Economic Analysis of AbClo, a Novel Abdominal Fascia Closure Device, for Patients With an Open Abdomen Following Trauma or Acute Abdominal Surgery.

BACKGROUND: Open Abdomen (OA) cases represent a significant surgical and resource challenge. AbClo is a novel non-invasive abdominal fascial closure device that engages lateral components of the abdominal wall muscles to support gradual approximation of the fascia and reduce the fascial gap. The study objective was to assess the economic implications of AbClo compared to negative pressure wound therapy (NPWT) alone on OA management. METHODS: We conducted a cost-minimization analysis using a decision tree comparing the use of the AbClo device to NPWT alone among patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure. The time horizon was limited to the length of the inpatient hospital stay, and costs were considered from the perspective of the US Medicare payer. Clinical effectiveness data for AbClo was obtained from a randomized clinical trial. Cost data was obtained from the published literature. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was incremental cost. RESULTS: The mean cumulative costs per patient were $76 582 for those treated with NPWT alone and $70,582 for those in the group treated with the AbClo device. Compared to NPWT alone, AbClo was associated with lower incremental costs of -$6012 (95% CI -$19 449 to +$1996). The probability that AbClo was cost-savings compared to NPWT alone was 94%. CONCLUSIONS: The use of AbClo is an economically attractive strategy for management of OA in in patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure.

The role of clinical and sonographic assessments in pre-operative evaluation of patients with splenic injuries in a resource-limited economy.

Background: Splenic trauma has been recognized as the most common cause of preventable deaths amongst trauma patients. Due to paucity of modern diagnostic imaging facilities in our setting, determination of the error rates and role of the simple, available diagnostic approaches are worthwhile and relevant to the practice of general surgery. Objectives: The aim was to determine the role and diagnostic accuracy of clinical and sonographic assessments of splenic injuries. Methods: This was a prospective study of the value of pre-operative clinical and sonographic assessments of patients with splenic injuries in our setting. Results: A total of 111 patients with abdominal trauma were evaluated. Of these, splenic injuries were confirmed in 75 patients intra-operatively, mainly from blunt trauma. Of the 97 cases diagnosed by clinical method, 66(68.0%) were confirmed by intraoperative findings. Similarly, of 86 sonographic diagnoses of splenic injuries, 61 (70.9%) truly had splenic trauma. Sensitivity for sonographic and clinical assessments was 84.7% and 78.9% respectively. False positive and negative rates for clinical (27.3% versus 44.1%) and ultrasonographic (29.1% versus 40.0%) assessments were high. Conclusions: Majority of splenic injuries were due to blunt abdominal trauma. The two diagnostic methods showed high sensitivity, but performed poorly for other validity tests.

Using Right-Sided Roll to Improve Reliability of Focused Assessment with Sonography in Trauma: An Eastern Association for the Surgery of Trauma Multicenter Prospective Study.

BACKGROUND: The Focused Assessment Sonography in Trauma (FAST) examination is the standard of care for detecting hemoperitoneum in hypotensive blunt trauma patients. A pilot study demonstrated earlier identification of intra-abdominal fluid via FAST after right-sided roll (FASTeR) when compared with the standard FAST. The purpose of this study was to evaluate this phenomenon prospectively in hypotensive blunt trauma patients. STUDY DESIGN: An Eastern Association for the Surgery of Trauma-approved multicenter prospective trial was performed June 2016 to October 2020 at 8 designated trauma centers. Hypotensive adult blunt trauma patients were included. A traditional FAST examination was performed. After this, the secondary survey logroll for back examination was standardized to the patient's right side. A repeat supine right upper quadrant ultrasound view was obtained. The presence or absence of hemoperitoneum was confirmed by CT scan or intraoperative findings. FAST and FASTeR were compared using receiver operating characteristics. The area under the curve was calculated. RESULTS: A total of 182 patients met inclusion criteria. A total of 65 patients (35.7%) had hemoperitoneum on CT scan or intraoperative findings. The sensitivity of FASTeR was 47.7%, and of FAST was 40.0% (p = 0.019). The receiver operating characteristics area under the curve of the FASTeR examination was 0.717 vs 0.687 for the FAST examination (p = 0.091). CONCLUSIONS: Addition of a right upper quadrant view after right-sided roll does improve the sensitivity of the FAST examination while maintaining the standard positive predictive value. We demonstrate a trend that does not reach statistical significance about the overall accuracy. This multicenter prospective trial was underpowered to reveal a statistically significant difference in the overall accuracy as measured by the receiver operating characteristics area under the curve.

