Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure

Purpose

We hypothesized that pediatric blunt trauma patients, initially evaluated at nontrauma centers with abdominal computed tomography (CT) scans, often undergo repeat scans after transfer. This study was designed to quantify this phenomenon, assess consequences, and elucidate possible causes.

Methods

This article is an institutional review board-approved, retrospective chart review of pediatric blunt abdominal trauma patients transferred to a level I trauma center from 2002 to 2007 and evaluated with abdominal CT at the trauma center or at a referring facility.

Results

A total of 388 patients met the study criteria, with 6 patients being excluded because of inability to verify outside records resulting in study group of 382 patients. Of those 382 patients, 199 (52%) underwent abdominal CT before transfer. Thirty-six (18%) of those 199 patients underwent repeat CT scanning at our level I trauma center. Of these 36 patients, 19 (53%) were transferred without their outside CT scans, with 10 (53%) of these 19 having significant abdominal injuries. Of the remaining 17, 6 (17%) had repeat scans to assess changes in vital signs, or patient condition, or because of inadequate outside imaging. The remaining 11 (30%) were repeated despite an acceptable outside CT and no change in patient condition. Only 2 of 11 resulted in changed management. Additional radiation delivered from these repeat scans totaled 180 mSv, and additional patient charges totaled more than $110,000. There was an apparent trend toward increased repeat scanning (from 6.7% in 2002 to 16.7% in 2007).

Conclusions

Abdominal CT scans, for evaluation of pediatric blunt trauma, are frequently repeated after transfer from outside hospitals. In many cases, repeat scans provide useful diagnostic information. However, more than 80% of repeat scanning is potentially preventable with better education of transport personnel (paramedics, emergency medical technicians, and nurses) and emergency department physicians.     

腹部外伤术后近期再手术38例

目的探讨腹部外伤术后近期再手术的原因、预防及处理措施。方法回顾性分析1999年3月至2009年10月收治的38例腹部外伤术后近期因不同原因非计划性再手术病人的临床资料。结果再手术38例中,腹腔大出血9例,消化道瘘8例,胰瘘4例,胆漏3例,腹腔脓肿5例,肠梗阻4例,小肠坏死1例,切口裂开2例,阴性再手术1例,肝脓肿1例。再次手术后死亡4例(10.5%),余痊愈。结论术中探查仔细,操作精细,加强术后观察,提高首次手术质量,是提高腹部外伤疗效的关键;而合理掌握再手术指征、实施及时有效的再次手术可避免疾病进一步恶化。     

胆石症合伴腹腔肿瘤的诊治：附36例报告

目的探讨胆石症合伴腹腔肿瘤患者漏诊原因及诊断治疗经验。方法回顾性分析诊治的胆石症合伴腹腔肿瘤36例的临床资料,男24例,女12例,年龄48～82岁。门诊均以胆石症诊断入院。结果 36例术前明确合并腹腔肿瘤诊断的18例,术中明确诊断12例,术后5 d至3个月明确诊断6例,并再次手术,均获肿瘤病理学诊断。36例中包括胆囊癌5例(13.9%),胆管癌4例(11.1%),肝癌3例(8.3%),十二指肠乳头癌3例(8.3%),胰腺癌6例(16.7%),胃癌6例(16.7%),结肠癌7例(19.4%),直肠癌2例(5.5%)。2例放弃手术治疗,2例行介入治疗,32例手术治疗,其中18例行肿瘤根治性切除术+胆囊切除术和/或胆道探查取石术,4例行肿瘤姑息性切除及胆囊切除术和/或胆道探查取石,4例行剖腹探查术;另6例行腹腔镜下胆囊切除术和/或胆道探查取石术中误诊者,术后5 d至3个月再次手术行肿瘤根治性切除4例,姑息性切除1例,介入治疗1例。结论胆石症可能合并腹腔肿瘤,特别是合并消化道肿瘤,但其漏诊几率较大。胆石症术前应仔细病史采集,对症状体征不典型者和老年患者术前进行系统全面检查,术中详细探查腹腔脏器,及时发现可能存在的腹腔肿瘤,术后对胆囊切除术后综合征患者应严密随访,以避免漏诊及延误治疗。     

上腹部器官簇移植手术方式的探讨

目的探讨上腹部器官簇移植治疗多脏器恶性肿瘤的可行性及临床效果。方法上腹部器官簇移植受者2例,其中男、女各1例;均为胰腺癌肝转移患者。2例患者分别于2004年5月和8月接受上腹部器官簇移植治疗,切除脏器包括全胃、肝脏、胰腺、脾脏、十二指肠及部分空肠,移植器官簇包括肝脏、胰腺、十二指肠。其中1例胰腺肿物侵犯肠系膜上动脉（SMA）,切断SMA后,其远端与右髂总动脉吻合重建血供。结果2例患者于术后4h及5h清醒,8h及10h后撤除呼吸机;术后第3天及第5天从外科加强治疗病房转至普通病房。肝功能指标在手术1周后趋于正常;胰腺功能在10d内达到正常范围。1例患者存活12个月,死于肿瘤复发;另1例术后恢复平稳,术后20d自动出院。结论肝胰十二指肠器官簇移植为上腹部局部多脏器恶性肿瘤提供了一种手术上可行并具有一定疗效的治疗方法。     

