Global 30-Day Morbidity and Mortality of Primary Bariatric Surgery Combined with Another Procedure: The BLEND Study.

BACKGROUND: No robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures. OBJECTIVES: The objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair. SETTING: This is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures. METHODS: The audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone. RESULTS: A total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%). CONCLUSION: Combining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion.

Global 30-day morbidity and mortality of surgery for perforated peptic ulcer: GRACE study.

BACKGROUND: There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these. METHOD: We performed an international study of adults (≥ 18 years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50 years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24 h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality. RESULTS:  1874 patients from 159 centres across 52 countries were included. 78.3% (n = 1467) of the patients were males and the median (IQR) age was 49 years (25). Thirty-day morbidity and mortality were 48.5% (n = 910) and 9.3% (n = 174) respectively. Median (IQR) hospital stay was 7 (5) days. Open surgery was performed in 80% (n = 1505) of the cohort. Age > 50 years [(OR = 1.7, 95% CI 1.4-2), (OR = 4.7, 95% CI 3.1-7.6)], female gender [(OR = 1.8, 95% CI 1.4-2.3), (OR = 1.9, 95% CI 1.3-2.9)], shock on admission [(OR = 2.1, 95% CI 1.7-2.7), (OR = 4.8, 95% CI 3.2-7.1)], and acute kidney injury [(OR = 2.5, 95% CI 1.9-3.2), (OR = 3.9), 95% CI 2.7-5.6)] were associated with both 30-day morbidity and mortality. Delayed presentation was associated with 30-day morbidity [OR = 1.3, 95% CI 1.1-1.6], but not mortality. CONCLUSIONS: This study showed that surgery for PPU was associated with high 30-day morbidity and mortality rate. Age, female gender, and signs of shock at presentation were associated with both 30-day morbidity and mortality.

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study.

Background: Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA. Methods: The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury. Results: 14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%. Conclusion: The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage. Level of evidence: 2.

Thoracic endovascular aortic repair in a case of grade III blunt aortic injury with aberrant vertebral artery origin.

Aberrant origin of the left vertebral artery (LVA) can pose a challenge during thoracic endovascular aortic repair. We encountered such a patient who was involved in a motor vehicle accident in whom computed tomography angiography revealed a grade IIIB blunt aortic injury with an anomalous origin of the LVA distal to the origin of the left subclavian artery. On-table aortography confirmed dominance of the LVA. Hence, an open left carotid-vertebral and then left carotid-subclavian artery bypass was performed, followed by thoracic endovascular aortic repair. The patient recovered well and was discharged home 3 days later.

Surgical site infections after trauma laparotomy. An observational study from a major trauma center in Saudi Arabia.

OBJECTIVES: To determine the incidence of surgical site infection (SSI) after trauma laparotomy and evaluate variables on presentation to the emergency department (ED) associated with the development of SSI. Methods: A retrospective cohort study was undertaken of patients presenting directly from the scene who underwent trauma laparotomy between January 2016 and December 2017. The primary outcome variable was SSI, as defined by the Centers for Disease Control and Prevention guideline. A univariate assessment with demographics, vital signs, and acute management was reported. Results: A total of 70 patients were included for data analysis. Of these, 9 (12.9%; 95% confidence interval (CI): 6.9-22.7%) patients developed SSI, including 5 patients with bowel injury (small bowel; n=3, colonic injuries; n=2). Most cases were diagnosed after 7 days in the hospital. All patients developed superficial incisional (skin and subcutaneous tissue) SSI. No predetermined variables, including bowel injury (p=0.08) or duration of surgery (p=0.09), demonstrated a statistically significant association with the development of SSI. Conclusion: Rates of SSI after trauma laparotomy were similar to previous reports from other centers. Surgical site infection after trauma laparotomy was diagnosed at a delayed time point after surgery, and patient demographics, injury characteristics, and acute surgical management did not appear to be associated with subsequent diagnosis of SSI.

Selective nonoperative management of liver gunshot injuries.

PURPOSE: Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. METHODS: A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. RESULTS: During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. CONCLUSION: The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.

Significant bleeding from Meckel's diverticulum after blunt abdominal trauma: a case report.

BACKGROUND: Meckel's diverticulum, with an incidence of 2%, is the most common congenital anomaly in the gastrointestinal tract. Its main complications are perforation, obstruction, and bleeding. A few studies have reported that blunt abdominal trauma may result in perforation or obstruction to Meckel's diverticulum. However, reports of significant major intestinal bleeding from Meckel's diverticulum as a complication of blunt abdominal trauma is rare. This paper present what we believe to be the first reported case of significant intestinal bleeding from a Meckel's diverticulum following blunt abdominal trauma. CASE PRESENTATION: A 12-year-old Saudi boy of Arab ethnicity presented to the King Saud Medical City emergency department with bleeding per rectum and mild abdominal pain following blunt trauma to his abdomen. On examination, his abdomen was slightly tender, bowel sounds were present, and he was hemodynamically stable. During admission, rectal bleeding was ongoing. On day 3 he deteriorated with decreasing blood pressure and hemoglobin, and increasing pulse rate with fever. After resuscitation and stabilization, he was urgently taken to the operating room for further diagnostic management and treatment. His nasogastric tube revealed bile without blood, and an intraoperative colonoscopy revealed altered blood within his whole colon and terminal ileum without a definite bleeding site. A laparotomy was performed, and an injured branch of the mesenteric artery supplying the Meckel's diverticulum was identified as the source of the significant arterial bleeding. Suture ligation controlled the bleeding, and the Meckel's diverticulum was resected. The patient remained stable after that until discharge without any further intestinal bleeding. CONCLUSION: Identifying bleeding as a complicated Meckel's diverticulum following blunt trauma to the abdomen can be challenging due to its low incidence and difficulties while making the diagnosis.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa.

Background: The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Methods: Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. Results: One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35-60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications (p = 0.074). Conclusion: Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

Time since injury is the major factor in preventing tranexamic acid use in the trauma setting: An observational cohort study from a major trauma centre in a middle-income country.

BACKGROUND: Haemorrhage is responsible for about a third of in-hospital trauma deaths. The CRASH-2 trial demonstrated that early administration of tranexamic acid, ideally within 3 hours, can reduce mortality from trauma-associated bleeding by up to 32%. OBJECTIVE: To explore whether, in our trauma network in a middle-income country, patients arrived at hospital soon enough after injury for tranexamic acid administration to be effective and safe. METHODS: A prospective cohort study of 50 consecutive patients admitted to our trauma unit was undertaken. Inclusion criteria were as for the CRASH-2 study: systolic blood pressure <90 mmHg and/or heart rate >110 beats per minute, with injuries suggestive of a risk of haemorrhage. Patients with isolated head injuries were excluded. The mechanisms of injury, time since injury and any reasons for delay were recorded. RESULTS: Thirteen (26%) patients presented early enough for tranexamic acid administration. Of these, only three patients presented within the 1st hour. Eleven patients had a documented time of injury >3 hours prior to presentation. We were unsure of the time of injury for 26 patients, although for most of these it was likely to be >3 hours before presentation. CONCLUSIONS: The majority (74%) of bleeding trauma patients did not present within the timeframe allowed for safe administration of tranexamic therapy. Of those who did, most would have benefited from even earlier commencement of therapy. This raises the possibility that tranexamic acid may be more effective on a population basis if incorporated into prehospital rather than in-hospital protocols; future studies should explore the benefits and risks of this approach.