Performance of Focused Assessment with Sonography for Trauma Following Resuscitative Thoracotomy for Traumatic Cardiac Arrest.

BACKGROUND: In patients undergoing resuscitative thoracotomy (RT) for traumatic cardiac arrest, focused assessment with sonography for trauma (FAST) is often used to look for intraperitoneal fluid. These findings can help determine whether abdominal exploration is warranted once return of spontaneous circulation is achieved; however, the diagnostic accuracy of FAST in this clinical scenario has yet to be evaluated. The purpose of this study was to assess the performance of FAST in identifying intra-abdominal hemorrhage following RT. METHODS: We performed a 3-year retrospective study at a high-volume level 1 trauma center from 2014 to 2016. We included patients who underwent RT in the Emergency Department. All FAST examinations were performed by non-radiologists. Operative findings, computed tomography reports, diagnostic peritoneal aspirate (DPA) results, and autopsy findings were used as reference standards to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the FAST. RESULTS: A total of 158 patients met our inclusion criteria. The median age was 35 years (interquartile range [IQR]: 23-53), 86.1% were male, and 60.1% sustained blunt trauma. Most patients suffered severe injuries with a median injury severity score of 27 (IQR: 18-38). The sensitivity, specificity, PPV, NPV, and accuracy of FAST for identifying intra-abdominal hemorrhage were 66.0%, 84.8%, 68.6%, 83.2%, and 78.5%, respectively. Among the 107 patients with a negative FAST, 22 (20.6%) underwent DPA, which was positive in 5 patients. CONCLUSIONS: FAST can be utilized in the diagnostic workup of trauma patients after RT. In patients with a positive FAST, exploratory laparotomy is warranted, whereas other diagnostic adjuncts such as DPA or mandatory abdominal exploration may be considered in patients with a negative FAST.

Effects of Branched-chain Amino Acids on Nutritional Metabolism and Pharmacoeconomics in Patients with Severe Abdominal Trauma.

OBJECTIVE: To observe the influences of branched-chain amino acids (BCAAs) on nutrition metabolism and prognosis of patients with severe abdominal trauma; at the same time, to analyze and evaluate the pharmacoeconomics of it. METHODS: A total of 75 severe abdominal trauma patients were recruited from June 2016 to December 2017 and randomly divided into control group and observation group. After surgery and basic treatment, parenteral nutrition support therapy with iso-nitrogen and iso-calorie of both groups was administered. Meanwhile, an equivalent of 8.5% (18AA-II) and 10% (20AA) compound AA injection was administrated to the control and observation groups, respectively. The nitrogen balance, serum protein level and plasma amino spectrum of the patients were observed before and after treatment. Besides, the hospital stay, survival rate, complications, adverse reactions and hospitalization costs were also compared. RESULTS: After a 7-day course treatment, the nitrogen balance level of the two groups was significantly improved, but no significant difference was found between them. In addition, the serum protein level and plasma amino spectrum of the two groups was generally improved when compared to before treatment. Compared with the control group, the level of albumin and transferrin in the observation group was improved significantly after treatment, while no difference in plasma amino spectrum was found between the two groups. Moreover, the cost analysis showed remarkably reduced hospitalization costs in the observation group. CONCLUSION: To a certain degree, BCAAs could improve the nutritional metabolism and prognosis of patients with severe abdominal trauma, and have good cost-effectiveness.

Assessment of trauma scoring systems in patients subjected to exploratory laparotomy.

OBJECTIVE: to assess the epidemiological profile of patients undergoing exploratory trauma laparotomy based on severity and prognosis criteria, and to determine the predictive accuracy of trauma scoring systems in terms of morbidity and mortality. METHODS: retrospective cohort study and review of medical records of patients undergoing exploratory laparotomy for blunt or penetrating trauma at the Hospital de Pronto Socorro de Porto Alegre, from November 2015 to November 2019. Demographic data, mechanism of injury, associated injuries, physiological (RTS and Shock Index), anatomical (ISS, NISS and ATI) and combined (TRISS and NTRISS) trauma scores, intraoperative findings, postoperative complications, length of stay and outcomes. RESULTS: 506 patients were included in the analysis. The mean age was 31 ± 13 years, with the majority being males (91.3%). Penetrating trauma was the most common mechanism of injury (86.2%), predominantly by firearms. The average RTS at hospital admission was 7.5 ± 0.7. The mean ISS and NISS was 16.5 ± 10.1 and 22.3 ± 13.6, respectively. The probability of survival estimated by TRISS was 95.5%, and by NTRISS 93%. The incidence of postoperative complications was 39.7% and the overall mortality was 12.8%. The most accurate score for predicting mortality was the NTRISS (88.5%), followed by TRISS, NISS and ISS. CONCLUSION: the study confirms the applicability of trauma scores in the studied population. The NTRISS seems to be the best predictor of morbidity and mortality.

