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Introduction: Abdominal trauma in children is a significant health concern that often leads to severe complications and even death. Children experience trauma more frequently than adults, with approximately one in four pediatric patients suffering from serious abdominal injuries. Falls are the leading cause of such trauma among children, which is intriguing considering that most hospital admissions for pediatric abdominal injuries result from blunt force impacts., Method: A retrospective cross-sectional analysis of medical records was conducted to examine all patients under the age of 16 who underwent exploratory laparotomy for abdominal trauma between January 1, 2020, and January 1, 2023. The clinical data were gathered using a data extraction sheet from each patient's medical charts. Information on socio-demographic characteristics, injury mechanisms, clinical conditions at the initial presentation, intraoperative findings and complications, and patient outcomes were collected., Results: The study involved a total of 90 patients, consisting of 72 males (80%) and 18 females (20%). The average age of the patients was 10, with a standard deviation of 4.7, ranging from 2 to 16 years. Half of the patients were below the age of 10, accounting for 46 individuals (51%). The causes of the injuries varied among patients below and above the age of 10. However, overall, bullet injuries were the most common cause, accounting for 28 cases (31%), followed by falls in 21 cases (23.3%), horse or donkey kicks in 10 cases (11.1%), stab injuries in 10 cases (11.1%), horn injuries in 7 cases (7.8%), and road traffic accidents in 6 cases (6.7%). Physical assault, blasts, and other types of injuries, such as hen bites and metal rod injuries, were observed in 8 cases (8.9%) of the patients. Fall accidents, horse or donkey kicks, and horn injuries were particularly more common among children below the age of 10, while bullet injuries and stab injuries were most common among those above the age of 10., Conclusion: Following abdominal trauma in children, a range of complications may arise, including immediate issues such as infections and hemorrhaging, as well as long-term consequences like impaired organ functionality and psychological distress. In our region, young children are particularly vulnerable to accidents involving falls, kicks from horses or donkeys, and injuries caused by horns. Therefore, it is crucial to educate parents about these hazards. Additionally, providing appropriate guidance on firearm safety is essential for individuals who possess such weapons., (© 2024. The Author(s).)

The radiologic finding of focal stenosis of the main pancreatic duct is highly suggestive of pancreatic cancer. Even in the absence of a mass lesion, focal duct stenosis can lead to surgical resection of the affected portion of the pancreas. We present four patients with distinctive pathology associated with non-neoplastic focal stenosis of the main pancreatic duct. The pathology included stenosis of the pancreatic duct accompanied by wavy, acellular, serpentine-like fibrosis, chronic inflammation with foreign body-type giant cell reaction, and calcifications. In all cases, the pancreas toward the tail of the gland had obstructive changes including acinar drop-out and interlobular and intralobular fibrosis. Three of the four patients had a remote history of major motor vehicle accidents associated with severe abdominal trauma. These results emphasize that blunt trauma can injure the pancreas and that this injury can result in long-term complications, including focal stenosis of the main pancreatic duct. Pathologists should be aware of the distinct pathology associated with remote trauma and, when the pathology is present, should elicit the appropriate clinical history., Competing Interests: Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

This review and case study illustrates a patient with a complete transverse transection of a non-pregnant uterus caused by blunt trauma associated with wearing a safety belt. The 31-year-old patient, who had a previous cesarean section, presented with impending hypovolemic shock caused by intra-abdominal hemorrhage secondary to blunt trauma while wearing a safety belt. On physical examination, a transverse straight line of ecchymosis along the line of a fastened safety belt was noted without any other external injury. The operative findings revealed a complete transverse transection which had cut through the lower part of the non-pathological, normal-sized uterus with active bleeding and mild injury to the small bowel without active bleeding. Total hysterectomy and simple closure of the small bowel were performed with successful outcomes. We hypothesize that transection was caused by the enormous pressure produced by blunt trauma transmitted through the abdomen by the fastened safety belt and the weakness of the uterine wall caused by the previous low transverse cesarean section which facilitated the separation and extension to the entire wall. In conclusion, this case study provides the following learning points: (1) Enormous forces produced by a fixed fastened safety belt during a car accident can cause complete transverse transection of a normal-sized, non-pathological uterus, leading to life-threatening intra-abdominal hemorrhage. (2) A previous cesarean section may potentiate the transection, especially when the uterus is repositioned above the pelvic brim. (3) The gynecologic condition should also be included in the differential diagnoses in cases of intra-abdominal hemorrhage. If highly suspected, gynecologists should be notified for early recognition and avoidance of delayed actions., (© 2023 International Federation of Gynecology and Obstetrics.)

