Category Archives: Abdomen

Consequences Of Embolizing Renal Injuries

In my last post, I noted that nonoperative management is the norm for dealing with high grade renal injuries. One of the possible options, angioembolization, was relatively infrequently used at only 6% of the time.

For management of other organs like the spleen, there are several angioembolization options. Depending on the type and severity of injury, selective (partial) or nonselective (main splenic artery) embolization can be carried out. For the liver, only selective embolization can be used. But what about the kidney? 

Are there consequences of nonselective renal embolization? Or should we always strive for selective control? The urology group of the University of Tennessee – Knoxville published a series of papers on their experience using embolization in patients with the most severe injuries (Grade 5). They retrospectively examined just over 3 years of admissions with this injury. Numbers were very small (6 men, 3 women).

But they also published a second paper, extending the review dates to capture one more male patient. And they followed this group for 1.5 to 5 years (mean 2.5 years) to determine if any delayed complications surfaced.

Here are the factoids:

  • Seven patients underwent full, nonselective embolization, and the other three had “super selective” embolization
  • All patients had control of bleeding without surgical intervention
  • Followup CT imaging showed no persistent extravasation or expanding hematoma
  • No patient developed complications, such as a retroperitoneal abscess, prolonged fever, or hypertension while in the hospital or during short-term followup
  • Most patients showed a very small increase in serum creatinine (mean 0.04), but one patient increased from 1.1 to 1.7
  • On longer term followup, one patient, age 51, developed hypertension 10 months after his injury. It is not possible to determine whether he was one of the 20% of older adults who develop hypertension, or whether it was due to the procedure. it was well-controlled with a single antihypertensive med.
  • None developed altered renal function, stones, chronic pain, fistula, or pseudoaneurysm

Bottom line: Obviously, the data is very limited with only 10 patients. However, it is very interesting to note that the majority of these patients underwent nonselective embolization of the renal artery without any adverse event. The one case of hypertension occurred with nonselective embolization, although I have seen several case reports where this occurs with selective embolization as well.

It is now well-accepted that high-grade renal injury can and should be managed nonoperatively if the patient’s hemodynamic status is reasonable. I recommend a trip to interventional radiology if the patient has active extravasation or a high-grade (Grade 4 or 5) injury, as these patients are at risk for loss of the entire kidney otherwise. Selective embolization can be attempted first, but don’t be shy to take out the entire organ if need be. 

References: 

  • Percutaneous embolization for the management of Grade 5 renal trauma in hemodynamically unstable patients: initial experience. J Urology 181:1737-1741, 2008.
  • Intermediate-term follow-up of patients treated with percutaneous embolization for Grade 5 blunt renal trauma. J Trauma 69(2):468-470, 2010.
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Contemporary Management Of Renal Injuries

A synopsis of contemporary management of renal injury was presented at the annual meeting of the American Association for the Surgery of Trauma last year. The Genito-Urinary Trauma Study Group (GUTS [groan!]) prospectively collected data on high-grade (grades 3-5) renal injuries from 14 Level I trauma centers over a 14 year period.

Here are some factoids from the article:

  • Expectant management (nonoperative or minimally invasive angio/stenting/drainage) was the norm, with 80% of these high-grade injuries dealt with in this manner
  • Only 6% of patients undergoing minimally invasive treatment underwent angioembolization
  • As expected, the higher the grade, the more likely the kidney would be removed (Grade 4 = 15%, Grade 5 = 62%)
  • Once operative management was performed, the nephrectomy rate escalated to 67%
  • Nephrectomy was more common in patients with penetrating trauma (60%)

Bottom line: Nonoperative management of renal injuries has long been the norm. This more recent review confirms it. Once the abdomen is opened, the chance of losing the entire kidney skyrockets. Expectant management (repeat exam and labs) is very common, and very successful. 

Angiography is an important adjunct, but was not used very commonly in this study. Perhaps the surgeons were concerned about complications from embolizing part or all of the kidney? I’ll discuss the consequences of this in my next post.

Reference: Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study. J Trauma 84(3):418-425, 2018.

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How To Evaluate A Stab To The Diaphragm – Part 2

Yesterday I gave a little perspective on the use of CT in assessing the diaphragm after penetrating injury. Today, I’ll break it down into some practical steps you can follow the next time you see one.

Step 1. Stable or unstable? If your patient arrives with unstable vital signs, and there is no other source but the abdomen, the answer is simple. Go to the OR for a laparotomy. Period. They are exsanguinating and the hemorrhage needs to be stopped.

Step 2. Mark the sites of penetration and take a chest x-ray. This will let you evaluate the potential trajectory of the object, and will give you your first glimpse of the diaphragm.

Step 3. Examine the abdomen. Actually, you should be doing this at the same time you are setting up for Step 2. If your patient has peritoneal signs, no further evaluation is needed. Just go to the OR for laparotomy. Look at the chest x-ray once you get there.

Step 4. Right side? If your appreciation of the path of penetration involves just the liver, take the patient to CT for evaluation of chest, abdomen, and pelvis. You need to see all three of these areas to assess for blood and fluid in both body cavities. After the study, if you still think the injury is limited to the liver, admit the patient for observation.

