Non-Operative Management with Angioembolization of Grade IV and V Renal Injuries in a Hybrid Emergency Room System

Renal injuries occur in more than 10% of patients who sustain blunt abdominal injuries. Non-operative management (NOM) is the established treatment strategy for lowgrade (I–III) renal injuries. However, despite some evidence that NOM can be successfully applied to high-grade (IV, V) renal injuries, it remains unclear whether NOM is appropriate in such cases. The authors report two cases of high-grade renal injuries that underwent NOM after embolization in a hybrid emergency room (ER) system with a 24/7 in-house interventional radiology (IR) team. A 29-year-old male visited Wonkwang University Hospital Regional Trauma Center complaining of right abdominal pain after being hit by a rope. Computed tomography (CT) was performed 16 minutes after arrival, and the CT scan indicated a grade V right renal injury. Arterial embolization was initiated within 31 minutes of presentation. A 56-year-old male was transferred to Wonkwang University Hospital Regional Trauma Center with a complaint of right flank pain. He had initially presented to a nearby hospital after falling from a 3-m height. Thanks to the key CT images sent from the previous hospital prior to the patient’s arrival, angiography was performed within 8 minutes of the patient’s arrival and arterial embolization was completed within 25 minutes. Both patients were treated successfully through NOM with angioembolization and preserved kidneys. Hematoma in the first patient and urinoma in the second patient resolved with percutaneous catheter drainage. The authors believe that the hybrid ER system with an in-house IR team could contribute to NOM and kidney preservation even in high-grade renal injuries.

Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis

Objectives Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency. Methods This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected. Results Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications. Conclusions CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

Characteristics Of Patients Of Descending Necrotizing Mediastinitis Thoracic, Cardiac And Vascular Surgery Subsection Thoracic In Dr. Mohammad Hoesin From 1 November 2019 To 30 November 2020

Background: Acute mediastinitis is an infection of the connective tissue of the interpleural mediastinal space. The infection may spread through the cervical spaces to the mediastinum, via negative intrathoracic pressure and gravity.1 Management of DNM with minimally invasive drainage, namely video-assisted thoracic surgical drainage (VATS),6 mediastinoscopy,7 and percutaneous catheter drainage,8,9 have been widely used. During early 1920s, data showed subsequent to broad-spectrum antibiotics, the mortality rate was about 40%.12 Furthermore, without prompt diagnosis and aggressive surgery, the mortality rate can reach up to 60%.13 Methods: This retrospective study has a descriptive research design. The number of samples is 19 subjects. Results: From January 1, 2019 to November 30, 2020 there were 19 DNM patients. In this study, most DNM patients were male, average age of 39 years, dental abscesses as the most common source of infection, neck exploration and sternotomy were the most common treatment option, most common outcome death, and the most common result of culture was Acinetobacter baumannii. Conclusion: Good non-operative and operative management can reduce mortality rate.

Splenocystojejunostomy for the treatment of a symptomatic splenic pseudocyst

Pancreatic pseudocyst is a widely recognised local complication following acute pancreatitis. Typically occurring more than four weeks after acute pancreatitis, a pseudocyst is a mature, encapsulated collection found within the peripancreatic tissues manifesting as abdominal pain, structural compression, gastroparesis, sepsis and organ dysfunction. Therapeutic interventions include endoscopic transpapillary or transmural drainage, percutaneous catheter drainage and open surgery. We present our management of idiopathic chronic pancreatitis complicated by a pancreatic pseudocyst extending to the splenic capsule in a 38-year-old man. A trial of conservative management was sought, but later escalated to percutaneous fluoroscopic drainage. Despite a period of volume reduction of the pseudocyst, reaccumulation occurred. We describe successful surgical treatment via means of a splenocystojejunostomy and subsequent pain reduction.

MO091BILATERAL EMPHYSEMATOUS PYELITIS: A CASE REPORT AND ULTRASONOGRAPHY FEATURES

Background and Aims Emphysematous pyelitis is a rare urinary infection with gas formation in the excretory system. Diabetes mellitus and urinary tract obstruction are the main risk factors. Most patients are women over 60 years old. The pathogenesis is unknown. Diabetes mellitus and the elevated glucose levels may create a favorable microenvironment for gas-forming microbes, but it does not exhaustively explain clinical and pathological symptoms. Escherichia Coli and Klebsiella Pneumoniae are the most involved bacteria. Clinical features are the same as other forms of pyelonephritis e.g. fever, chills, flank abdominal pain, nausea and vomiting. Ultrasonography, and especially computed tomography (CT) are important diagnostic tools for demonstration of gas within pelvicalyceal system, urethers or even in bladder. Use of parenteral antibiotic, relief of urinary tract obstruction if present, percutaneous catheter drainage of gas and purulent material and nephrectomy are the mainstays of therapy. This report introduces a case of bilateral emphysematous pyelitis with emphasis on its ultrasound presentation. This is one of the few cases of bilateral emphysematous pyelitis reported in literature. Method A 49-year-old female presented to the emergency with asthenia, epistaxis, orthostatic hypotension and nocturnal cramps. Two months before she was referred to Department of Nephrology for proteinuria. In that occasion, renal ultrasound showed normal kidneys and renal biopsy was performed. She started oral therapy with corticosteroid for ANCA-negative vasculitis and iatrogenic diabetes mellitus occurred. She was admitted again to our Department of Nephrology, blood test was performed and revealed: white cell count 20.500/ml; glucose 243 mg/dl; serum creatinine 2.3 mg/dl; C-reactive protein, 0.65 mg/dl ( &lt; 0.5), procalcitonin 2.05 µg/l (nv &lt; 0.5). Urine culture was positive for E. Coli. Results Renal ultrasound revealed the presence, in both kidney pelvises, of multiple and diffuse hyperechogenic images associated with some reverberation artefacts. The ultrasound findings were unusual and of doubtful interpretation: staghorn calculi, encrusted pyelitis, gas? (Fig. 1, 2). Reverberation artifacts give rise the suspicion of gas presence in kidney pelvises, usually absent in case of staghorn calculi and encrusted pyelitis. CT confirmed the diagnosis of bilateral emphysematous pyelitis due to the diffuse presence of gas within the renal calyces, also extending to the ureters and bladder lumen (Fig. 3). We promptly started parental antimicrobial therapy with cefalosporine. After one week we observed a clinical and laboratory improvement, and the renal ultrasound revealed the resolution of bilateral pelvises alteration (Fig. 4). Conclusion In emphysematous pyelitis, renal ultrasound is characteristic due to the presence of diffuse hyperechogenic images located in the renal pelvis associated with some reverberation artifacts, usually absent in case of renal stones. Therefore, the renal ultrasound in association with clinical and laboratory findings, especially in patient with positive urine culture, should arouse the suspicion of emphysematous pyelitis to start promptly antimicrobial therapy, even when CT examination is not immediately available.