Background: Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds., Methods: Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis., Results: 5984 patients met inclusion criteria with 7 ​% and 8 ​% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 ​%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 ​% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients., Conclusions: In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds., Level of Evidence: Prognostic and Epidemiological; Level IV., Competing Interests: Declaration of Competing interest The authors have no conflicts of interest or funding to disclose. All American Journal of Surgery Disclosure forms have been supplied and are provided as supplemental digital content., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Vaginal pessaries are widely considered to be a safe and effective non-surgical management option for women with pelvic organ prolapse. Complications may occur, and are more frequent with improper care and certain device designs and materials. It is imperative to provide information to patients about potential complications. We present the case of a woman in her 70s who presented to the Emergency Department with increasing groin and abdominal pain following a vaginal pessary insertion 2 days prior for grade 3 vaginal vault prolapse. On presentation, her abdomen was markedly distended with guarding. Laboratory investigations showed a significant acute kidney injury with a metabolic acidosis. An initial non-contrast CT showed fluid and inflammatory changes surrounding the bladder, and bladder perforation was suspected. A subsequent CT cystogram showed extravasation of contrast from the bladder into the peritoneal cavity, in keeping with an intraperitoneal bladder rupture. The patient underwent an emergency bladder repair in theatre., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention., Methods: PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I 2 values were used to assess for heterogeneity., Results: The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I 2  = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I 2  = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I 2  = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I 2  = 89%., Conclusion: This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results., Competing Interests: Declaration of Competing Interest The authors do not have a financial interest or relationship to disclose regarding this research project., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification., Study Design: This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC)., Results: Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%., Conclusions: This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The availability of endovascular techniques has led to a paradigm shift in the management of vascular injury. Although previous reports showed trends towards the increased use of catheter-based techniques, there have been no contemporary studies of practice patterns and how these approaches differ by anatomic distributions of injury. The objective of this study is to provide a temporal assessment of the use of endovascular techniques in the management of torso, junctional (subclavian, axillary, iliac), and extremity injury and to evaluate any association with survival and length of stay., Methods: The American Association for the Surgery of Trauma (AAST) Prospective Observational Vascular Injury Treatment registry (PROOVIT) is the only large multicenter database focusing specifically on the management of vascular trauma. Patients in the AAST PROOVIT registry from 2013 to 2019 with arterial injuries were queried, and radial/ulnar, and tibial artery injuries were excluded. The primary aim was to evaluate the frequency in use of endovascular techniques over time and by body region. A secondary analysis evaluated the trends for junctional injuries and compared the mortality between those treated with open vs endovascular repair., Results: Of the 3249 patients included, 76% were male, and overall treatment type was 42% nonoperative, 44% open, and 14% endovascular. Endovascular treatment increased an average of 2% per year from 2013 to 2019 (range, 17%-35%; R 2  = .61). The use of endovascular techniques for junctional injuries increased by 5% per year (range, 33%-63%; R 2  = .89). Endovascular treatment was more common for thoracic, abdominal, and cerebrovascular injuries, and least likely in upper and lower extremity injuries. Injury severity score was higher for patients receiving endovascular repair in every vascular bed except lower extremity. Endovascular repair was associated with significantly lower mortality than open repair for thoracic (5% vs 46%; P < .001) and abdominal injuries (15% vs 38%; P < .001). For junctional injuries, endovascular repair was associated with a non-statistically significant lower mortality (19% vs 29%; P = .099), despite higher injury severity score (25 vs 21; P = .003) compared with open repair., Conclusions: The reported use of endovascular techniques within the PROOVIT registry increased more than 10% over a 6-year period. This increase was associated with improved survival, especially for patients with junctional vascular injuries. Practices and training programs should account for these changes by providing access to endovascular technologies and instruction in the catheter-based skill sets to optimize outcomes in the future., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Vascular injuries and hemorrhaging are serious potential complications in the management of patients with blunt abdominal trauma. The treatment depends on the extent and localization and can range from surveillance to endovascular treatment up to open surgery. The keys to success include the focused assessment with sonography for trauma (FAST) management and timely decision making. Abdominal vascular trauma continues to be a difficult problem and open and endovascular techniques continue to evolve in order to address this complex disease process., (© 2023. The Author(s).)

