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Background Pretibial lacerations are common injuries that have a significant yet underestimated association with morbidity and mortality. Although they may occur in any age group, they are commonly followed by an often relatively minor trauma in elderly and frail patients. The six-month mortality among such patients may be more than double the age group average. Currently, 5.2 in 1000 patients per year present to the emergency departments in UK hospitals due to pretibial lacerations. The associated acute admissions have a high financial cost. Despite the significant disease burden, there is a paucity of evidence on the optimal management of such injuries. This study aimed to describe the typical demographic and injury factors of individuals presenting to two district general hospitals, as well as their subsequent management and referral. Methodology Relevant patients were identified through NHS coding searches. Subsequently, it was found that 99 patients presented to an NHS trust with pretibial lacerations throughout 2020. A retrospective manual evaluation of clinical documentation was performed to identify the details of the patients' injury, management, referral, and demographics. Results The patients had a mean age of 55.4 (SD 28.3), and 56.6% were female. The most commonly presenting mechanism of injury was direct blunt trauma. The majority of cases were solely managed and discharged directly by the emergency department (74.8%). Of the 99 patients, 25 (25.3%) were referred to specialist services, 12 (12.1%) were managed conservatively, and 13 (13.1%) underwent operative intervention. The mean length of stay for those referred was 5.9 days, and the mean for the same was greater for those managed conservatively compared to those managed operatively (9.0 vs. 2.6 days). Among patients discharged by the emergency department, the most common method of wound closure was steristrips (n = 40; 54.1%), followed by conservative management with dressings (n = 22; 29.7%), sutures (n = 10, 13.5%) and glue (n = 5; 6.8%). Conclusions Overall, this study showed that the majority of patients presenting with pretibial lacerations have minor wounds that can be effectively managed in the emergency department. However, those with considerably more injuries should be provided an early referral to specialist services, where they would ideally receive early surgery and comprehensive follow-up.
RESUMO
BACKGROUND: Anastomotic leaks (AL) and gastric conduit necrosis (CN) are serious complications following oesophagectomy. Some studies have suggested that vascular calcification may be associated with an increased AL rate, but this has not been validated in a United Kingdom population. AIM: To investigate whether vascular calcification identified on the pre-operative computed tomography (CT) scan is predictive of AL or CN. METHODS: Routine pre-operative CT scans of 414 patients who underwent oesophagectomy for malignancy with oesophagogastric anastomosis at the Queen Elizabeth Hospital Birmingham between 2006 and 2018 were retrospectively analysed. Calcification of the proximal aorta, distal aorta, coeliac trunk and branches of the coeliac trunk was scored by two reviewers. The relationship between these calcification scores and occurrence of AL and CN was then analysed. The Esophagectomy Complications Consensus Group definition of AL and CN was used. RESULTS: Complication data were available in n = 411 patients, of whom 16.7% developed either AL (15.8%) or CN (3.4%). Rates of AL were significantly higher in female patients, at 23.0%, compared to 13.9% in males (P = 0.047). CN was significantly more common in females, (8.0% vs 2.2%, P = 0.014), patients with diabetes (10.6% vs 2.5%, P = 0.014), a history of smoking (10.3% vs 2.3%, P = 0.008), and a higher American Society of Anaesthesiologists grade (P = 0.024). Out of the 14 conduit necroses, only 4 occurred without a concomitant AL. No statistically significant association was found between calcification of any of the vessels studied and either of these outcomes. Multivariable analyses were then performed to identify whether a combination of the calcification scores could be identified that would be significantly predictive of any of the outcomes. However, the stepwise approach did not select any factors for inclusion in the final models. The analysis was repeated for composite outcomes of those patients with either AL or CN (n = 69, 16.7%) and for those with both AL and CN (n = 10, 2.4%) and again, no significant associations were detected. In the subset of patients that developed these outcomes, no significant associations were detected between calcification and the severity of the complication. CONCLUSION: Calcification scoring was not significantly associated with Anastomotic Leak or CN in our study, therefore should not be used to identify patients who are high risk for these complications.