Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis.

BACKGROUND: Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave's syndrome (BS). METHODS: We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. RESULTS: Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8-5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2-7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2-6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1-3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1-3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. CONCLUSIONS: This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review.

PURPOSE: Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. METHODS: A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. RESULTS: There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. CONCLUSION: Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons.

BACKGROUND: Retained hemothorax and/or empyema is a commonly recognized complication of penetrating chest injuries that may be treated by early video-assisted thoracoscopy (VATS). However, the use of VATS in blunt chest trauma is less well defined. Our acute care surgeon (ACS) group aggressively treats complications of penetrating chest trauma with VATS, and our results suggested that the early use of VATS by ACS should be expanded. MATERIALS: A retrospective review of Trauma Center admissions between January 2007 and December 2009 was performed to identify patients with blunt thoracic injuries who underwent VATS. RESULTS: Eighty-three patients underwent VATS to manage thoracic complications arising from their blunt chest trauma. All operations were performed by ACS. The majority of patients (73%, 61 of 83) were treated with VATS for retained hemothorax, 18% for empyema (15 of 83), and 10% for persistent air leak (8 of 83). All (15) patients who developed empyema had chest tubes placed in the emergency department. No patient treated with VATS for a persistent air leak required further operation or conversion to thoracotomy. VATS performed ≤5 days after injury was associated with a lower conversion to open thoracotomy (8% vs. 29.4%, p < 0.05). Hospital length of stay (LOS) was significantly lower for patients receiving VATS ≤5 days after injury (11 ± 6 vs. 16 ± 8, p < 0.05). No patient treated with VATS ≤5 days had persistent empyema; however, five patients treated with VATS for retained hemothorax or empyema >5 days after injury required further intervention for thoracic infection. Multivariate analysis demonstrated that both a diagnosis of empyema and VATS >5 days after injury were predictors of increased LOS and increased conversion to thoracotomy. CONCLUSIONS: Early VATS can decrease hospital LOS and thoracotomy rate in patient suffering blunt thoracic injuries. ACS can perform this procedure safely and effectively.

Aggressive operative treatment for emetogenic rupture yields superior results.

The treatment of emetogenic rupture remained controversial and was particularly so when the patient arrived for definitive care greater than 24 hours postrupture. We treated patients with continued extravasation of contrast from the esophagus by early operation regardless of the timing of their presentation. All primary repairs received a reinforced closure and many delayed repairs had an onlay flap for closure of the leak. We treated 31 patients with emetogenic rupture; 24 of 25 patients with extravasation had operative repair, whereas six with small, contained ruptures were treated medically. Twelve were operated on within 24 hours, whereas 24 presented from 36 to 796 hours postrupture. We were able to achieve closure of the defect by primary suture repair or with a tissue flap in all patients. There were no postoperative leaks. One patient each died in the operated group and observed group. There were minimal complications and a relatively short hospital stay. Our results support the use of aggressive operative treatment for emetogenic rupture regardless of the timing of patient presentation. Such treatment preserved esophageal function and was accomplished with relatively low morbidity and mortality.

Decreasing regional neurosurgical workforce-a blueprint for disaster.

BACKGROUND: Traumatic brain injuries are a frequent cause of death and a substantial source of morbidity. Neurosurgeons (NS) are commonly involved in the management of patients with moderate and severe traumatic brain injuries to minimize morbidity from both primary and secondary brain injuries. However, NS willing to care for injured patients have become increasingly scarce. Although many institutions have been individually affected by shortages of NS providing care to injured patients, data on regional changes in NS availability and the effect on patient care are limited. METHODS: We queried a state discharge database for all traumatic intracranial hemorrhages (ICH) and skull fractures from 2004 to 2007 by International Classification of Diseases-9th Rev.-Clinical Modification codes. Institutions were categorized as those that admitted >30 or <30 ICH patients per year. The state medical society provided the number of NS practicing in the state per year. RESULTS: The total number of patients with significant head injuries increased over the study period. The number of NS decreased over the same time period. A greater proportion of patients were managed in centers admitting >30 ICH per year, and the number of facilities admitting <30 ICH per year decreased. CONCLUSION: In this state, increasing numbers of patients with ICH are being concentrated in a small number of centers, while the number of NS available to care for them has decreased. Shortages in neurosurgical workforce for patients with traumatic ICH have the potential for catastrophic consequences on a regional basis if effective solutions to this manpower issue are not created.

Recidivism rates following firearm injury as determined by a collaborative hospital and law enforcement database.