Aim: The long-term urological sequelae after iatrogenic ureteral injury (IUI) during colorectal surgery are not clearly known. The aims of this work were to report the incidence of IUI and to analyse the long-term consequences of urological late complications and their impact on oncological results of IUI occurring during colorectal surgery through a French multicentric experience (GRECCAR group)., Method: All the patients who presented with IUI during colorectal surgery between 2010 and 2019 were retrospectively included. Patients with ureteral involvement needing en bloc resection, delayed ureteral stricture or noncolorectal surgery were not considered., Results: A total of 202 patients (93 men, mean age 63 ± 14 years) were identified in 29 centres, corresponding to 0.32% of colorectal surgeries (n = 63 562). Index colorectal surgery was mainly oncological (n = 130, 64%). IUI was diagnosed postoperatively in 112 patients (55%) after a mean delay of 11 ± 9 days. Intraoperative diagnosis of IUI was significantly associated with shorter length of stay (21 ± 22 days vs. 34 ± 22 days, p < 0.0001), lower rates of postoperative hydronephrosis (2% vs. 10%, p = 0.04), anastomotic complication (7% vs. 22.5%, p = 0.002) and thromboembolic event (0% vs. 6%, p = 0.02) than postoperative diagnosis of IUI. Delayed chemotherapy because of IUI was reported in 27% of patients. At the end of the follow-up [3 ± 2.6 years (1 month-13 years)], 72 patients presented with urological sequalae (36%). Six patients (3%) required a nephrectomy., Conclusion: IUI during colorectal surgery has few consequences for the patients if recognized early. Long-term urological sequelae can occur in a third of patients. IUI may affect oncological outcomes in colorectal surgery by delaying adjuvant chemotherapy, especially when the ureteral injury is not diagnosed peroperatively., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5]., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Injuries during initial port placement in minimally invasive abdominal surgery are rare but can cause major morbidity. We aimed to characterize the incidence, consequence, and risk factors for injury occurring on initial port placement., Methods: This is a retrospective review of a General Surgery quality collaborative database with supplementary input from the Morbidity and Mortality conference database at our institution between 6/25/2018 and 6/30/2022. Patient characteristics, operative details, and postoperative course were assessed. Cases with an injury on entry were compared to cases without an injury to identify risk factors for injury., Results: 8844 minimally invasive cases were present between the two databases. Thirty-four injuries (0.38%) occurred during initial port placement. Seventy-one percent of injuries were bowel injuries (full or partial thickness) and the majority (79%) of injuries were recognized during the index operation. Median surgeon experience for the cases with an injury was 9 years (IQR 4.25-14.5) compared to 12 years of experience for all surgeons contributing to the database (p = 0.004). Previous laparotomy was also significantly correlated with the rate of injury on entry (p = 0.012). There was no significant difference in the rate of injury based on method of entry (cut-down: 19 (55.9%), optical entry without Veress: 10 (29.4%), Veress followed by optical entry: 5 (14.7%), p = 0.11). BMI > 30 kg/m 2 (injury: 16/34 vs no injury: 2538/8844, p = 0.847) was not associated with an injury. Fifty-six percent (19/34) of patients with an injury on initial port placement required laparotomy at some point in their hospital course., Conclusions: Injuries are rare during initial port placement for minimally invasive abdominal surgery. In our database, history of a previous laparotomy was a significant risk factor for an injury and appears to be more consequential than commonly implicated factors such as technique, patient body habitus, or surgeon experience., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The aim of this study was to evaluate the indications and management of grade III-IV postoperative complications in patients requiring vacuum-assisted open abdomen after debulking surgery for ovarian carcinomatosis., Methods: Retrospective study of prospectively collected data from patients who underwent a cytoreductive surgery by laparotomy for an epithelial ovarian cancer that required postoperative management of an open abdomen. An abdominal vacuum-assisted wound closure (VAWC) was applied in cases of abdominal compartmental syndrome (ACS) or intra-abdominal hypertension, to prevent ACS. The fascia was closed with a suture or a biologic mesh. The primary aim was to achieve primary fascial closure. Secondary outcomes considered included complications of cytoreductive surgery (CRS) and open abdominal wounds (hernia, fistula)., Results: Two percent of patients who underwent CRS required VAWC during the study's patient inclusion period. VAWC indications included: (i) seven cases of gastro-intestinal perforation, (ii) three necrotic enterocolitis, (iii) two intestinal ischemia, (iv) three anastomotic leakages and (v) four intra-abdominal hemorrhages. VAWC was used to treat indications (i) to (iv) (which represented 73.7% of cases), to prevent compartmental syndrome. Primary fascia closure was achieved in 100% of cases, in four cases (21.0%) a biologic mesh was used. Median hospital stay was 65 days (range: 18-153). Four patients died during hospitalization, three of these within 30 days of VAWC completion., Conclusion: VAWC for managing open abdominal wounds is a reliable technique to treat surgical post-CRS complications in advanced ovarian cancer and reduces the early post-operative mortality in cases presenting with severe complications., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The algorithm of spleen and sterno-vertebrocostal segment models creation, the use of which allows to simulate various variants of conditions of spleen damage occurrence, is proposed. These data can be used for simulation of blunt abdominal trauma as a part of situational forensic medical examinations production. The results of performed experimental works on this issue showed the efficacy and adequacy of created models, which makes implementation of spleen injuries modelling into routine forensic medical expert practice promising.

Purpose: The purpose of this study was to describe the nature and reasons for the fall, the injuries caused and their prognosis., Patients and Methods: This was a descriptive cross-sectional study over a period of 9 years. Patients admitted for abdominal trauma from a fall from a height during the study period were included. Ultrasound and CT scan allowed diagnosis of the lesion. Patients in shock who do not respond to resuscitation are considered to have unstable hemodynamics., Results: fifty-three cases of abdominal trauma by falling from a height, including 11 adults and 42 children, were collected. They were 46 men and 7 women. The average age was 11.6 years. In 86.8% (n=46) of the cases it was a fall from the top of a tree. There were 83% (n=44) abdominal contusion and 17% (n=9) open trauma. Other lesions were associated in 28.3% (n=15) of cases. There were 26 splenic lesions (49%), 14 liver (22.6%) and 6 hollow organs (11.3%). Non-operative treatment was applied in 79.2% (n=42) of cases. Morbidity was 9.4% (n=5) and mortality 5.7% (n=3)., Conclusion: Abdominal trauma from a fall from a height was dominated by falls from the top of fruit trees, and occurred in young male subjects., (Le comité de rédaction se réserve le droit de renvoyer aux auteurs avant toute soumission à l'avis des lecteurs les manuscrits qui ne seraient pas conformes à ces modalités de présentation. En outre il leur conseille de conserver un exemplaire du manuscrit, des figures et des tableaux.)

Introduction: Vascular injury is a serious complication during lumbar fusion surgery, leading to massive blood loss and life-threatening circulatory failure. In this study, we report on a patient with abdominal aorta injury at L2-L3 level during lumbar fusion surgery via posterior approach. Fortunately, our patient was successfully managed with prompt intervention., Patient Concerns: A 73-year-old female was admitted to our department of low back and bilateral leg pain with claudication for over 6 months., Diagnosis: L2-S1 spinal canal stenosis, with abdominal aorta injury at the L2-L3 level during lumbar fusion surgery via a posterior approach., Interventions: L2-S1 decompression and fusion via a posterior approach was employed for spinal canal stenosis. Transluminal angioplasty with stent placement was successfully performed to stop the bleeding., Outcomes: During the procedure, it was decided that staunching the active bleeding was necessary and attention should be paid to the vital signs and blood pressure. Vascular surgical intervention was immediately scheduled when the blood pressure dropped. After stent placement, hemodynamic parameters stabilized., Conclusion: In this case report we review the prevalent sites, predisposing risk factors, diagnosis, and treatment of acute abdominal aortic injury during posterior lumbar fusion surgery, in view of our case findings. Although the incidence of vascular injury during lumbar fusion surgery is low, it is often easily overlooked. Consequently, during surgery, physicians should always be alert to the risk of vascular injury and master its clinical characteristics. Once injury is suspected, active and effective measures should promptly be taken for diagnosis and treatment to avoid serious adverse consequences., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization., Methods: A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated., Results: Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity., Conclusion: We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema., Level of Evidence: Systematic Review and Meta-Analysis; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice., Objective: To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS., Design, Setting, and Participants: This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS., Exposures: Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum., Main Outcomes and Measures: Presence of HVI diagnosed at the time of operative intervention., Results: A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70)., Conclusions and Relevance: The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.

