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Summary: Background: Transcatheter arterial embolization (TAE) is an effective alternative to nonoperative management (NOM) to improve the spleen salvage rate for patients with blunt splenic injuries (BSIs), but it is not always available at some institutions. Moreover, laparoscopy has also been used to diagnose and treat trauma, including BSIs. Methods: We present our 11-year experience in performing laparoscopic surgery for spleen salvage in patients with severe BSIs when TAE is infeasible. The outcomes of laparoscopic surgery or TAE for spleen salvage in hemodynamically stable patients with severe BSIs were compared. Results: Fifty-six patients underwent interventions for severe BSIs during this period. Twenty patients underwent laparoscopic surgery, and 36 underwent TAE. There were no significant differences in demographics, preoperative conditions, or clinical characteristics (all p > 0.05). In the laparoscopic surgery group, 15 patients (75 %) underwent laparoscopic splenorrhaphy for spleen salvage surgery, and five (25 %) required splenectomy. No complications requiring intervention were observed in the laparoscopic surgery group, whereas three patients in the TAE group required a late splenectomy for splenic abscess. No significant differences were detected in the splenic preservation rate, complication rate, or length of hospital stay between the groups (all p > 0.05). Conclusion: Laparoscopy is feasible and safe for managing hemodynamically stable patients with severe BSIs, and the outcomes are comparable to those of TAE. When TAE is infeasible, laparoscopy can be considered an alternative to increase the spleen salvage rate.

Introduction Pelvic fractures often result in life-threatening bleeding and hemodynamic instability. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising strategy for patients with severe pelvic fractures, facilitating subsequent hemostatic interventions. Transcatheter arterial embolization (TAE) is a well-established procedure for managing pelvic fractures accompanied by hemorrhage.Ideally, an angiographic access point distinct from the initial REBOA placement is sought to maintain REBOA deflation without complete removal, thereby preventing hemodynamic instability during the procedure. However, in cases of extreme and severe pelvic trauma, gaining access for REBOA is already challenging, not to mention the additional difficulty posed by subsequent angiographic access.This study aims to assess the challenges associated with gaining access in cases where successful TAE was ultimately performed, particularly in the context of severe pelvic trauma. We investigate the complexities surrounding access management and its implications for patient outcomes.Methods We conducted a retrospective analysis of patients who presented with pelvic fractures and underwent sequential REBOA and TAE procedures at our institution between 2017 and 2023. We excluded patients with Abbreviated Injury Scores (AIS) ≥3 in systems other than the pelvis, those who underwent TAE prior to REBOA, and cases of suboptimal REBOA insertion.We collected demographic data, injury characteristics, details of the REBOA and TAE procedures, information on complications, and data on patient survival. The primary endpoints of our analysis included overall survival and the success of TAE (defined as post TAE mean arterial pressure (MAP) ≥65 mm Hg). Secondary endpoints encompassed the duration details of two interventions.Results Between 2017 and 2023, a total of 17 patients were included in this study. Among this cohort, 12 (70.6%) were male, with a median age of 51 years. Overall survival was 23.5%. Patients were grouped into angiography after REBOA deflation (AAD) or angiography after REBOA removal (AAR). AAR group was younger (39.0 vs 63.0, p=0.030) and had higher Shock Index at triage (2.30 vs 1.10, p=0.015). More patient whose post TAE MAP >=65 mm Hg was found in the AAR group, although no significant difference on overall survival (25.0% vs 22.2%, p=1.000). Angiographic cannulation times, pre-angiographic MAP, and amount of pre-angiographic transfusion of packed red blood cell were similar across groups.Conclusion Our findings provide empirical insights into vascular access selection and suggest that AAR in the management of severe pelvic fractures can be beneficial, particularly when pre-angiographic resuscitation is sufficient. Larger studies are required to validate these observations and assess long-term outcomes.Level of evidence III.

