Blunt Thoracic Aortic Injuries (BTAI) are the second leading cause of trauma-related deaths in the United States. Using the Harborview grading system, BTAI can be classified as minimal, moderate or severe. Patients with BTAI often present with multiple concomitant injuries, including solid organ injuries, which can influence treatment decisions. While moderate BTAI can undergo semi-elective repair, the optimal management of moderate BTAI with associated solid organ injury (SOI) is unknown. The aim of this study was to analyze our experience with patients presenting with concomitant moderate BTAI and SOI.

We conducted a single-center retrospective study of patients who underwent thoracic endovascular aortic repair (TEVAR) for treatment of moderate BTAI between March 2015 and December 2023. SOI's and their grades were identified, and our institutional solid organ injury protocol was followed for each patient. Our endpoints included surgical timing, outcomes and the need for reintervention.

214 patients presented with BTAI during the study period. 88 patients underwent TEVAR for moderate BTAI and 46 (52 %) of those presented with concomitant SOI. SOI's included liver (63%), spleen (59%) and kidney injuries (37%). Patients with SOI did trend towards longer time from presentation to repair, however, no difference was noted intraoperatively in the dosing of heparin used or activated clotting time between the two groups. Only one patient experienced a bleeding complication associated with their solid organ injury after receiving systemic heparinization during TEVAR and required a return to the operating room for a splenectomy on postoperative day 1. Patients with SOI did have a longer length of stay (LOS); no aortic-related mortalities were noted in either group. Thirty-day all-cause mortality was 4% for patients with SOI and 5% for non-SOI patients (P=0.92).

Patients with moderate BTAI and SOI can safely undergo TEVAR with systemic heparinization without an increased risk of complications. Their prolonged hospital length of stay underscores the severity of their injuries and the multifaceted challenges involved in managing this critically ill patient population.

According to the American Association for the Surgery of Trauma, distal pancreatectomy or pancreatic duct drainage is recommended for grade III traumatic pancreatic injuries. We report a case of traumatic pancreatic injury involving the main pancreatic duct in which this method failed to drain fluid from the area distal to the injury site. A 19-year-old woman presented with a bruised upper left abdomen after a bicycle fall. Computed tomography revealed a linear area of poor contrast in the pancreatic body, leading to the diagnosis of grade III pancreatic injury. Endoscopic retrograde pancreatography revealed damage to the pancreatic duct, prompting endoscopic pancreatic stent placement. We added abdominal cavity drainage, peritoneal lavage, and endoscopic ultrasound-guided transgastric pseudocyst drainage. In the patient with pancreatic duct injury, drainage distal to the injury site was unattainable with a pancreatic duct stent; therefore, alternative drainage sites were utilized, thereby obviating the need for surgery.

Because of their vague and subtle indications and symptoms, pancreatic injuries are frequently misdiagnosed. It's crucial to have a high level of clinical suspicion. The presence of other organ solid lesions and vascular injuries, as well as the patient's hemodynamic condition, will determine how these injuries are treated. A surgical approach is mandatory when a ductal disruption occurs. The case of a 32-year-old man who experienced an upper abdominal blunt trauma is presented. He was admitted to our hospital with an acute abdomen 48 hours later. A complete transection of the major pancreatic duct was discovered during surgical investigation, and a distal pancreatectomy with en bloc splenectomy was performed. Even in a delayed context, distal pancreatectomy can be safely performed and is the best option.

Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.

Pancreatic trauma is a rare but potentially lethal entity which requires a high level of clinical suspicion. Early diagnosis and assessment of the integrity of the pancreatic duct are essential since ductal injury is a crucial predictor of morbimortality. Overall mortality is 19%, which can rise to 30% in cases of ductal injury. The diagnostic and therapeutic approach is multidisciplinary and guided by a surgeon, imaging specialist and ICU physician. Laboratory analysis shows that pancreatic enzymes are frequently elevated, which is a low specificity finding. In hemodynamically stable patients, the posttraumatic condition of the pancreas is firstly evaluated by the multidetector computed tomography. Moreover, in case of suspicion of ductal injury, more sensitive studies such as Endoscopic Retrograde Cholangiopancreatography or cholangioresonance are needed. This narrative review aims to analyze the etiopathogenesis and pathophysiology of pancreatic trauma and discuss its diagnosis and treatment. Also, the most clinically relevant complications will be summarized.

Trauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation.

A systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation.

Twelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12).

Based on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.

The animal models of traumatic pancreatitis (TP) were established to evaluate the specific mechanisms by which umbilical cord mesenchymal stem cell-derived exosomes (ucMSC-Ex) exert therapeutic effects. Sixty four rats were randomly divided into eight groups, including TP groups with three different degrees and relevant groups with ucMSC-Ex treated. The degrees of pancreatic tissue injury were evaluated by Histological Examination. Furthermore, enzyme-linked immunosorbent assay were applied to evaluate the activity of pancreatic enzymes and levels of inflammatory factors in serum. Finally, the apoptotic effects of each group were evaluated by TUNEL, western blot (WB), and real time fluorescence quantitative polymerase chain reaction (RT-qPCR). The pancreatic histopathological score and serum amylase and lipase levels gradually increased in various degrees of TP and the levels in the treatment group were all significantly decreased. The apoptosis index gradually increased in each TP group and significantly decreased in the treatment group in TUNEL results. WB and RT-qPCR showed the same trend, that bax and caspase-3 gradually increased and bcl-2 gradually decreased in TP groups. Compared with TP groups, the expression of bax and caspase-3 were lower while bcl-2 expression was higher in the treatment group. ucMSC-Ex suppressed the inflammatory response and inhibited pancreatic acinar cell apoptosis to promote repair of injured pancreatic tissue.

Pancreatic trauma is rare compared to other abdominal solid organ injuries, accounting for 0.2%-0.3% of all trauma patients. Moreover, this type of injury may frequently be overlooked or not readily appreciated on initial clinical examinations and investigations. The organ injury scale determines the severity of the trauma. Nonetheless, there are conflicting recommendations for the best strategy in severe cases. Overall, conservative management of induced severe traumatic pancreatitis is adequate. Modern imaging modalities such as ultrasound scanning and computed tomography scanning can detect injuries in fewer than 60% of patients. However, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) have diagnostic accuracies approaching 90%-100%. Thus, management options include ERCP and stent placement or distal pancreatectomy in cases of complete gland transection and wide drainage only for damage control surgery, which can prevent mortality but increases the risk of morbidity. In the majority of cases, surgical intervention is not required and should be reserved for only severe grade III to grade V injuries.

Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital.

This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012.

Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death.

Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.

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.

Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions.

The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size.

In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions.

Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making.

Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.

The liver is the most commonly injured solid organ in blunt abdominal trauma. Although the incidence of hepatic lacerations continues to rise, non-operative management with angioembolization is currently the standard of care. While active arterial hemorrhage is commonly embolized in grade 3 or 4 injuries, patients with grade 5 injuries frequently require operative intervention.

A 30-year-old man presented to our level I trauma center following a motor scooter accident. CT abdominal imaging revealed a grade 5 right lobar hepatic laceration. He underwent successful angioembolization without further hemorrhage. The patient later developed abdominal discomfort that worsened to peritonitis and he was taken for laparoscopic drainage of massive hemoperitoneum with bile peritonitis. Postoperatively, the patient's abdominal pain abated and he tolerated oral dietary advancement.

Surgical management of blunt hepatic trauma continues to evolve in tandem with minimally invasive interventional techniques. Patients with high-grade lacerations are at higher risk for developing biliary peritonitis, hemobilia, persistent hemoperitoneum, and venous hemorrhage after angioembolization. Accordingly, the primary role of surgery has shifted in select patients from laparotomy to delayed laparoscopy to address the aforementioned complications.

While laparotomy remains crucial for hemodynamically unstable patients, angioembolization is the primary treatment option for stable patients with hemorrhage from liver trauma. The combination of angioembolization and delayed laparoscopy may be considered in stable patients with even the highest liver injury grades.

Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma.

Systematic literature review until May 2018.

Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries.

Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.