Military training is intense, difficult and often dangerous, so all kinds of injuries or diseases frequently occur during training. Most of the previous studies and reviews on military training-related injuries focused on musculoskeletal system, whereas there are no reviews of abdominal injuries and diseases. Although the incidence of military training-related abdominal injuries and diseases is relatively low, the patients' condition is often critical especially in the presence of abdominal organ injury, leading to multi-organ dysfunction syndrome and even death. This paper elaborates on common types of military training-related abdominal injuries and diseases as well as the prevention and treatment measures, which provides some basis for scientific and reasonable training and improvement of medical security., (Copyright © 2022 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon., Objective: Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy?, Results: The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform a regular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary., Conclusion: Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars., Methods: Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals., Results: Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality., Discussion: Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

Objective: As obesity rates climb, it is important to study its effects on motor vehicle safety due to differences in restraint interaction and biomechanics. Previous studies have shown that an abdominal seatbelt sign (referred hereafter as seatbelt sign) sustained from motor vehicle crashes (MVCs) is associated with abdominal trauma when located above the anterior superior iliac spine (ASIS). This study investigates whether placement of the lap belt causing a seatbelt sign is associated with abdominal organ injury in occupants with increased body mass index (BMI). We hypothesized that higher BMI would be associated with a higher incidence of superior placement of the lap belt to the ASIS level, and a higher incidence of abdominal organ injury., Methods: A retrospective data analysis was performed using 230 cases that met inclusion criteria (belted occupant in a frontal collision that sustained at least one abdominal injury) from the Crash Injury Research and Engineering Network (CIREN) database. Computed tomography (CT) scans were rendered to visualize fat stranding to determine the presence of a seatbelt sign. 146 positive seatbelt signs were visualized. ASIS level was measured by adjusting the transverse slice of the CT to the visualized ASIS level, which was used to determine seatbelt sign location as superior, on, or inferior to the ASIS., Results: Obese occupants had a significantly higher incidence of superior belt placement (52%) vs on-ASIS placement (24%) compared to their normal (27% vs 67%) BMI counterparts (p < 0.001). Notable trends included obese occupants with superior placement having less abdominal organ injury incidence than those with on-ASIS belt placement (42% superior placement vs 55% on-ASIS). In non-obese occupants, there was a higher incidence of abdominal organ injury with superior lap belt placement compared to on-ASIS placement counterparts (Normal BMI: 62% vs 41%, Overweight: 57% vs 43%)., Conclusions: In CIREN occupants with abdominal injury, those with obesity are more prone to positioning the lap belt superior to the ASIS, though the impact on abdominal injury incidence remains a key point for continued exploration into how occupant BMI affects crash safety and belt design.

Shortages of grafts for liver transplant remain a persistent problem. The use of lacerated livers for liver transplant can add an option for extended criteria donations, especially during the COVID-19 pandemic. We present the case of a successful liver transplant performed using a high-grade lacerated liver previously treated with superselective arterial embolization and packing for bleeding control. In view of the absence of guidelines for the use of lacerated livers for transplant, we also performed a review of the literature on injured liver grafts that were used for liver transplants. Meticulous care and careful selection of recipients were essential prerequisites for achieving successful outcomes.

Background: To the best of our knowledge, splenic rupture caused by hit by a pitch (HBP) has not been previously reported. We present a patient who underwent emergency laparotomy for splenic rupture after being HBP during a baseball game., Case Presentation: A 41-year-old male was HBP in the left abdomen during his first at-bat during a baseball game. During the operation, vascular injury of the splenic hilum and a deeply extending parenchymal injury were observed, and splenectomy was performed. Histologic findings were consistent with splenic rupture., Conclusions: The patient's postoperative course was uneventful. Although extremely rare, the possibility of intra-abdominal organ injury should be considered in batters who are hit in the abdomen by a pitched baseball, as illustrated by our patient., (© 2021. The Author(s).)