Assessment of trauma scoring systems in patients subjected to exploratory laparotomy / Avaliação dos escores de trauma em pacientes submetidos à laparotomia exploradora

ABSTRACT Objective: to assess the epidemiological profile of patients undergoing exploratory trauma laparotomy based on severity and prognosis criteria, and to determine the predictive accuracy of trauma scoring systems in terms of morbidity and mortality. Methods: retrospective cohort study and review of medical records of patients undergoing exploratory laparotomy for blunt or penetrating trauma at the Hospital de Pronto Socorro de Porto Alegre, from November 2015 to November 2019. Demographic data, mechanism of injury, associated injuries, physiological (RTS and Shock Index), anatomical (ISS, NISS and ATI) and combined (TRISS and NTRISS) trauma scores, intraoperative findings, postoperative complications, length of stay and outcomes. Results: 506 patients were included in the analysis. The mean age was 31 ± 13 years, with the majority being males (91.3%). Penetrating trauma was the most common mechanism of injury (86.2%), predominantly by firearms. The average RTS at hospital admission was 7.5 ± 0.7. The mean ISS and NISS was 16.5 ± 10.1 and 22.3 ± 13.6, respectively. The probability of survival estimated by TRISS was 95.5%, and by NTRISS 93%. The incidence of postoperative complications was 39.7% and the overall mortality was 12.8%. The most accurate score for predicting mortality was the NTRISS (88.5%), followed by TRISS, NISS and ISS. Conclusion: the study confirms the applicability of trauma scores in the studied population. The NTRISS seems to be the best predictor of morbidity and mortality.

RESUMO Objetivo: analisar o perfil epidemiológico dos pacientes submetidos a laparotomia exploradora por trauma com base em critérios de gravidade e prognóstico, e determinar a acurácia preditiva dos escores de trauma em termos de morbimortalidade. Métodos: estudo de coorte retrospectiva e revisão de prontuários dos pacientes submetidos a laparotomia exploradora por trauma contuso ou penetrante no Hospital de Pronto Socorro de Porto Alegre no período de novembro de 2015 a novembro de 2019. Foram avaliados dados demográficos, mecanismo do trauma, lesões associadas, índices fisiológicos (RTS e Shock Index), anatômicos (ISS, NISS e ATI) e mistos (TRISS e NTRISS), achados intraoperatórios, complicações pós-operatórias, tempo de internação e desfecho. Resultados: foram incluídos 506 pacientes na análise. A idade média foi de 31 ± 13 anos, com predomínio do sexo masculino (91,3%). O trauma penetrante foi o mecanismo de lesão mais comum (86,2%), sendo a maioria por arma de fogo. A média do RTS na admissão hospitalar foi 7,5 ± 0,7. A média do ISS e do NISS foi 16,5 ± 10,1 e 22,3 ± 13,6, respectivamente. A probabilidade de sobrevida estimada pelo TRISS foi de 95,5%, e pelo NTRISS de 93%. A incidência de complicações pós-operatórias foi de 39,7% e a mortalidade geral de 12,8%. O escore com melhor acurácia preditiva foi o NTRISS (88,5%), seguido pelo TRISS, NISS e ISS. Conclusões: o estudo confirma a aplicabilidade dos escores de trauma na população em questão. O NTRISS parece ser o sistema com melhor acurácia preditiva de morbimortalidade.

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions.

BACKGROUND: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status.

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013-2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88-6.69) (OR: 11.24; 95% CI: 8.53-13.95), more time spent in ICU (2.73; 1.70-3.76) (7.98; 6.10-9.87), and increased risk for surgical site infection (1.32; 1.03-1.68) (2.54; 1.71-3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis.

INTRODUCTION: The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). METHODS: We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. RESULTS: Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = -0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. CONCLUSION: As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial.

