Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service.

BACKGROUND: The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. METHODS: From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. RESULTS: Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). CONCLUSION: In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.

Meta-analysis of COVID-19 prevalence during preoperative COVID-19 screening in asymptomatic patients.

OBJECTIVES: Patients with COVID-19 may be asymptomatic and are able to transmit COVID-19 during a surgical procedure, resulting in increased pressure on healthcare and reduced control of COVID-19 spread. There remains uncertainty about the implementation of preoperative screening for COVID-19 in asymptomatic surgical patients. Therefore, this study aims to determine the prevalence of preoperative COVID-19, confirmed by reverse transcriptase PCR (RT-PCR), in asymptomatic patients. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Pubmed and Embase databases were searched through 20 February 2022. ELIGIBILITY CRITERIA: All COVID-19 articles including preoperative asymptomatic patients were included. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed risk of bias. Meta-analysis was performed to determine the prevalence of COVID-19 with 95% CI. Moreover, estimated positive predictive value (PPV), negative predictive value, false-positives (FP) and false-negatives were calculated for preoperative asymptomatic patients. RESULTS: Twenty-seven studies containing 27 256 asymptomatic preoperative screened patients were included, of which 431 were positive for COVID-19 by RT-PCR test. In addition, the meta-analysis revealed a pooled COVID-19 prevalence of 0.76% (95% CI 0.36% to 1.59%). The calculated PPV for this prevalence is 40.8%. CONCLUSIONS: The pooled COVID-19 prevalence in asymptomatic patients tested preoperatively was 0.76%, with low corresponding PPV. Consequently, nearly three-quarters of postponed surgical procedures in asymptomatic preoperative patients may be FP. In the event of similar pandemics, modification of preoperative mandatory RT-PCR COVID-19 testing in asymptomatic patients may be considered.

Surgical treatment of large contaminated abdominal wall defects.

BACKGROUND: Repair of a large, severely contaminated abdominal wall defect is a challenging problem. Most patients are currently treated with a multistaged procedure, which is time consuming, carries a high complication rate, and is often not finalized. STUDY DESIGN: In this study, our experience with a one-stage repair of contaminated abdominal wall defects using the Components Separation Method was evaluated with respect to morbidity and recurrence. Medical records of patients with contaminated abdominal wall defects, treated with the Components Separation Method from 1996 to 2000, were studied. Patients were invited to visit the outpatient clinic for a physical examination. RESULTS: Twenty-six patients with a median age of 49 years and a mean defect size of 267 cm2 were treated. Intraoperative contamination, graded according to the National Research Council (NRC), showed 22 National Research Council III patients and 4 National Research Council IV patients. Postoperatively, five superficial wound infections, three cases of pneumonia, three instances of recurrent enterocutaneous fistulation, and two cases of sepsis were observed. One of the patients with sepsis died after anastomotic disruption led to peritonitis and multiple organ failure. Two asymptomatic recurrences were diagnosed (8%) after a median followup of 27 months. CONCLUSIONS: Large contaminated abdominal wall hernias can be closed by the Components Separation Method, with a low recurrence rate but considerable morbidity.

Incisional hernia repair: abdominoplasty, tissue expansion, and methods of augmentation.

Incisional hernia repair without mesh mainly consists of tissue transfer to bridge or close the defect. Bridging includes rotational or free musculocutaneous flaps, rendering acceptable short-term results but a rather disappointing long-term outcome. Abdominal wall closure where there has been significant loss of domain, with intraperitoneal organs residing permanently outside the abdominal cavity, can only be achieved using the patients' own tissue if preoperative expansion of the abdominal cavity is performed using artificial expanders or pneumoperitoneum. From a scientific point of view, however, evidence supporting any treatment option is weak because prospective randomized controlled trials are virtually impossible to conduct owing to the inhomogeneity of the patient population being considered. Treatment of this condition by the above-mentioned means should therefore be proposed on an individual basis utilizing one or more of the many possible techniques described.