antibody. This report describes spontaneous splenic rupture caused by infectious mononucleosis and compares characteristics of traumatic versus non-traumatic cases.
Abdomen ; Abdominal Pain ; Cough ; Dizziness ; Emergency Service, Hospital ; Estrogens, Conjugated (USP) ; Follow-Up Studies ; Herpesvirus 4, Human ; Humans ; Infectious Mononucleosis ; Laparotomy ; Male ; Nausea ; Pharyngitis ; Spleen ; Splenectomy ; Splenic Rupture ; Young Adult

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Delayed Small Bowel Ischemia following Minor Mesenteric Injury

Gil Hwan KIM ; Jae Hun KIM ; Sang Bong LEE

Journal of Acute Care Surgery.2019;9(2):66-68. doi:10.17479/jacs.2019.9.2.66

We report a case of delayed presentation of small bowel ischemia following minor mesenteric injury after blunt abdominal trauma. Traumatic small bowel and/or mesenteric injury is rare, and minor mesenteric injury is usually managed conservatively. However, mesenteric injury may cause potentially fatal conditions such as hemorrhages or peritonitis in extremely rare cases and require laparotomy. We present a case of small bowel ischemia that occurred 3 days after minor mesenteric injury from blunt abdominal trauma.
Abdominal Injuries ; Accidents, Traffic ; Hemorrhage ; Ischemia ; Laparotomy ; Peritonitis

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Surgical Management of Intestinal Obstruction from Phytobezoar

Man Hon TANG ; Gregory HENG

Journal of Acute Care Surgery.2019;9(2):60-65. doi:10.17479/jacs.2019.9.2.60

PURPOSE: Phytobezoar is the most common type of bezoar, which can occasionally present as an intestinal obstruction. In this study, the surgical experience and outcome in the management of intestinal obstruction caused by bezoars are described.METHODS: A retrospective analysis of all operative cases of bezoars (n = 36) at Khoo Tech Puat hospital between 2011–2017 was performed. Patient demographics, imaging and operative findings, characteristics of bezoars and related morbidities were analyzed. The study population was subdivided into 2 groups based on operative intervention (fragmentation and milking of bezoars, versus enterotomy and/or bowel resection).RESULTS: There were 36 cases of bezoars in 35 patients that were included in this study. Computed tomography scans were diagnostic of bezoars in 27 cases (75%). There were 20 cases (55.6%) that underwent fragmentation and milking of bezoars. The remaining 16 cases (44.4%) required an enterotomy or bowel resection. Bezoars that required enterotomy / bowel resection were more likely to be distally located in the ileum (75% vs 40%, p = 0.01), larger in volume (86.5 mL vs 63 mL, p = 0.04), with significant increase in morbidity rates (43.8% vs 5%, p < 0.01) compared with all other cases of bezoars.CONCLUSION: Risk factors for enterotomy / bowel resection in bezoar bowel obstruction include, non-diagnostic computed tomography scans, distally located, and larger volumes of bezoars. Fragmentation and milking should be attempted first as it has lower morbidity rates than enterotomy / bowel resection surgery.
Bezoars ; Demography ; Humans ; Ileum ; Intestinal Obstruction ; Milk ; Retrospective Studies ; Risk Factors

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Evaluation of Medical Emergency Team Activation in Surgical Wards

Moon Suk CHOI ; Dae Sang LEE ; Chi Min PARK

Journal of Acute Care Surgery.2019;9(2):54-59. doi:10.17479/jacs.2019.9.2.54

PURPOSE: A review was performed to determine the frequency of activating medical emergency teams (MET) in surgical wards, so that resource allocation could be optimized.METHODS: A retrospective observational study was performed to determine the time and frequency when MET were deployed (N = 465) to patients (n = 387) who were admitted to the surgical ward, from March 2013 to July 2016 due to emergency situations.RESULTS: Of the 465 MET activations, 8 did not incur any further intervention. The review showed an average of 151 minutes from onset of symptoms to MET activation, and an average of 110 minutes until intervention (additional diagnosis / treatment). The number of MET activations increased year by year from 2013 to 2016. The transfer of patients to the intensive care units also increased from 34 in 2013, to 82 in 2016. The lowest number of MET activations occurred between 04:00 and 05:00, but there was no difference in the number of MET activations between day and night. However, MET activation in response to acute respiratory distress was significantly higher during the nighttime (p = 0.003).CONCLUSION: Patients admitted to a surgical ward have more serious complications. This study showed that the use of MET in surgical wards has increased year by year, and the frequency of calls between day and night was not different, except higher MET activations observed at night in patients with acute respiratory distress.
Diagnosis ; Emergencies ; Hospital Mortality ; Hospital Rapid Response Team ; Humans ; Intensive Care Units ; Observational Study ; Resource Allocation ; Retrospective Studies

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Inhalation Sedation: A Systematic Review and Meta-Analysis

JinA MO

Journal of Acute Care Surgery.2019;9(2):45-53. doi:10.17479/jacs.2019.9.2.45

PURPOSE: The safety and effectiveness of inhalation sedation, a technique that enables sedation using the inhalation of an anesthetic in an out-of-theater environment was evaluated in this study.METHODS: Electronic literature databases were used to identify the safety assessments and the tests for efficacy of inhalation sedation. Data was retrieved from 1980 to 2017. Safety assessment was based on identifying complications encountered during treatment, and included assessment of the concentration of inhalation anesthetic in the air, gaseous exposure, cardiac index and blood test results, and effectiveness was based on the depth of sedation, degree of pain experienced by the patient, and medical outcomes.RESULTS: The safety of inhalation sedation was similar to intravenous sedation. However, inhalation sedation should be used with caution as repetitive interventions increased liver toxicity, as indicated by the Gasification Force Test Inhalation sedation was clinically effective, and demonstrated a similar depth of sedation, with equally effective pain relief compared with intravenous sedation. In addition, the time taken for cannula removal, and for recovery were typically faster.CONCLUSION: Inhalation sedation was safe and effective and provided similar results to intravenous sedation. However, physicians should be aware that when using inhaled anesthetics, hepatotoxicity has been reported so liver function should be carefully monitored.
Anesthetics ; Catheters ; Hematologic Tests ; Humans ; Hypnotics and Sedatives ; Inhalation ; Liver