Importance: The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown. Objective: To determine if the FAST examination during initial evaluation of injured children improves clinical care. Design, Setting, and Participants: A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center. Interventions: Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone. Main Outcomes and Measures: Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges. Results: Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291). Conclusions and Relevance: Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting. Trial Registration: clinicaltrials.gov Identifier: NCT01540318.

Importance of diagnostic laparoscopy in the assessment of the diaphragm after left thoracoabdominal stab wound: A prospective cohort study.

BACKGROUND: Stab wounds in the left thoracoabdominal region may cause diaphragmatic injury. The aim of the present study was to determine incidence of diaphragmatic injury and role of diagnostic laparoscopy in detection of injury in patients with left thoracoabdominal stab wound. METHODS: Total of 81 patients (75 male, 6 female; mean age 27.5±9.8 years; range 14 to 60 years) who presented with left thoracoabdominal stab wound between April 2009 and September 2014 were evaluated. Laparotomy was performed on patients who had hemodynamic instability, signs of peritonitis, or organ evisceration. Remaining patients were followed conservatively. After 48 hours, diagnostic laparoscopy was performed on patients without laparotomy indication to examine the left diaphragm for injury. Follow-up and treatment findings were prospectively evaluated. RESULTS: Thirteen patients underwent laparotomy while diagnostic laparoscopy was performed on remaining 68 patients. Left diaphragmatic injury was observed in 19 patients (23.5%) in the study group. Four injuries were diagnosed by laparotomy and 15 were diagnosed by laparoscopy. Presence of hemopneumothorax did not yield difference in incidence of diaphragmatic injury (p=0.131). No significant difference was detected in terms of diaphragmatic injury with respect to entry site of stab wound in the thoracoabdominal region (p=0.929). CONCLUSION: It is important to evaluate the diaphragm in left thoracoabdominal stab injuries, and diagnostic laparoscopy is still the safest and most feasible method.

Defining the gastroesophageal junction in trauma: Epidemiology and management of a challenging injury.

BACKGROUND: Injuries to the gastroesophageal (GE) junction are infrequently encountered because of the high mortality of associated injuries. Consequently, there is a paucity of literature on the patient demographics and treatment options. The aim of this study was to examine the epidemiology, surgical management, and outcomes of these rare injuries. METHODS: Patients presenting to LAC + USC Medical Center (January 2008 to August 2016) with traumatic esophageal or gastric injury (DRG International Classification of Diseases-9th Rev.-Clinical Modification and 10th Rev. codes) were extracted from the trauma registry. Patient charts were reviewed, and all patients who sustained an injury to the GE junction were enrolled. Patient demographics, injury characteristics, procedures, and outcomes were analyzed. RESULTS: Of the 238 patients who sustained an injury to the esophagus or stomach during the study period, 28 (12%) were found to have a GE junction injury. Mean age was 26 years (range, 14-57 years), 89% male. Mechanism of injury was penetrating in 96% (n = 27), the majority of which were gunshot wounds (n = 22, 81%). Most patients (n = 18, 64%) were taken directly to the operating room. Ten (36%) underwent computed tomography scan before going to the operating room, all demonstrating a GE junction injury. All patients underwent repair via laparotomy. One (4%) also required thoracotomy to facilitate delayed reconstruction. GE junction injuries were typically managed with primary repair (n = 22, 79%). Associated injuries were frequent (n = 26, 93%), and injury severity was high (mean Injury Severity Score, 25 [9-75]). Mortality was 25% (n = 7), and all patients required intensive care unit admission. Most did not require total parenteral nutrition (n = 25, 89%) or a surgically placed feeding tube (n = 26, 93%). Of the 13 patients who presented for clinical follow-up, all but one (n = 12, 92%) were eating independently by the first clinic visit. CONCLUSION: GE junction injuries are uncommon and occur almost exclusively after penetrating trauma. Patients are severely injured with a high mortality rate and frequently have associated intracavitary injuries. Most can be fixed through the abdomen alone and do not require thoracotomy for repair. Despite the severity of injuries, the majority of survivors are eating independently by the first clinic visit. LEVEL OF EVIDENCE: Epidemiological, level V.