Objectives: Injuries associated with bicycles can generally be categorized into 2 types: injuries from falling from/off bicycles and injuries from striking the bicycle. In the second mechanism category, most occur as a result of children striking their body against the bicycle handlebar. The purpose of this study was to evaluate the presentation, body location, injury severity, and need for intervention for pediatric handlebar injuries at a single level one pediatric trauma center and contrast these against other bicycle-related injuries in children., Methods: This work is a retrospective review of the trauma registry over an 8-year period. Individual charts were then reviewed for patients' demographic factors, injury details, and other clinical/radiographic findings. Each patient was then categorized as either having a handlebar versus nonhandlebar injury. Additionally, each patient's injuries were classified according to affected body "zone(s)" and the need for intervention in relation to these injuries. During the course of chart review, several unique radiographic and history/physical findings were noted and are also reported., Results: During the study period, 385 patients were identified that met study criteria. Bicycle handlebars were involved in 27.8% (107/385) of injuries and 72.2% (278/385) were nonhandlebar injuries. There were differences in injury severity score, Head Abbreviated Injury Scale, length of stay between patients with handlebar versus nonhandlebar injuries, respectively. There were also differences in incidence of injuries across most body zones between patients with handlebar versus nonhandlebar injuries. There was statistically significant difference in need for intervention for abdominal solid organ injuries among handlebar versus nonhandlebar injuries mechanisms (21.6% vs 0%; P = 0.026), respectively. Sixteen patients with a handlebar injury underwent abdominal computed tomography (CT), which found only pericolic/pelvic free fluid or were negative for any disease and had normal/mildly elevated liver function test results at the time of arrival with otherwise normal laboratory workup results. Two patients required laparotomy for bowel injury and presented with peritonitis less than 12 hours after injury. The remaining patients did not have peritonitis on examination and were discharged without operative intervention 12 to 24 hours after injury without further event., Conclusions: The bicycle handlebar is a unique mechanism of injury. The location, need for intervention, and the nature of the injury can vary significantly compared to other bicycle injuries. Handlebar injuries are more likely to cause abdominal and soft tissue injuries, whereas nonhandlebar injuries are more likely to cause extremity and skull/neck/central nervous system injuries. Because more than 20% of the reported handlebar injuries did not involve the abdomen or thoracoabdominal/extremity soft tissue as well as the variable presentation of handlebar injuries, it is imperative for the physician to consider this mechanism in all bicycle injuries. In addition, even within the same area of the body, handlebar injuries can be very different compared to nonhandlebar (i.e., orthopedic vs vascular injuries in the extremities). Physical examination and observation remain paramount when laboratory and radiographic workups are equivocal., Competing Interests: Disclosure: The authors declare conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The U.S. prison population has increased substantially in recent years, and violent injury is common among prisoners. We sought to describe injury patterns and other characteristics of prisoners who presented to a trauma center after injury. Because penetrating trauma from an improvised weapon (e.g., shank) is frequent, we also sought to compare characteristics and outcomes of prisoners and non-prisoners who sustained an anterior abdominal stab or shank wound (AASW)., Methods: We analyzed injured adult prisoners who presented to a Level 1 trauma center between February, 2011, and April, 2017. We described characteristics of the injured prisoners and their hospitalizations. We compared prisoners who sustained an AASW to a random sample of non-prisoners with the same mechanism of injury using the chi-square test, Student's t-test, and logistic and Poisson regression., Results: Of 14,461 hospitalized injured adults, 299 (2.0%) were injured while incarcerated. 185 (62%) encounters involved interpersonal violence and 36 prisoners (12%) presented with self-inflicted injuries. 98 (33%) had a psychiatric disorder. Among 33 prisoners and 66 non-prisoners who sustained an AASW, prisoners were less likely to have undergone a laparotomy [14/33 (42%) vs 44/66 (67%); RR 0.64 (95% CI 0.41-0.98)] or sustained an injury requiring operative intervention [2/33 (6%) vs 23/66 (35%); RR 0.17 (95% CI 0.04-0.69)]., Conclusions: Many injured prisoners have psychiatric illness, are involved in interpersonal violence, or harm themselves. Among hospitalized patients, abdominal stab/shank wounds sustained in prison are less likely to result in significant injuries or operative intervention than similar wounds in non-prisoners., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: In laparoscopic surgery, surgical instruments are inserted from a trocar to the target organ in a blind fashion, which carries a risk of organ injury. To clarify the risks associated with surgical instrument insertion, we measured grip strength and pushing/pressing force during surgical instrument insertion in laparoscopic surgery., Methods: Using forceps with sensors inside a trocar, 10 urologists performed a laparoscopic procedure in pigs, in which they were asked to touch the abdominal wall. The surgeons closed their eyes during the procedure and stopped moving the forceps when they felt them come into contact with the abdominal wall. They were ordered to grip the forceps strongly or softly and to move them rapidly or slowly during the procedure. Grip strength and the pushing/pressing force when the forceps hit the abdominal wall were measured and analyzed., Results: The mean pushing/pressing force when the surgeons gripped the forceps strongly and moved them rapidly (strong/rapid), strongly/slowly, softly/rapidly, and softly/slowly were 2.8, 2.0, 1.7, and 1.1 N, respectively. The pushing/pressing force was significantly greater when the surgeons gripped the forceps strongly, regardless of the forceps speed (P < .001). The pushing/pressing force was significantly greater when the surgeons moved the forceps rapidly, regardless of grip strength (P < .001)., Conclusions: When surgeons insert laparoscopic instruments through trocars, the instruments should be gripped softly and moved slowly to avoid organ injuries., (© 2020 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Background and purpose - COVID-19 lockdowns have resulted in noteworthy changes in trauma admissions. We report and compare the incidence and characteristics of severe injuries (New Injury Severity Score [NISS] > 15) during the COVID-19 lockdown in Finland with earlier years.Methods - We retrospectively analyzed incidence rate, injury severity scores, injury patterns, and mechanisms of injury of all severely injured patients (NISS >15) in 4 Finnish hospitals (Tampere University Hospital, Kuopio University Hospital, Central Finland Hospital, Mikkeli Central Hospital) during the 11-week lockdown period (March 16-May 31, 2020) with comparison with a matching time period in earlier years (2016-2018). These 4 hospitals have a combined catchment area of 1,150,000 people or roughly one-fifth of the population of Finland.Results - The incidence rate of severe injuries during the lockdown period was 4.9/10 5 inhabitants (95% CI 3.7-6.4). The incidence rate of severe injuries during years 2016-2018 was 5.1/10 5 inhabitants (CI 3.9-6.5). We could not detect a significant incidence difference between the lockdown period and the 3 previous years (incidence rate difference -0.2 (CI -2.0 to 1.7). The proportion of traffic-related accidents was 55% during the lockdown period and 51% during previous years. There were no detectable differences in injury patterns. During the lockdown period, the mean age of patients was higher (53 years vs. 47 years, p = 0.03) and the rate of severely injured elderly patients (aged 70 or more) was higher (30% vs. 16%).Interpretation - Despite heavy social restrictions, the incidence of severe injuries during the lockdown period was similar to previous years. Notably, a decline in road use and traffic volumes did not reduce the number of severe traffic accidents. Although our data is compatible with a decrease of 2.0 to an increase of 1.7 severely injured patients per 10 5 inhabitants, we conclude that severely injured patients do not disappear even during pandemic and stabile hospital resources are needed to treat these patients.