Intra abdominal hypertension and the abdominal compartment syndrome

The patho-physiological significance of raised intra-abdominal pressure, known as Intra Abdominal Hypertension, with subsequent organ dysfunction and failure, known as Abdominal Compartment Syndrome, has recently been demonstrated to occur relatively frequently in mixed populations of critically ill patients. Clinical diagnosis is unreliable, so routine measurement of intra abdominal pressure should be undertaken, particularly in specific groups of patients known to be at high risk. Whilst definitive therapy requires surgical abdominal decompression, less invasive therapies have been investigated and, if initiated early, may help to minimise progression of the condition. Clearly defined indications for surgical intervention remain elusive however and require prospective investigation. This review summarises the patho-physiology of the syndrome, its diagnosis and surveillance, and current management strategies, both medical and surgical.     

腹腔镜微创技术施行直肠癌腹会阴联合切除手术的体会

目的:总结腹腔镜微创技术施行腹会阴联合切除术(abdom inal pelvic resection,APR)治疗低位直肠癌的手术体会。方法:2003年1月至2006年12月,我院为17例低位直肠癌患者行腹腔镜微创APR根治术。其中男10例,女7例,45~82岁,平均72岁。腹部手术在腹腔镜下完成,会阴部手术按常规手术进行。结果:17例中14例(82.4%)采用完全腹腔镜术式,3例(17.6%)采用腹腔镜辅助术式。手术中均未行盆底腹膜关闭和结肠造口旁间隙关闭。平均手术时间为(166.2±42.7)m in,全组无手术死亡病例。术后早期并发症有会阴部切口感染2例(11.8%),不全性肠梗阻1例(5.9%)。术后随访2~48个月,平均26个月,最长无瘤生存期48个月,造口旁疝1例(5.9%),远处转移1例(5.9%),无局部复发,无戳口和切口肿瘤种植以及肠梗阻发生。结论:腹腔镜微创技术用于APR手术具有患者创伤小的优势;术中造成的系膜裂孔和盆底腹膜均无缝合关闭的必要,但结肠造口必须严密缝合腹膜防止造口旁疝形成;会阴部手术必须严格无菌操作预防感染。腹腔镜微创技术是APR手术的较好方式。     

腹茧症7例临床分析

目的:探讨腹茧症病因诊断和治疗的方法.方法:对2004～2006年住院7例腹茧症患者的临床资料进行回顾性分析.结果:6例有外科急腹症的表现,术前分别诊断为:消化道穿孔、十二指肠淤滞症、盆腔囊肿、盆腔子宫内膜异位症、原因不明的急性肠梗阻;另1例行胃癌手术时发现本病.7例术前均未明确诊断,经手术证实为腹茧症.术后全部治愈出院,随访无复发. 结论:腹茧症临床表现不典型,诊断困难,误诊率高,确诊需剖腹探查和病理切片.纤维包膜切除术和肠粘连松解术是治疗本病的有效方法.     

腹腔镜诊断治疗腹部刺伤90例报告

目的：探讨腹腔镜诊断及治疗腹部刀刺伤的价值。方法：腹部刀剌伤90例患者术前探查示与腹腔相通,应用腹腔镜完成诊断及治疗。结果：90例患者均在腹腔镜下明确诊断。17例无腹腔内脏损伤,52例于腹腔镜下完成治疗,21例中转开腹。结论：诊断明确的腹部刀刺伤选用腹腔镜探查,多可同时完成治疗,只少部分病例需开腹手术。     

Repair of an Abdominal Aortic Aneurysm with a Remarkably Dilated Meandering Artery: Report of a Case

A 73-year-old man on dialysis for chronic renal dysfunction was referred to our hospital for surgical treatment of an abdominal aortic aneurysm (AAA). Preoperative angiography showed a remarkably developed meandering artery branching from the inferior mesenteric artery (IMA). The superior mesenteric and celiac arteries were occluded at the origin, and all blood flow to the abdominal organs was apparently supplied by collateral circulation from the IMA. Considering the risk of mesenteric ischemia after aortic clamping in conjunction during surgery, we used a perfusion catheter with a 12-F balloon to create a shunt to the IMA from the subclavian artery. The operation was successful and the patient recovered uneventfully. We describe this surgical procedure for its effectiveness in preventing postoperative mesenteric ischemia in a rare case of an AAA with complex branching lesions.     

Scar endometriosis—a gynaecologic pathology often presented to the general surgeon rather than the gynaecologist: report of two cases

Introduction Scar endometriosis develops in and is adjacent to surgical scars at the site of previous abdominal operations. The most frequent clinical presentation of the disease is that of a palpable subcutaneous mass near surgical scars associated with cyclic pain and swelling during menses. Endometriosis of the surgical scar is often referred to the general surgeons because the clinical presentation suggests an incisional hernia or other conditions related to the general surgery. Cyclical symptoms such as pain and swelling, in relation to surgical scars, which worsen at the time of menstruation, are nearly pathognomonic of scar endometriosis. However, often the diagnosis of endometriosis is not suggested until after histology has been performed. Case report We present two cases of cutaneous endometriosis that has occurred on the site of previous cesarean section scar area.