Late Radiological and Clinical Outcomes of Traumatic Thoracic Aortic Injury Managed with Thoracic Endovascular Aortic Repair.

PURPOSE: Patients treated with thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury (TTAI) are often young and data on long-term durability of this treatment is not widely documented. The aims of this study were to report the New Zealand (NZ) national experience of TEVAR and to assess the durability of late outcomes and radiological follow-up of patients treated for TTAI. METHODS: Consecutive patients treated with TEVAR during a 12-year period from all tertiary centers in NZ were included. Early (30-day), late survival and radiological imaging data were recorded to document late graft-related complications and re-interventions. RESULTS: 88 patients with a median (range) age of 35 (15-87) year and 63 (71.6 %) males were included. Eleven patients (12.5 %) died within 30 days, of which three were aortic related deaths. The median (range) follow-up was 76.3 (0.3-164.6) months. Six (7.8 %) patients died during the follow-up period due to non-aortic-related causes. Nine (11.5 %) patients were lost to follow-up of which three emigrated overseas. Of those on surveillance, two patients required TEVAR re-intervention to previously treated aortic segments; one for a type 1b endoleak and the other for a symptomatic pseudo-coarctation. Both were treated successfully with a TEVAR. CONCLUSIONS: This multicenter study suggests that TEVAR is a durable option for treatment of traumatic thoracic aortic injury. Although, stent graft complications were uncommon, but when it occurred, it leads to re-intervention. Further radiological follow-up is required particularly in young patient to document late aortic/stent complications.

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

Surgery in New Zealand.

Surgery in New Zealand is performed by more than 500 surgeons who serve a population of 3.8 million people. Most of the surgeons are trained in New Zealand under the auspices of the Royal Australasian College of Surgeons. Surgical services are consistent with the highest standards of Western countries.

The effect of enteral feeding on gastric pH. Tie for second place Jobst award.

To study the effect of jejunal feeding on gastric pH, 13 multiply injured trauma patients having needle catheter jejunostomies were prospectively evaluated. Normal saline and one-half strength Traumacal were infused alternately at 50 cc/hr for 24 hours and gastric pH was measured every other hour. If gastric pH dropped to 4.5 or below, patients received 30 cc of antacid via nasogastric tube. A total of 324 gastric pH determinations were made and 93 doses of antacids were administered. Average gastric pH during Traumacal infusion was 5.34 and did not significantly differ from the average pH (5.37) during saline infusion. Using multivariate analysis to control for antacids, along with diurnal and day-to-day variations, no statistically significant effect of jejunal feeding on gastric pH could be demonstrated. These results suggest that prophylaxis for stress ulceration needs to be maintained in severely injured patients fed via the jejunum.

Injury scaling at autopsy: the comparison with premortem clinical data.

The difference between injury scaling performed in the same patients on the basis of clinical information only and postmortem examination only is largely unknown. We compared scores in all 279 trauma patients who died in the Department of Critical Care Medicine at Auckland Hospital from 1982 through 1987 (93% blunt trauma, 4% penetrating trauma, 3% burns; median time until death--2 days) using both the 1980 and 1985 revisions of the Abbreviated Injury Scale (AIS-80, AIS-85) and derived Injury Severity Scores (ISS-80, ISS-85) where such scoring was based on clinical information only (CLAIS, CLISS) or postmortem findings only (PMAIS, PMISS). For the group as a whole, there was little difference in the distribution of scores between CLAIS and PMAIS or between CLISS and PMISS. However, CLISS-80 was different from PMISS-80 in 68% of individual patients. Most major differences between CLAIS and PMAIS (two AIS grades or more) occurred in the Head region, where injury scoring based on physiological features (e.g. coma) occurred without an anatomic injury of similar AIS grade, or in the Thorax region where therapy had either abolished the evidence of injury (e.g. pneumothorax) or injuries were discovered at postmortem examination which had not been appreciated clinically. Injury scaling data derived only from postmortem examination is not equivalent to that derived clinically. For maximum accuracy, postmortem data must be derived from an examination specifically guided by the needs of injury scaling and in full cognizance of injuries recognised and treated clinically.

A comparison of AIS-85 with AIS-80 for injury scaling in blunt trauma.

As the effects on injury scaling of the differences between the 1980 and 1985 revisions of the AIS are unknown in blunt trauma, we compared them in all 1270 critically injured (median ISS, 26) blunt trauma patients (75% male, 74% road crash, overall mortality 17%) admitted to the Department of Critical Care Medicine at Auckland Hospital from 1983 through 1987. In 911 patients (72%) there were no differences between AIS-80 and AIS-85 in any body region or in derived ISS. Changes in AIS grades were most common in the abdomen (205 patients), thorax (100 patients), and head (61 patients) regions. Median ISS overall for the 1270 patients was unchanged at 26. One percent of patients had changes in ISS of 16-24 points. Direct comparison of groups of patients scored with these two revisions of the AIS is inappropriate, particularly in those with abdomen region injury.