Background and Aims: Diaphragmatic ruptures are associated with blunt abdominal or thoracic trauma and often occur in car and motorbike accident with a high energy impact., Case Presentation: We report two cases of patients victims of car and motorbike accidents that were referred to the Emergency Department of our Hospital in August and September 2017 for a politrauma. The patients were both diagnosed with a left diaphragmatic rupture with herniation of the stomach in the chest, and decomposed fractures of the ribs. One of the two patients reported a large abdominal wound with loss of substance in the site of the impact. Both patients underwent to open emergency surgery with primary repair of the phrenic rupture. The post-operative course was characterized by the occurrence of complications such as respiratory distress and emothorax for one of the patients., Conclusion: Traumatic rupture of the diaphragm can be associated to blunt or penetrating abdominal trauma in car and motorbike accident with a prevalence of the left-sided lesions. In patients with politrauma an associate rupture of the diaphragm should be always suspected especially in motor accident where high energy impact can generate a traumatic laceration of the respiratory muscle. The treatment of associate thoracic wall fractures to prevent weaning and respiratory distress in intubated patient should be discussed.

BACKGROUND We report the case of a patient undergoing a colonoscopy during which pressure applied on the abdomen by a nurse assisting in the procedure caused an extraluminal mesenteric tear. Mesenteric tears can be life-threating and need to be managed appropriately. This is the first case reported in the literature describing abdominal counter-pressure applied in the endoscopic procedure room as the cause of traumatic bowel injury. CASE REPORT A 72-year-old woman presented for a screening colonoscopy. Advancement of the colonoscope became so difficult that the procedure was temporarily aborted. To reduce looping of the colonoscope, the nurse assistant applied a forceful two-handed counter-pressure maneuver upon the abdomen to help the endoscopist advance the colonoscope to the cecum. After the procedure, the patient complained of abdominal pain and nausea. A CT scan of the abdomen showed a hematoma abutting the anterior abdominal wall. Unfortunately, laparoscopic surgery was hastily recommended over conservative medical management. Approximately 500 mL of old blood was evacuated. The patient survived postoperative complications, including pneumonia, respiratory failure, and sepsis. CONCLUSIONS Mesenteric tears are a rare but potentially life-threatening complication of colonoscopy. Post-colonoscopy patients with severe nausea, abdominal pain and/or distention, who fail to demonstrate free air in the abdomen, should have a CT scan with i.v. contrast to assess their condition. Hemodynamically stable patients should be managed with serial vitals and bedside observations, laboratory tests, imaging studies, fluid replenishment, and medication, to avoid unnecessary high-risk surgery. Abdominal counter-pressure applied safely during colonoscopy can reduce the risk of injury inherent in the procedure.

Traumatic abdominal wall injuries encompass a broad clinical and radiological spectrum and are identified in approximately 9% of blunt trauma patients. The most severe form of abdominal wall injury-a traumatic abdominal wall hernia-is seen in less than 1.5% of blunt abdominal trauma patients. However, the incidence of concurrent intra-abdominal injuries in these patients is high and can result in significant morbidity and mortality. Although the diagnosis of abdominal wall injuries is typically straight forward on CT, associated injuries may distract the interpreting radiologist in more subtle cases. Thus, it is important for the radiologist to identify abdominal wall injuries and their associated injuries on admission CT, as these injuries typically require surgical correction early in the course of their management. Untreated abdominal wall injuries subject the patient to increased risk of delayed bowel incarceration and strangulation. Therefore, it is important for the radiologist to be knowledgeable of injuries to the abdominal wall and commonly associated injuries to provide optimal patient triage and expedite management.