BACKGROUND: Recidivism is a key outcome measure for injury prevention programs. Firearm injury recidivism rates are difficult to determine because of poor longitudinal follow-up and incomplete, disparate databases. Reported recidivism rates from trauma registries are 2% to 3%. We created a collaborative database merging law enforcement, emergency department, and inpatient trauma registry data to more accurately determine rates of recidivism in patients presenting to our trauma center following firearm injury. METHODS: A collaborative database for Jefferson County, Kentucky, was constructed to include violent firearm injuries encountered by the trauma center or law enforcement from 2008 to 2019. Iterative deterministic data linkage was used to create the database and eliminate redundancies. From patients with at least one hospital encounter, raw recidivism rates were calculated by dividing the number of patients injured at least twice by the total number of patients. Cox proportional hazard models were used to evaluate risk factors for recidivism. The cumulative incidence of recidivism over time was estimated using a Kaplan-Meier survival model. RESULTS: There were 2, 363 assault-type firearm injuries with at least 1 hospital encounter, approximately 9% of which did not survive their initial encounter. The collaborative database demonstrated raw recidivism rates for assault-type firearm injuries of 9.5% compared with 2.5% from the trauma registry alone. Risk factors were young age, male sex, and African American race. The predicted incidence of recidivism was 3.6%, 5.6%, 11.4%, and 15.8% at 1, 2, 5, and 10 years, respectively. CONCLUSION: Both hospital and law enforcement data are critical for determining reinjury rates in patients treated at trauma centers. Recidivism rates following violent firearm injury are four times higher using a collaborative database compared with the inpatient trauma registry alone. Predicted incidence of recidivism at 10 years was at least 16% for all patients, with high-risk subgroups experiencing rates as high as 26%. LEVEL OF EVIDENCE: Epidemiological, level III.

Impact of hollow viscus injuries on outcome of abdominal gunshot wounds.

Abdominal gunshot wounds (GSW) are a source of morbidity and mortality. Limited data are available on the effect of hollow viscus injuries (HVI) secondary to gunshot wounds. GSW sustained in the Louisville area from 2004 to 2007 were reviewed. Attention was given to the impact of HVI from abdominal GSW. Statistical significance was determined. One-hundred ten patients sustained GSW with peritoneal violation. Eighty-six had HVI. Eighteen died after laparotomy with 15 having an HVI. Patients undergoing damage control (DC) have a significant increase in mortality compared with those not requiring DC. Exsanguination was the major cause of mortality (67%). Mortality directly related to HVI was found in 11 per cent. Twenty patients underwent DC with 11 deaths. Isolated HVI did not show a significantly increased mortality compared with other injury patterns involving solid organ or major vascular structures. Various methods of repair showed no significant survival advantage. Recognition and repair of HVI in abdominal GSW is crucial to patient salvage. Definitive repair of HVI at the initial operation should be considered. Primary repair of HVI is preferred although no survival disadvantage is seen in other forms of repair in marginally stable patients. Definitive repair at the initial operation decreases complications.

Management differences for pediatric solid organ injuries in a rural state.

Pediatric liver and spleen injuries are frequently treated in specialized hospitals. Not all injured children, however, are treated in referral centers. We evaluated the management of pediatric liver and spleen injuries in a rural state without a state trauma system to determine if differences existed between trauma centers and nontrauma centers. A state database was queried for patients < or = 15-years-old who suffered liver and spleen injuries from 2003 to 2005. Iatrogenic injuries were excluded. There were 115 pediatric liver and 183 pediatric spleen injuries. Fifty per cent of liver and 63 per cent of spleen injuries in nontrauma centers were isolated solid organ injuries compared with 18 per cent and 36 per cent, respectively, in trauma centers. The mortality rate for both liver and spleen injuries was similar in trauma and nontrauma centers. Hospital charges were higher in trauma centers but this was due to patients with associated injuries. The nonoperative management rate was similar for liver injuries. Pediatric patients with splenic injuries had a lower rate of nonoperative management in nontrauma centers (75% to 90%, nontrauma vs trauma). In Kentucky, pediatric solid organ injuries are usually managed nonoperatively in both trauma and nontrauma centers, but trauma centers cared for fewer isolated solid organ injuries.

Operative Management of Thoracic Gunshot Wounds: More Aggressive Treatment Has Been Required over Time.

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.

Is splenectomy after trauma an endangered species?

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 +/- 0.9 days, 10.9% mortality) compared with trauma (11.0 +/- 0.5 days, 7.7% mortality) or medical (9.7 +/- 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training.

Blunt liver injury in children and adults: is there really a difference?

Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (> or = 18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.

Esophagectomy for end stage achalasia.

Esophageal myotomy is the standard primary therapy for achalasia. However, reports on long-term results of myotomy have suggested a deterioration of outcome over time with many patients presenting with end stage disease several years after esophagomyotomy. Eight patients who had previously undergone esophagomyotomy for achalasia presented with recurrent or worsening symptoms, and after preoperative evaluation, were treated by esophagectomy via laparotomy and right thoracotomy. The mean age at the time of myotomy was 52 years (range 18 to 62 years), and the mean time until esophagectomy was 12.5 years (range 2 to 18 years) after the initial myotomy. The median time until esophagectomy was performed after myotomy was 14 years. All patients in this series gained weight (mean, 23 pounds; range, 9 to 42 lbs) following esophagectomy, and none of the patients complained of dysphagia at follow-up or developed stricture. There were no major complications (including anastomotic leak) or deaths in this series. Five of the patients have been followed a mean of six years and remain well. Esophagectomy is a safe and appropriate treatment option in the setting of recurrent and end stage achalasia.

