James M. Haan

To determine the need for further therapy in patients with persistent or new pseudoaneurysms (PSAs) after splenic main coil embolization. The institutional review board approved the study. The study group consisted of 400 hemodynamically stable patients (261 men, 139 women; mean age, 38.5 years) with blunt splenic injury. Abdominal computed tomography (ACT) images were assessed for grade of splenic injury, volume of hemoperitoneum, and evidence of splenic vascular injury including splenic vascular lesions and active bleeding. Splenic arteriography was performed for high-grade splenic injury and for ACT evidence of vascular injury. Follow-up ACT was reviewed for evidence of new or persistent PSAs after main coil embolization of the splenic artery. Medical records were reviewed to determine final outcome and any additional therapies used. Thirty-two patients had persistent (27) or new PSAs (5) after main coil embolization. Of these patients, two required splenectomy and one splenorrhaphy. The nonoperative salvage rate was 91% and the splenic salvage rate was 94%; this was comparable to the overall salvage rate of 95%. Splenic embolization remains a valuable adjunct in splenic salvage. Patients with persistent or new splenic PSAs after main coil embolization have similar splenic salvage rates to the overall cohort without additional therapies.

The objective of this study was to evaluate incidence of chylous injury in blunt trauma using a retrospective chart review. We present two patients who sustained chyle duct injury after blunt trauma. The first patient is a pedestrian struck by car. Abdominal CT scan revealed duodenal thickening and a moderate amount of paraduodenal fluid, which prompted surgical exploration. At laparotomy, the patient was found to have a disruption of his lymphatics at the level of the inferior vena cava (IVC) without duodenal injury treated with hemoclips, fibrin sealant and elemental gastrojejunal feeds. The second patient was involved in a high speed motor vehicle collision (MVC) resulting in transection of the mesentery of the transverse colon. Disrupted lacteals were treated intra-operatively with hemoclips and fibrin sealant decreasing the lymph leak. In both cases, the leak completely resolved with use of tube feedings with medium chain triglycerides. On literature review, six prior patients with spontaneous chylous retroperitoneum were described undergoing similar operative management. Chylous leakage due to blunt trauma is a rare finding. Mechanism of injury includes hyperextension or flexion resulting in stretching and shearing of the tethered lymphatics. Open ligation or clipping of the injured ducts seems effective. Tube feeds with medium chain triglycerides may enhance efficacy of operative treatment.

Background: Daily multidisciplinary discharge rounds have been shown to decrease length of stay (LOS), increase patient volumes, and virtually eliminates “bypass” (inability to accept admissions). Originally, these were attended by senior house staff from each trauma team. Implementation of the 80-hour workweek precluded house staff participation, raising concerns that these rounds would loss their benefits. Certified nurse practitioners (CRNPs) were added to the trauma teams to assist in patient care and represent the team on discharge rounds, replacing the fellows. We hypothesized that this would offset any potential negative effects. Methods: A senior trauma physician leads discharge rounds, focusing on each patient's plan of care. Rounds cover 90 inpatient beds and last approximately 60 minutes. CRNPs from each trauma team, orthopedics, and neurosurgery as well as the teams' discharge planner, hospital bed manager, unit nursing staff, and physical, occupational, and speech therapists participate in discharge rounds. Results: The results are stratified by time period: June 1998 to May 1999 is before discharge rounds, June 1999 to May 2001 is during the house staff period, and June 2001 to May 2004 is when CRNPs replaced fellows and residents. During the 5-year period, 1999 to 2004, daily discharge rounds maintained their efficacy. We have increased admissions, whereas LOS has remained the same. Admissions of greater than 24 hours have increased, whereas average injury severity score has statistically remained the same. Bypass has virtually been eliminated. Conclusions: Adding CRNPs to discharge rounds has allowed us to have the continued benefits of decreased LOS and increased patient volume. Bypass remains rare. CRNPs can effectively replace some house staff functions.

The utility of esophagogastroduodenoscopy (EGD) performed at the time of percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of PEG yielded clinically useful information important in patient care. We also reviewed the outcome and complication rates of EGD-PEG performed by trauma surgeons.

The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.

Splenic embolization can increase nonoperative salvage. However, complications are not clearly defined. A retrospective multicenter review was performed to delineate the risks and benefits of splenic embolization. A retrospective chart review of all patients undergoing splenic embolization from 1997 to 2002 at four separate Level I trauma centers was performed. Reviewed results included patient demographics, admission and follow-up computed tomographic scan results, angiographic technique, and patient outcomes including splenic salvage rate and procedural complications. A total of 140 patients were reviewed. The majority were young male patients involved in motor vehicle crashes. These patients had high abdominal computed tomographic grades of splenic injury and moderate Injury Severity Scores. The splenic salvage rate was 87%, which decreased with increasing injury grade. However, over 80% of splenic injury grades 4 and 5 were successfully managed nonoperatively. Significant hemoperitoneum did not affect success, but the presence of arteriovenous fistula was associated with a high failure rate, even with embolization. Salvage rates were similar between main coil and subselective embolization groups. Patients over 55 years of age did no worse than younger patients. Major complications included bleeding in 16 patients; 6 splenic abscesses, with 5 patients requiring splenectomy; and 1 episode of arterial injury requiring operative repair. Splenic embolization remains a valuable technique in splenic salvage, especially in higher grade injuries. Complications are common but do not seem to affect outcome.