Abstract Background Amyand’s hernia (AH) is an appendix (with or without acute inflammation) trapped within an inguinal hernia. Most AH with acute appendicitis had a preexisting appendix within the hernia sac. We herein report a variant of AH that has never been described before. An inflamed appendix that was managed conservatively was found to have migrated and trapped in the sac of a previously unrecognized right inguinal hernia 6 weeks after the index admission, resulting in a secondary Amyand’s hernia. Case presentation A 25-year-old healthy Taiwanese woman had persistent right lower abdominal pain for 1 week and was diagnosed with perforated appendicitis with a localized abscess by abdominal computed tomography (CT). No inguinal hernia was noted at that time. Although the inflamed appendix along with the abscess was deeply surrounded by bowel loops so that percutaneous drainage was not feasible, it was treated successfully with antibiotics. However, she was rehospitalized 6 weeks later for having a painful right inguinal bulging mass for a week. Abdominal CT revealed an inflamed appendix with abscess formation in an indirect inguinal hernia raising the question of a Amyand’s hernia with a perforated appendicitis. Via a typical inguinal herniorrhaphy incision, surgical exploration confirmed the diagnosis, and it was managed by opening the hernial sac to drain the abscess and reducing the appendix into the peritoneal cavity, followed by conventional tissue-based herniorrhaphy and a laparoscopic appendectomy. She was then discharged uneventfully and remained well for 11 months. Conclusions Unlike the traditional definition of Amyand’s hernia, where the appendix is initially in the hernia sac, the current case demonstrated that Amyand’s hernia could be a type of delayed presentation following initial medical treatment of acute appendicitis. However, it can still be managed successfully by a conventional tissue-based herniorrhaphy followed by laparoscopic appendectomy.

BackgroundAcute graft-versus-host disease (aGVHD) is a severe and fatal complication after orthotopic liver transplantation (OLT). Clinical manifestations of severe aGVHD can resemble drug-induced Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), and there are also various medications, such as antibiotics and immunosuppressants, used after transplantation, causing a diagnostic dilemma. Furthermore, there have been no standardized diagnostic and therapeutic strategies for OLT-aGVHD due to its rarity.Case summaryA 52-year-old man presented with generalized maculopapular eruptions, fever, and pancytopenia 1 month after OLT and 4 days after taking sulfamethoxazole/trimethoprim. After assessment of the scoring criteria for drug causality of drug allergy, histopathological findings of skin biopsy, lymphocyte activation test of the potential offending drug, and microchimerism study, the diagnosis was in favor of aGVHD mimicking SJS/TEN. Considering severe sepsis, the anti-tumor necrosis factor alpha (TNF-α) agent, etanercept, was used to replace tacrolimus and corticosteroid. Skin lesions resolved gradually after anti-TNF-α biologics rescue; tacrolimus and corticosteroid therapy were re-administrated after controlling sepsis. Pancytopenia recovered and the patient was discharged in a stable condition.ConclusionWe demonstrated a diagnostic strategy for OLT-aGVHD. Targeting therapy with anti-TNF-α blockade and a temporary withdrawal of traditional immunosuppressants may be among effective and safe therapeutic options of OLT-aGVHD for those with severe sepsis.

Background: Acute graft-versus-host disease (aGVHD) is a severe and fatal complication after orthotopic liver transplantation (OLT). Clinical manifestations of severe aGVHD can resemble drug-induced Stevens– Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), and there are also various medications, such as antibiotics and immunosuppressants, used after transplantation, causing a diagnostic dilemma. Furthermore, there have been no standardized diagnostic and therapeutic strategies for OLT-aGVHD due to its rarity. Case summary: A 52-year-old man presented with generalized maculopapular eruptions, fever, and pancytopenia 1 month after OLT and 4 days after taking sulfamethoxazole/trimethoprim. After assessment of the scoring criteria for drug causality of drug allergy, histopathological findings of skin biopsy, lymphocyte activation test of the potential offending drug, and microchimerism study, the diagnosis was in favor of aGVHD mimicking SJS/ TEN. Considering severe sepsis, the anti-tumor necrosis factor alpha (TNF-a) agent, etanercept, was used to replace tacrolimus and corticosteroid. Skin lesions resolved gradually after anti-TNF-a biologics rescue; tacrolimus and corticosteroid therapy were re-administrated after controlling sepsis. Pancytopenia recovered and the patient was discharged in a stable condition. Conclusion: We demonstrated a diagnostic strategy for OLT-aGVHD. Targeting therapy with anti-TNF-a blockade and a temporary withdrawal of traditional immunosuppressants may be among effective and safe therapeutic options of OLT-aGVHD for those with severe sepsis. [ABSTRACT FROM AUTHOR]