Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

/pdf/duodeno-pancreatic-and-extrahepatic-biliary-tree-trauma-wses-3t4ecr7gtu.pdf

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research. 

/pdf/wses-guidelines-on-blunt-and-penetrating-bowel-injury-3gcjit1h.pdf

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

AAA is relatively common in the elderly. EVAR in this population is efficient with a success rate exceeding 90% in all cases. Since open repair has extensively being reported and studied, we focus on endovascular repair of this pathology in this chapter. J. Boccardo

Geriatric Trauma and Acute Care Surgery

Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.

/pdf/the-prognosis-of-blunt-bowel-and-mesenteric-injury-the-52yy3c5995.pdf

The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey.

Decision making in management of blunt bowel and mesenteric injury (BBMI) is difficult. This study aimed to identify indicators for laparotomy and appropriate time intervals to surgery. We retrospectively reviewed our hospital’s trauma registry to identify patients with a diagnosis of BBMI from February 2011 to July 2017. Patients requiring therapeutic surgical treatment (OM group) were compared with those who did not (NOM group). Preoperative risk factors for surgery (with p < 0.1 by univariate analysis) were integrated in a multivariate logistic regression model. In the OM group, we identified relevant factors for time intervals to surgical interventions. Among 2808 trauma patients admitted to our hospital, 83 (3.0%) had bowel and mesenteric injury; 6 patients with penetrating trauma, 2 lethal, untreated cases, and 2 patients who underwent exploratory laparotomy were excluded. Finally, 73 patients (47 males), with a mean Injury Severity Score (ISS) of 23, were included. Results from univariate analysis identified three relevant factors between the OM and NOM groups: ISS score (p = 0.036), hemodynamic instability (p = 0.041), and free air (p = 0.0018). Multivariate analysis revealed one relevant factor, free air (p = 0.0002). Short intervals between hospital admission and intervention were associated with 7-day mortality (p = 0.029), hemodynamic instability (p = 0.0009), focused assessment with sonography for trauma positive (p < 0.0001), and mesenteric extravasation (p = 0.012). Early surgical intervention is essential in cases of hemodynamically unstable BBMI and bowel perforation with free air; nevertheless, it is associated with high mortality. We suggest that prompt transport along with early intervention could significantly lessen mortality.

Surgical intervention for blunt bowel and mesenteric injury: indications and time intervals

Background The diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high. Patients and methods Blunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR ≥ 1. CT findings, DPL and surgery results, and global outcome were analyzed. Results Thirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion ( p  = 0.02) and small bowel wall abnormalities ( p  = 0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 ( n  = 10 patients), and the specificity reached 90% (CI 95% [73–98]). Conclusion DPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR ≥ 1. Indications for exploratory laparotomy could be restricted to patients with a CCR ≥ 4 to improve the specificity of diagnosis management.

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma.

/pdf/internal-fistula-leakage-due-to-a-road-traffic-accident-a-477iuncwyx.pdf

Internal fistula leakage due to a road traffic accident: a fortuitous diagnosis of Crohn's disease.

Poster: "ESSR 2017 / P-0256 / Common peroneal nerve: Imaging findings with an emphasis on ultrasound " by: " Q. Monzani , G. Mercy, J.-L. Brasseur, A. Fustier, M. Wagner, O. Lucidarme; Paris/FR"

Common peroneal nerve: Imaging findings with an emphasis on ultrasound

Resume L’imagerie joue un role important dans la prise en charge des patients avec un carcinome hepatocellulaire (CHC) car elle permet de poser un diagnostic sans qu’une preuve histopathologique soit necessaire contrairement a d’autres cancers. Le Liver Imaging Reporting and Data System (LI-RADS) est un systeme de standardisation du compte rendu radiologique en imagerie hepatique chez des patients a risque de CHC. Ce systeme est destine a tous les radiologues, medecins specialistes ou medecins generalistes. Le LI-RADS assigne a chaque observation — c’est-a-dire a toute anomalie — une categorie qui reflete sa probabilite d’etre un CHC. Ce systeme a ete cree pour ameliorer la communication entre les differents intervenants dans la prise en charge des patients, ainsi que l’enseignement et la recherche. C’est un outil evolutif enrichi par la retroaction des utilisateurs. Le but de cette mise au point est de presenter LI-RADS version 2017, expliquer les categories LI-RADS, detailler l’algorithme et tableau pour le classement des observations dans le cadre d’un diagnostic de CHC en tomodensitometrie ou imagerie par resonance magnetique, definir les criteres diagnostiques majeurs et auxiliaires pour parvenir a classer les lesions et souligner les benefices potentiels de l’utilisation de LI-RADS.

Iconographies supplémentaires de l'article : LI-RADS pour le diagnostic de carcinome hépatocellulaire en TDM et IRM

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CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma.

Internal fistula leakage due to a road traffic accident: a fortuitous diagnosis of Crohn's disease.

Common peroneal nerve: Imaging findings with an emphasis on ultrasound

Iconographies supplémentaires de l'article : LI-RADS pour le diagnostic de carcinome hépatocellulaire en TDM et IRM