Injury severity scoring: a comparison of early clinical versus discharge diagnosis.

The Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) are objective means of assessing injury. Accepted methodology involves retrospective scoring of injury based on discharge diagnoses. Recently, early clinical scoring, supplemented by review at discharge, has been introduced. A prospective study was instituted to compare these methodologies. Four hundred sixty consecutive victims of blunt trauma were scored using both clinical and retrospective methodologies by independent, blinded observers. Of these, 333 patients had a change in ISS, 174 with a change of greater than four points. The population mean ISS remained unchanged; however, paired values were significantly different (p less than .03). We conclude that either methodology is applicable for studies of large populations of trauma victims. When accurate individual AIS or ISS scoring is required, the clinical method combined with discharge review is most appropriate.

Ruptured abdominal aortic aneurysms: clinical presentation in Auckland 1993-1997.

BACKGROUND: Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32-95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA. METHODS: A review was undertaken of hospital and Coroner's files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997. RESULTS: Three hundred and twenty-nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty-three patients (16%) were initially misdiagnosed. CONCLUSIONS: Although our ability to correctly diagnose a RAAA has improved since Osler's time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non-specific or atypical.

Trauma training in Australia and New Zealand: results of a survey of advanced surgical trainees.

BACKGROUND: The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training. METHODS: A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons. RESULTS: Two hundred and seventy-two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations. CONCLUSIONS: Regional rotations may need to be developed to even out trainees' experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.

Exsanguinating upper extremity vascular injury: is an initial approach by clavicular resection adequate?

Clavicular resection has been recommended by some as an acceptable approach to the repair of subclavian and axillary vascular injuries. We believe this may not be the best approach in patients with severe trauma and exsanguinating injuries. During the last 5 years, we have treated 11 patients with trauma to the subclavian or axillary vessels, four of whom presented in shock from exsanguinating injuries. After initial fluid resuscitation, we operated on each patient by resecting the medial portion of the clavicle. Three of the four patients required further surgery or extension of the incision to control bleeding. In our experience, clavicular resection as a primary approach to exsanguinating injuries did not provide either adequate tamponade of bleeding or the exposure needed to repair injured vessels safely. Clavicular resection may be acceptable for hemodynamically-stable patients with minimal soft tissue damage and simple, right-sided vessel lacerations, but we cannot recommend it as an initial approach in patients with severe, exsanguinating injuries.

Injury severity scoring: influence of timing and nurse raters on accuracy.

The Abbreviated Injury Scale (AIS) and its incorporation into the Injury Severity Score (ISS) have become accepted as objective ways to quantitate the severity of trauma. To examine the practicality of using critical care nurses to initiate injury scoring within the first 24 hours of admission, a prospective study was undertaken. Nurses on the trauma intensive care unit were asked to calculate the ISS in patients admitted to the unit over a 4-month period. Scoring was completed within 24 hours of admission and recorded on an edited single-page chart constructed from the 1980 revision of the AIS. All patients were followed up until discharge, and the ISS was reviewed in the light of discharge diagnoses. One hundred four patients were studied, and accurate scores were calculated in 54 patients (51.9%). In three patients (2.9%) the single-page chart did not allow accurate scoring, and in 18 patients (17.3%) the diagnoses noted subsequent to the scoring time frame resulted in inaccuracy. Human errors resulted in inaccuracy in 28% of patients. In comparison with a concurrent study involving surgical residents, human error rates were similar. However, scoring within 24 hours, as opposed to 72 hours, resulted in significantly more errors related to diagnostic uncertainty. Initiation of the scoring process soon after admission, with subsequent correction during the hospital course, allows important information to be available at the earliest time.

Patterns of injury in motor vehicle trauma.

One hundred and sixty victims of motor vehicle accidents presenting to Auckland Hospital were evaluated to determine patterns of injury, overall injury severity, and outcome. Motor vehicle occupants comprised 51% of the group, pedestrians 28% and motorcyclists 21%. Mortality was 7.4%, 20% and 2.9% respectively for these three groups. The mean injury severity score was 19. Head and external injuries were common, each occurring in over 60% of all patients. In motorcyclists however, head injuries were less common (47%) (p less than 0.05) and facial injuries occurred in only 9% compared to 23% (p = ns) of the other two injury groups. Overall, severe chest or abdominal injury was present in only 16% of patients but these injuries occurred in 58% of those patients with severe head injury and extremity fractures (p less than 0.001). In motor vehicle occupants the combination of severe head injury and lower extremity fracture was associated with severe chest or abdominal injury in 8/9 patients. The patterns of injury identified here may be helpful in triaging patients to appropriate care facilities.