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Management of an Open Abdomen Considering Trauma and Abdominal Sepsis: A Single-Center Experience

Young Un CHOI ; Seung Hwan LEE ; Jae Gil LEE

Journal of Acute Care Surgery.2019;9(2):39-44. doi:10.17479/jacs.2019.9.2.39

PURPOSE: To describe the experience of patients over a 7-year period who have had open abdomen (OA) surgery, at a tertiary university hospital.METHODS: The medical records of 59 patients, who were managed with OA after a laparotomy between March 2009 and December 2015, were reviewed retrospectively. The data collected included demographics, indication for OA, abdominal closure methods, abdominal closure rate, the intensive care unit stay duration, mechanical ventilation duration, hospital stay duration, and complications.RESULTS: Forty-seven patients (37 males, 78.7%) with a mean age of 52.2 ± 16.7 years were reviewed in the study. The indications for OA were traumatic intra-abdominal bleeding in 23 patients (48.9%), non-traumatic bowel perforation in 10 (21.3%), non-traumatic bleeding in 7 (14.9%), and bowel infarction in 6 (12.8%). The abdominal wall was closed in 38 patients (80.9%). Primary closures and fascial closure using an artificial mesh were performed on 21 (44.7%) and 12 patients (25.5%), respectively. The median number of dressing changes was 0 (interquartile range 0 – 1). The median duration of the intensive care unit and hospital stays were 12.0 and 32.0 days, respectively. The median interval to abdominal closure was 4 days (interquartile range 2 – 10.3 days). Twenty-seven patients developed complications, including uncontrolled sepsis (21.3%), entero-atmospheric fistula (19.1%), ventral hernia (8.5%), bleeding (4.3%), and lateralization (4.3%). The mortality rate was 44.7% with sepsis being the main cause of death (61.9%).CONCLUSION: Traumatic intra-abdominal bleeding was a common indication for OA. Primary closure was performed in most patients, and frequent complications resulted in poor patient outcomes.
Abdomen ; Abdominal Wall ; Abdominal Wound Closure Techniques ; Bandages ; Cause of Death ; Demography ; Fistula ; Hemoperitoneum ; Hemorrhage ; Hernia, Ventral ; Humans ; Infarction ; Intensive Care Units ; Intra-Abdominal Hypertension ; Intraabdominal Infections ; Laparotomy ; Length of Stay ; Male ; Medical Records ; Mortality ; Respiration, Artificial ; Retrospective Studies ; Sepsis

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The Benefits and Risks of Performing Incidental Appendectomy

Jin Young LEE ; Young Hoon SUL ; Jin Bong YE ; Seung Je GO ; Jin Suk LEE ; Hong Rye KIM ; Soo Young YOON ; Joong Suck KIM

Journal of Acute Care Surgery.2019;9(2):35-38. doi:10.17479/jacs.2019.9.2.35

Acute appendicitis is the most common indication for emergency abdominal surgery worldwide. The risks and benefits of incidental appendectomy during other operations have been debated for over a century. There is no right answer to the question of whether or not to perform incidental appendectomy. Although there are only a few indications where it is explicitly recommended such as in gynecological surgery, malrotation, and Ladd's procedure, incidental appendectomy is cost-effective in selected patient groups, especially in the young, without an increase in morbidity and mortality. In this review, the literature on incidental appendectomy was assessed from several perspectives.
Adolescent ; Appendectomy ; Appendicitis ; Costs and Cost Analysis ; Emergencies ; Female ; Gynecologic Surgical Procedures ; Humans ; Mortality ; Risk Assessment

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Acute Appendicitis

Daibo KOJIMA ; Ari LEPPÄNIEMI ; Suguru HASEGAWA

Journal of Acute Care Surgery.2019;9(2):31-34. doi:10.17479/jacs.2019.9.2.31

Acute appendicitis (AA) is one of the most common causes of acute abdominal pain, which can progress to perforation of the appendix and peritonitis. Recently, AA has been classified into uncomplicated (nonperforated, no phlegmon) or complicated (abscess, perforation, phlegmon) appendicitis, for an appropriate initial treatment. With respect to surgical treatment of AA, laparoscopic surgery has been widely accepted worldwide as a safe and feasible first-line treatment. Over the last decade, non-operative treatment has been proposed as an alternative to surgery in uncomplicated AA, and has also played an important role in the management of complicated AA. AA is also the most common cause for abdominal surgery during pregnancy, though an accurate diagnosis of AA during pregnancy is challenging. In this review, the topics being discussed include: 1) Non-operative management for uncomplicated AA, 2) Management for AA in pregnancy, 3) Management for complicated appendicitis (especially immediate laparoscopic surgery for appendiceal abscess), 4) Appendiceal neoplasms related to complicated AA.
Abdominal Pain ; Appendiceal Neoplasms ; Appendicitis ; Appendix ; Diagnosis ; Laparoscopy ; Peritonitis ; Pregnancy

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