Background: Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) has not been specifically examined after shotgun injuries. Because of the unpredictable nature of shotgun pellets, it is unclear if SNOM after shotgun wounds is safe. The study objective was to examine outcomes after SNOM for shotgun wounds to the abdomen., Methods: Patients with isolated abdominal shotgun wounds were identified from the National Trauma Data Bank (2007-2017). Transfers, arrival without signs of life, death in the emergency department, severe (Abbreviated Injury Scale ≥3) extra-abdominal injuries, abdominal Abbreviated Injury Scale = 6, and missing data were exclusion criteria. Patients with abdominal handgun wounds (GSWs) were used for comparison. Study groups of shotgun-injured patients were defined by management strategy: operative management (OM) (exploratory laparotomy ≤4h) versus SNOM (no exploratory laparotomy ≤4h). Outcomes were compared by mechanism of injury (shotgun versus GSW) and management strategy (OM versus SNOM) using univariate and multivariate analyses., Results: After exclusions, 1425 patients injured by abdominal shotgun wounds were included. Shotgun-injured patients underwent SNOM more frequently than GSW patients (42% versus 34%, P < 0.001). On multivariate analysis, injury by shotgun was independently associated with SNOM (OR 1.443, P = 0.040). Shotgun injuries were significantly more likely to fail SNOM (OR 2.401, P = 0.018). Failure of SNOM occurred earlier among shotgun-than GSW-injured patients (15 versus 24h, P = 0.011). SNOM after shotgun injury was associated with lower mortality than OM, even when patients failed SNOM (P < 0.001). Complications were uniformly higher after OM than SNOM, even when SNOM failed (P < 0.05)., Conclusions: SNOM was utilized more commonly after shotgun wounds than GSWs. However, SNOM was more likely to fail after shotgun injury and tended to occur earlier after admission. SNOM after shotgun injury was associated with improved mortality and decreased complication rates when compared with OM, even when patients failed SNOM. SNOM appears to be a safe and beneficial management strategy after shotgun wounds to the abdomen., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Abstract: We describe 13 children who presented to the Penn State Health Milton S. Hershey Medical Center (HMC) with pediatric soccer-related abdominal organ injuries. A review of the Pennsylvania Trauma System Foundation's Trauma Registry was performed between 2001 and 2015 for children with soccer injuries hospitalized at trauma centers across Pennsylvania. Out of 52 children at Hershey Medical Center, 13 suffered abdominal organ injuries. Injuries included the spleen [5], kidney [4], liver [2], and combined organ involvement [2]. All patients presented with abdominal and/or flank pain. All patients with kidney injuries presented with hematuria. All patients presented after a player-to-player (P2P) contact. Nearly all patients (12/13) were treated nonsurgically. Our findings showed that abdominal organ injuries constitute a substantial portion of pediatric soccer injuries requiring hospitalization, with spleen being the organ injured most frequently. Soccer-related abdominal organ injuries should be suspected in players who suffer abdominal and/or flank pain, and/or hematuria after a P2P contact., (Copyright © 2021 by the American College of Sports Medicine.)

Rationale: Pediatric sports injuries, including those from baseball, most often are musculoskeletal injuries and rarely include blunt abdominal injuries. Duodenal injury is rare and often associated with other organ injuries. Because it has a relatively high mortality, early recognition and timely treatment are needed. Here, we report a case of successful treatment of a pediatric patient with duodenal injury incurred in the context of school baseball., Patient Concerns: A 13-year-old boy suffered blunt abdominal trauma and a right-hand injury caused by beating his abdomen strongly with his own right knuckle after he performed a diving catch during a baseball game. On the following day, the abdominal pain had worsened., Diagnoses: Computed tomography led to a suspicion of injury to the horizontal part of the duodenum., Interventions: The duodenal injuries were repaired by simple closure. On the 10th post-operative day, an abscess formed in the retroperitoneal cavity because of an occult pancreatic injury. Ultrasound-guided percutaneous drainage of the cavity was performed., Outcomes: The post-operative course of the abscess drainage was uneventful. The patient was discharged from our hospital on day 72 after admission and was in good health at the 9-month follow-up., Lessons: Regardless of the type of injury, we must assess the life-threatening conditions that can be expected based on the mechanism of the injury. In duodenal injuries, it is critical to perform surgical procedures and post-operative management based on the assumption of injuries to other organs., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

The discovery of exogenous particles in the broncho-pulmonary tree is frequently described in forensic literature, especially in lung samples, in the context of aspirated gastric content during the death agony period or during resuscitation. We report an original observation of a multi-visceral dispersion of exogenous particles detected, in an 8-year-old boy, who allegedly fell from a 2-m high brick-wall. The autopsy found major liver fracture and diaphragm rupture with massive internal hemorrhage without gastric wall rupture. The histological analyses have identified round to oval bodies in the lung bronchi, alveoli, and, rarely, in vascular sections, and also on the surface of several samples. These particles stained strongly pink by the periodic acid Schiff method, evoking dried vegetables. Two hypotheses were invoked: aspirated vegetable particles into the bronchial tree or parasitic infection, like pinworm larva. In order to characterize the nature of these particles, different legumes were cooked, embedded in paraffin wax, and examined under light microscope. Simultaneously, morphological comparison between the gastric content and pinworm larva and lentils was made and a PCR analysis was performed on gastric fluid sample. The DNA sequencing showed a Fabaceae plant family, Lens culinaris. The possibility of a hematogenous dissemination of the starch grains during a perimortem aspiration of gastric content seems unlikely, and a contamination from the gastric content of the organs samples during the autopsy or the pathologic macroscopic and microscopic processes seems to be the principal hypothesis. The formal identification of such particles is important to avoid the misdiagnosis of a potential parasitic infection. The risk of confusion can be detrimental in some circumstances.

Introduction: Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries., Methods: A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality., Results: Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance., Conclusions: This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement., Level of Evidence: IV.