Penetrating trauma in Auckland.

To establish the spectrum of penetrating trauma presenting to a city hospital and review the results of management, all patients brought to the resuscitation room at Auckland Hospital over a one year period were evaluated. Of 602 patients, only 41 (7%) had penetrating injuries. Thirty-one patients had stab or slashing injuries, seven had gunshot wounds and three had other forms of penetrating injury. Overall mortality was 17% which included 4/31 stab wounds and 3/7 gunshot wounds. Three of the four patients with fatal stab wounds died from exsanguination in the resuscitation room. A system which allows prompt resuscitation and rapid transfer to the operating theatre is needed to improve survival in patients suffering exsanguinating injury.

Trauma data collection using a customised trauma registry: a New Zealand experience.

AIM: To describe the process of selection and adaptation of a trauma registry and the initial experience with its use. METHOD: The decision-making processes involved in selection of a data set and computer software are described. The problems associated with collection of data, recording and analysis are outlined. RESULTS: In the 6 months from 1 January to 30 June 1995, 615 patients were entered on the Auckland Hospital trauma registry. 590 patients were discharged or transferred alive and 25 (4.1%) died in hospital. Median length of stay of survivors was 6 days (mean 9.03 days) with median ICU stay being 0 days (mean 0.81 days). A range of difficulties including data collection, recording and analysis were experienced. CONCLUSION: Despite some teething problems, establishment of a trauma registry has proven to be an achievable task within the trauma service. Recording of data which allows assessment of the quality of care, resource use and outcome has been possible. Effectiveness of the trauma service has been enhanced by the availability of this data.

Trauma form documentation in major trauma.

AIMS: To examine the impact of a standardised trauma form for documentation in cases of major trauma, a prospective study was undertaken. METHODS: Records written by medical staff pertaining to the assessment and treatment of major trauma patients in the resuscitation room were scored against a panel of parameters derived from advanced trauma life support guidelines. Demographics, aetiology, trauma scores and outcome data were obtained from a trauma registry. Attitudes of medical staff involved in major trauma to the trauma form were assessed using a questionnaire. RESULTS: The trauma form was used in 53 of 69 (76.8%) consecutive cases of major trauma seen over a three month period. No significant differences existed in demographics, aetiology, trauma scores or outcome between form and formless groups. In the form group, a median of 44 of 51 (86.3%) relevant information parameters were documented versus 32 of 51 (62.7%) in the formless group, p < 0.0001. A positive approach to the trauma form was indicated by the questionnaire results. CONCLUSION: The use of a standardised form improves documentation in major trauma.

Hydatid disease at a peripheral hospital: a review of 25 years' experience.

A review of all patients presenting to Rotorua Hospital over a 25 year period with a diagnosis of hydatid disease was undertaken. The type of presentation, symptoms, signs, and results of investigations were all recorded. Where patients were submitted to surgery, the nature of the procedure and the postoperative course were noted. Mortality, and the presence or absence of recurrent disease at follow up was noted. Thirty-six patients were thus reviewed and the male to female ratio was 24:12. Twenty-nine of the patients were Maori and seven were European. Twenty-one of the patients (58 percent) had liver cysts alone, and 12 of the patients presented acutely. All but six of the patients underwent surgery at rotorua Hospital with a wide variation in the nature of the operative procedures. The overall mortality from hydatid disease was 11 percent and over a mean period of 8.9 years, of the 25 patients available for follow up, 22 remained free of the disease.

Acute selenium poisoning: case report.

A case of self-poisoning with sodium selenate sheep drench, along with blood and urine levels of selenium, is reported. Treatment included gastric lavage, diuresis, vitamin C, and dimercaprol, and the patient recovered without sequelae.

Trauma and co-morbidity--a pilot study.

AIMS: To study the adult trauma patient population at the Auckland Hospital in order to determine the age distribution of trauma, the prevalence and importance of co-morbid conditions and any effect of the latter on the length of stay in the hospital. METHODS: Data were collected on 78 consecutive patients admitted to the Auckland Hospital under the Trauma team between December 1999 and January 2000. Data were collected by interviewing the patient, as well as reviewing patient's medical notes and the Trauma Registry. RESULTS: The prevalence of co-morbidities was 14.7%. No co-morbidity was found below the age of 40 years, but the prevalence of co-morbidity increased with age. The average length of stay for patients with no comorbidities and an Injury Severity Score (ISS) >15 was 19 days while for those with co-morbidities was 24.5 days--an increase of 29%. CONCLUSION: This pilot study has found that a significant number of trauma patients being admitted to Auckland Hospital have a pre-existing co-morbid condition that may alter their length of stay. It is an important issue that warrants further investigation, in order to devise a more accurate prognostic scoring system.