Step 5. Left side? Look at that chest x-ray again. If there are any irregularities at all, strongly consider going to the OR and starting with diagnostic laparoscopy. These irregularities can be glaring, like in the x-ray above. But they can be subtle, like some haziness above the diaphragm or small hemothorax. Obviously, if the injury is as clear as on the x-ray above, just open the abdomen. But if in doubt, start small. And remember my advice on “lunchothorax.”

Step 6. Admit and observe. Check the abdomen periodically, and repeat the chest x-ray daily. If anything changes, consider diagnostic laparoscopy. As a general rule, I don’t keep patients NPO “just in case.” Most will pass this test, and I don’t see a reason to starve my patients for the low likelihood they need to go to the OR.

Step 7. Make sure your patient gets a follow up evaluation. See them in your outpatient clinic, get a final chest x-ray and abdominal exam before you completely clear them.

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How To Evaluate A Stab To The Diaphragm – Part 1

Penetrating injury to the diaphragm, and specifically stab wounds, have been notoriously hard to diagnose since just about forever. Way back in the day (before CT), we tried all kinds of interesting things to help figure out if the patient had a real injury. Of course, we could just go to the OR and lap the patient (laparoscopy did not exist then). But the negative lap rate was significant, so we tried a host of less invasive techniques.

Remember diagnostic peritoneal lavage? Yeah, we tried that. The problem was that the threshold for red cells per cubic mm was not well defined. Some would supplement this technique with a chest tube to see if lavage fluid would drain out. And one paper described instilling nuclear medicine tracer into the abdomen and sitting the patient under a gamma camera for a few hours to see if any ended up in the chest. Groan!

We thought that CT would save us. Unfortunately, resolution was terrible in the early years. If you could actually see the injury on CT, it was probably because a large piece of stomach or colon had already fallen through it. But as detectors multiplied and resolution improved, we could begin to see some smaller defects. But we still missed a few. And the problem is that left-sided diaphragmatic holes slowly enlarge over time (years), until the stomach or colon falls through it. (See below)

A group of radiologists and surgeons in a Turkish trauma hospital recently published a modest series of patients with left-sided diaphragm injuries evaluated by CT. They looked at about 5 years of their experience in a group of patient who were at risk for the injury due to a thoraco-abdominal stab wound. Unstable patients were immediately taken to OR. All of the remaining patients underwent an initial CT scan, followed by diagnostic laparoscopy after 48 hours if they remained symptom free.

Here are the factoids:

  • A total of 43 stable patients with a left thoraco-abdominal stab were evaluated
  • 30 patients had a normal CT, and 13 had the appearance of an injury
  • Of those who were CT positive, only 9 of 13 (69%) actually had the injury at operation
  • Two of the 30 (7%) who were CT negative were found to have a diaphragm injury during followup laparoscopy
  • So in the author’s hands, there was 82% sensitivity, 88% specificity, a positive predictive value of only  69%, and a negative predictive value of 93%

Bottom line: The authors somehow looked at the numbers and concluded that CT is valuable for detecting left diaphragm injury. Huh? They missed 7% of injuries, only finding them later at laparoscopy. And they had a 31% negative laparotomy rate. 

Now, it could be that the authors were using crappy equipment. Nowhere in their paper do they state how many detectors, or what technique was used. Since it took place over a 5 year period, it is quite possible that the earlier years of the study used equipment now considered to be out of date, or that there was no standardized technique.

CT may not yet be ready for prime time. But it can be a valuable tool. Tune in tomorrow for some tips on how and when to look for this insidious injury.

Reference: Evaluation of diaphragm in penetrating left thoracoabdominal
stab injuries: The role of multislice computed tomography. Injury 46:1734-1737, 2015.

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Splenic Vascular Blush

Contrast blush is always a concern when seen on CT of the abdomen for trauma. It can represent one of two things, and both are bad:

  • Active extravasation of contrast
  • Splenic pseudoaneurysm

These two clinical issues can be distinguished by looking at the location of the contrast and its persistence. A pseudoaneurysm is located within the parenchyma, and the contrast will wash away, so it will not be visible on delayed images. Contrast that extends beyond the parenchyma or persists in delayed views represents active bleeding. In either case, the failure rate of nonoperative management exceeds 80% in adults without additional measures being taken.

Clinically, these patients usually act as if they are losing volume and require additional crystalloid and/or blood transfusion. The natural history in adults is for bleeding to continue or for the pseudoaneurysm to rupture, resulting in a quick trip to the operating room.

If vital signs can be maintained with fluids and blood, a trip to interventional radiology may solve the problem. Selective or nonselective embolization can be carried out and patients with only a few bleeding points can be spared operation. However, if multiple bleeding areas are seen, it is probably better to head to the OR for splenorrhaphy or splenectomy.

The image below shows likely areas of extravasation. They are a bit large to be pseudoaneurysms.

Spleen Blush-CT

Children are different than adults. Extravasation from spleen injuries in prepubescent children frequently stops on its own. Angiography should only be used if the child is failing nonoperative management.

Next post: A new paper looks at the natural history of these lesions.

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