Objective: The objective is to report sex-related variation in 3-point belt-related abdominal injuries in Crash Injury Research Engineering Network (CIREN) cases., Methods: A query of CIREN cases was made for those with the highest ranked Collision Deformation Classification (CDC) to the front plane, a principal direction of force (PDOF) ±20° from 0°, and Abbreviated Injury Scale (AIS) 2+ abdomen injuries attributed to the seat belt. Patterns of injury were categorized as above the crest of the ilium, injuries below the crest of the ilium, and injuries above and below the ilium. This was done in the context of autonomous vehicle occupant kinematics testing results. Twelve 5th and 95th percentile 3-point belt-restrained postmortem human subjects were subjects; test speeds and recline angles varied. Abdomen injuries were anticipated; none were observed., Results: Thirty-five occupants with belt-related abdominal injuries were identified. Seventeen case occupants sustained an injury only within the pelvic contents: 5 women and 12 men. Nine of the 17 were at or above the 81st percentile for height, 13 were between the 62nd and 80th percentile for height, and 4 were less than the 50th percentile for height., Conclusions: The stature component of the body mass index (BMI) appears to be a plausible candidate for an independent variable that is a contributing factor explaining the incidence of pelvic contents injuries when a 3-point belt-restrained occupant is involved in a frontal impact.

Crossbow fatalities are a rare occurrence, but crossbow use is on the rise. The manner of death in crossbow fatalities is overwhelmingly opined accident or suicide, not homicide. Despite their increasing use and reports of at least 14 crossbow-related homicides in the media for the last 5 years, crossbow homicides are rarely reported in the medical literature; only 10 articles that discussed 20 crossbow homicides were identified in the PubMed database. Here, we describe a case of a 20-year-old man who was found dead in his driveway after being shot in the abdomen with a crossbow by another person. The crossbow bolt had a mechanical 2-blade broadhead that transected the descending aorta and lodged in his vertebra. When completing a medicolegal death investigation and postmortem examination on suspected crossbow-related deaths, knowledge of crossbow components, its utility as a weapon, wound patterns, and how it can cause death are important. This case serves to build on the limited medical literature of crossbow homicides, educate forensic pathologists about the features of crossbow deaths, and highlight manner of death considerations.

Background: "Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries., Methods: -approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded., Results: We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation., Conclusions: Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT., Methods: A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project., Results: In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model., Conclusions: ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Pancreatic injuries are rare. Reports are lacking from defined European populations covering all ages and genders and in areas with a low prevalence of penetrating trauma. We aimed to review pancreatic injuries identified within a defined population., Methods: Observational cohort study from a prospectively maintained trauma registry and all patients coded for a pancreatic injury between January 1, 2004 and December 31, 2018., Results: A total of 14 patients with pancreatic injury were identified over a 15-year time period. Pancreatic injuries represented 0,19% (14/7207) of all trauma patients and 3,1% (14/454) of patients with documented abdominal injuries. Nine patients 64% (9/14) were children, representing 1% (9/869) of all injured children in the registry and 11,4% (9/79) of children with documented abdominal injuries. Median age was 10,5 years (range 3-58). Ten were male (71%) and 86% (12/14) suffered blunt trauma. Median AAST-OIS was 2 (1-4). Single organ injury occurred in 43% (6/14). Concomitant liver injury was the most frequent associated intra-abdominal injury found in 29% (4/14). Four patients (29%) had associated injuries in other body regions, all thoracic injuries. Median ISS was 9,5 (4-41).Operative management was needed for four of the pancreatic injuries, one spleen-preserving distal pancreatectomy, one spleen-sacrificing distal pancreatectomy and two peripancreatic drainages. One patient died within 30-days, but the death was unrelated to the pancreatic injury., Conclusions: Incidence of pancreatic injuries is low, even among trauma patients with documented abdominal injuries. Most pancreatic injuries occurred in children. Injuries requiring surgery was rare.

Introduction: Acute intervention (AI) for solid organ injury (SOI) is rare in hemodynamically stable children. Pediatric guidelines recommend admission with follow-up laboratories, even for low-grade injuries., Methods: Data sets from two large multicenter prospective observational studies were used to analyze a cohort of children (age, <17 years) with grade I to III SOI following blunt abdominal trauma. Children with hollow viscus injuries were excluded. Patients were divided into (a) those with or without other major injuries (OMIs) (traumatic brain injury, hemothorax or pneumothorax, pelvic fracture, urgent orthopedic or neurosurgical operations) and (b) with grade I or II versus grade III injuries. Outcomes included AIs (transfusion, angiography, abdominal operation) and disposition (admission unit and length of stay)., Results: There were 14,232 children enrolled in the two studies, and 791 patients had a SOI (5.6%). After excluding patients with hollow viscus injuries and higher-grade SOIs, 517 patients with a grade I to III SOI were included, and 262 of these had no OMI. Among patients with no OMI, none of 148 patients with grade I or II SOI underwent AI, while only 3 of 114 patients with grade III injuries underwent AI (3 transfusions/1 angioembolization). All three had hemoperitoneum; two of three had an additional organ with a grade II injury. Among grade I and II SOIs with no OMI, 28 (18.9%) of 148 were admitted to an intensive care unit, 110 (74.3%) of 148 to floor, and 7 (4.7%) of 148 discharged home from emergency department; median length of stay 2 days. Among grade III SOIs with no OMI, 38 (33.3%) of 114 were admitted to an intensive care unit and 61.4% to the floor; median length of stay was 4 days. Among 255 patients with a grade I to III SOI and other major organ system injuries, 31 (12.2%) underwent AI., Conclusion: No patient with a grade I and II SOI and no OMI following blunt abdominal trauma received intervention, suggesting that patients with low-grade SOI without OMIs could be safely observed and discharged from the emergency department., Level of Evidence: Therapeutic study, level IV.