Operative fixation of chest wall fractures: an underused procedure?

Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously without specific treatment. However, a small subset of patients have fractures that produce overlying bone fragments that may produce severe pain, respiratory compromise, and, if untreated mechanically, result in nonunion. We performed open reduction and internal fixation on seven patients with multiple rib fractures-five in the initial hospitalization and two delayed--as well as 35 sternal fractures (19 immediate fixation and 16 delayed). Operative fixation was accomplished using titanium plates and screws in both groups of patients. All patients with rib fractures did well; there were no major complications or infections, and no plates required removal. Clinical results were excellent. There was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with no complications occurring in this group. Three patients had their plates removed after boney union was achieved. No evidence of infection or nonunion occurred. The excellent results achieved in the subset of patients with severe chest wall deformities treated initially at our institution and those referred from outside suggest that operative fixation is a useful modality that is likely underused.

Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries.

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2-18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.

Morbid obesity impacts mortality in blunt trauma.

Twenty-six per cent of adults in the Unites States are obese and trauma remains a major cause of death. We assessed the impact of morbid obesity on mortality in patients with blunt trauma. We reviewed the records of patients with a body mass index 40 kg/m2 or greater injured by blunt trauma from 1993 to 2003 and compared them with a 4:1 control population with a normal body mass index and matched for sex and constellation of injuries. For comparison, patients were categorized by Injury Severity Score 9 or less or Injury Severity Score 10 or greater. Student t test and chi2 were used for statistical analysis. P < 0.05 was considered significant. One hundred seven morbidly obese patients were identified and compared with 458 control subjects with a normal body mass index and matched for sex and constellation of injuries. Although the morbidly obese patients were found to be significantly younger, those who incurred multiorgan injury experienced a significantly longer hospital length of stay and displayed a greater than fourfold increase in mortality when compared with the control subjects. Furthermore, the number of morbidly obese patients admitted over the 10-year period significantly increased by fourfold (0.4% to 1.5%). Over the last decade, there has been a significant increase in morbidly obese patients cared for in our trauma center. Although these patients were significantly younger with a similar Glasgow Coma Score as that of the control population, morbid obesity significantly increased mortality when the injury from blunt trauma transitioned from a single to a multiorgan injury.

Randomized Controlled Trial Evaluating the Efficacy of Peritoneal Resuscitation in the Management of Trauma Patients Undergoing Damage Control Surgery.

BACKGROUND: Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery. These data represent the outcomes of a single institution randomized controlled trial into the efficacy of PR as a management option in these patients. STUDY DESIGN: From 2011 to 2015, one hundred and three patients were enrolled in a prospective randomized controlled trial evaluating the use of PR in the treatment of patients undergoing damage control surgery compared with conventional resuscitation (CR) alone. Patient demographics, clinical variables, and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. RESULTS: After initial screening, 52 patients were randomized to the PR group and 51 to the CR group. Age, sex, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared with the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days; p ≤ 0.002). Volume of resuscitation and blood products transfused in the initial 24 hours was not different between the groups. Primary fascial closure rate was higher in the PR group (83% vs 66%; p ≤ 0.05). Intra-abdominal complications were lower in the PR compared with the CR group (8% vs 18%), with abscess formation rate (3% vs 14%; p < 0.05) being significant. Patients in the PR group had a lower 30-day mortality rate, despite similar Injury Severity Scores (13% vs 28%; p = 0.06). CONCLUSIONS: Peritoneal resuscitation enhances management of damage control surgery patients by reducing time to definitive abdominal closure, intra-abdominal infections, and mortality rates.

Training of general surgical residents: what model is appropriate?

The training of general surgical residents has been a relatively stable process for the past several decades. However, a variety of forces have caused several recent changes in the education of general surgeons and more potentially radical alterations have been recommended by some surgical leaders. Much of the initiative for changing training is due to the inexorable forces of specialization and the increasingly vigorous competition for qualified trainees in various surgical disciplines. Decisions made within the next few years will likely decide the future of general surgery as a specialty.

Morbidity and mortality in vascular surgery: the Kentucky experience with a statewide database.

Efforts at improvement in quality of care for surgical patients have required multiple strategies that include local, regional, and national efforts to influence processes and outcomes, and examination of outcome databases with and without risk stratification. In the mid to late 1980s, there was an effort to examine the outcome of two high-risk procedures (carotid endarterectomy and abdominal aortic aneurysm repair) on all Medicare patients in the state of Kentucky with an effort to determine the outcome of their treatment and improve the quality of care delivered to them. Even though this experience is somewhat dated, it still represents a unique examination of a large number of patients treated by numerous surgeons. Furthermore, all charts reviewed by the author presented an opportunity to compare actual patient data with that obtained from an administrative data set. This report also examines the author's attempts at improving outcome.