M. Abu-Gazala, N. Shussman, S. Abu-Gazala, R. Elazary, M. Bala, S. Rozenberg, A. Klimov, A.I. Rivkind, D. Arbell, G. Almogy and A.I. Bloom
Background: Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported.
Objectives: To present our experience with endovascular management of blunt renal artery injury, and review the literature.
Methods: We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications.
Results: Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered.
Conclusions: Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.
E. Nahum, U. Pollak, O. Dagan, G. Amir, G. Frenkel and E. Birk
Background: B-type natriuretic peptide (BNP) has been shown to have prognostic value for morbidity and mortality after cardiac surgery. Less is known about its prognostic value in infants.
Objectives: To investigate the predictive value of BNP levels regarding the severity of the postoperative course in infants undergoing surgical repair of congenital heart disease.
Methods: We conducted a prospective comparative study. Plasma BNP levels in infants aged 1–12 months with congenital heart disease undergoing complete repair were measured preoperatively and 8, 24 and 48 hours postoperatively. Demographic and clinical data included postoperative inotropic support and lactate level, duration of mechanical ventilation, intensive care unit (ICU) and hospitalization stay.
Results: Cardiac surgery was performed in 19 infants aged 1-12 months. Preoperative BNP level above 170 pg/ml had a positive predictive value of 100% for inotropic score ≥ 7.5 at 24 hours (specificity 100%, sensitivity 57%) and 48 hours (specificity 100%, sensitivity 100%), and was associated with longer ICU stay (P = 0.05) and a trend for longer mechanical ventilation (P = 0.12). Similar findings were found for 8 hours postoperative BNP above 1720 pg/ml. BNP level did not correlate with measured fractional shortening.
Conclusions: In infants undergoing heart surgery, preoperative and 8 hour BNP levels were predictive of inotropic support and longer ICU stay. These findings may have implications for preplanning ICU loads in clinical practice. Further studies with larger samples are needed.
G. Yaniv, O. Mozes, G. Greenberg, M. Bakon and C. Hoffmann
Background: Misinterpretation of head computerized tomographic (CT) scans by radiology residents in the emergency department (ED) can result in delayed and even erroneous radiology diagnosis. Better knowledge of pitfalls and environmental factors may decrease the occurrence of these errors.
Objectives: To evaluate common misinterpretations of head CT scans by radiology residents in a level I trauma center ED.
Methods: We studied 960 head CT scans of patients admitted to our ED from January 2010 to May 2011. They were reviewed separately by two senior neuroradiologists and graded as being unimportant (score of 1), important but not requiring emergent treatment (score of 2), and important requiring urgent treatment (score of 3). We recorded the time of day the examination was performed, the year of residency, the site, subsite and side of the lesion, the pathology, the anatomical mistake, false-positive findings, and the attending neuroradiologists' score.
Results: A total of 955 examinations were interpreted of which 398 had misinterpreted findings that were entered into the database, with the possibility of multiple errors per examination. The overall misinterpretation rate was 41%. The most commonly missed pathologies were chronic infarcts, hypodense lesions, and mucosal thickening in the paranasal sinuses. The most common sites for misdiagnosis were brain lobes, sinuses and deep brain structures. The highest percentage of misinterpretation occurred between 14:30 and 20:00, and the lowest between 00:00 and 08:00 (P < 0.05). The overall percentage of errors involving pathologies with a score of 3 by at least one of the neuroradiologists was 4.7%. Third-year residents had an overall higher error rate and first-year residents had significantly more false-positive misinterpretations compared to the other residents.
Conclusions: The percentage of errors made by our residents in cases that required urgent treatment was comparable to the published data. We believe that the intense workload of radiology residents contributes to their misinterpretation of head CT findings.
E. Glassberg, D. Neufeld, I. Shwartz, I. Haas, P. Shmulewsky, A. Benov and H. Paran
Background: Laparoscopic repair of giant diaphragmatic hernias (GDH) can be challenging, especially when partial or complete volvulus of the herniated stomach is encountered.
Objectives: To review our experience with laparoscopic repair of GDH, emphasizing preoperative investigation, technical aspects, and outcome.
Methods: We conducted a retrospective review of patients operated on for GDH who were diagnosed when at least half the stomach was found in the mediastinum at surgery. Technical aspects and surgical outcomes were evaluated.
Results: Fifty patients underwent laparoscopic GDH repair during an 8 year period. Four patients admitted with acute symptomatic volvulus of the stomach were initially treated by endoscopic decompression followed by surgery during the same admission. Two cases were converted to open surgery. Initial surgery was successful in 45 patients; 3 had an immediate recurrence, 1 was reoperated for dysphagia during the same admission, and 1 had a mediastinal abscess. During long-term follow-up, six patients required reoperation for recurrent hernias. Another four patients had asymptomatic partial herniation of the stomach. The main reason for failure was incomplete reduction of the hernia sac, especially the posterior component. No correlation was found between the type of repair and surgical failure. Most patients who did not undergo an anti-reflux procedure had postoperative reflux unrelated to their preoperative workup.
Conclusions: Laparoscopic repair of GDH is challenging, but practical and safe. It should be the treatment of choice for this potentially life-threatening condition. Careful attention to pitfalls, such as the posterior element of the sac, and routine performance of an anti-reflux procedure are crucial.
E. Heldenberg and A. Bass
A. Shturman, M. Gellerman and S. Atar
A. Eyal, Z. Adler, M. Boulos and I. Marai
S. Perlman, O. Paz, Z. Hagay, S. Shimoni, A. Caspi and S. Goland