Evaluación de criterios para laparotomía en lesiones abdominales por arma blanca / Laparotomy criteria assessment in abdominal stab wounds

Introducción: las lesiones traumáticas penetrantes del abdomen involucran usualmente la violación de la cavidad abdominal por una herida realizada con arma blanca u otro tipo de objeto cortopunzante. Esto constituye un problema de salud y uno de los motivos de urgencia, más comunes en la consulta de cirugía. En Cuba, los accidentes donde se incluyen este tipo de lesiones constituyeron la quinta causa de defunciones, en ambos sexos, en el año 2014. Objetivo: evaluar los criterios indicativos de laparotomía en pacientes con heridas abdominales por arma blanca. Método: se realizó un estudio de evaluación de medios diagnósticos en pacientes sometidos a una laparotomía exploratoria por herida abdominal con arma blanca. La población estuvo constituida por todos los pacientes con este tipo de lesión y la muestra por los intervenidos quirúrgicamente. Se evaluaron diversos elementos clínicos y complementarios indicativos de laparotomía ante la posibilidad de lesión orgánica significativa. Resultados: la edad promedio fue de 32 años; predominó el sexo masculino (91,3 por ciento). De los pacientes, 41,3 por ciento se presentaron signos de intoxicación exógena, y 51,25 por ciento de las laparotomías fueron terapéuticas. Mostraron mejores resultados de sensibilidad, especificidad y valores predictivos positivos la presencia de choque hipovolémico (84,2 por ciento), signos clínicos de hemorragia continua (82,4 por ciento) y perforación obvia del tracto gastrointestinal (90,9 por ciento). Entre los complementarios la laparoscopia mostró valores de sensibilidad (89,5 por ciento) y especificidad (81,8 por ciento) superior al resto. Conclusiones: el choque hipovolémico, los signos de hemorragia continua, signos de perforación obvia del tracto gastrointestinal, y la laparoscopia revelaron los mejores resultados como criterios indicativos de laparotomía en heridas abdominales por arma blanca(AU)

Introduction: penetrating traumatic lesions of the abdomen usually leads to damage in the abdominal cavity from a wound caused with a white weapon or other sharp-piercing object. This circumstance constitutes a health problem and one of the most common reasons for emergency consultation in surgery. This type of lesions was the fifth leading cause of death for both sexes in Cuba in 2014. Objective: to evaluate the criteria indicative of laparotomy in patients with abdominal wounds caused with a white weapon. Method: a diagnostic modalities assessment study was carried out in patients who underwent exploratory laparotomy for abdominal wound caused by a white weapon. The target group was made up by the patients with this type of lesions. The sample consisted of surgery patients (n= 80). Several clinical and complementary elements indicative of laparotomy were assessed before the possibility of significant organic lesions. Results: the average age was 32 years, with a predominance of males (91.3 percent). 41.3 percent of the patients showed exogenous intoxication signs, only 51.25 percent of laparotomies were therapeutic ones. The presence of hypovolemic shock (84.2 percent), clinical signs of ongoing bleeding (82.4 percent) and obvious gastrointestinal tract perforation (90.9 percent) showed better sensitivity, specificity and positive predictive values. Among the complementary tests, laparoscopy showed values of sensitivity (89.5 percent) and specificity (81.8 percent) higher than the others. Conclusions: hypovolemic shock, signs of ongoing bleeding and signs of obvious gastrointestinal tract perforation, and laparoscopy showed the best results as criteria indicative of laparotomy in abdominal stab wounds(AU)

Nontrauma open abdomens: A prospective observational study.

BACKGROUND: Damage-control surgery with open abdomen (OA) is described for trauma, but little exists regarding use in the emergency general surgery. This study aimed to better define the following: demographics, indications for surgery and OA, fascial and surgical site complications, and in-hospital/long-term mortality. We hypothesize that older patients will have increased mortality, patients will have protracted stays, they will require specialized postdischarge care, and the indications for OA will be varied. METHODS: A prospective observational study of emergency general surgery OA patients from June 2013 to June 2014 was performed. Demographics, clinical/operative variables, comorbidities, indications for procedure and OA, wound/fascial complications, and disposition were collected. Patients were stratified into age groups (≤ 60, 61-79, and ≥ 80 years). Six-month and 1-year mortality was determined by query of the Social Security Death Index. RESULTS: A total of 338 laparotomies were performed, of which 96 (28%) were managed with an OA. Median age was 61 years (interquartile range [IQR], 0-68 years), and 51% were male. The median Charlson Comorbidity Index was 2 (IQR, 1.5-5.1), and the median hospital stay was 25 days (IQR, 15-50 days). The most common indications for operation were perforated viscus/free air (20%), mesenteric ischemia (17%), peritonitis (16%), and gastrointestinal hemorrhage (12%). The most common indication for OA was damage control (37%). In the 63 patients with fascial closure, there were 9 (14%) wound infections and 6 (10%) fascial dehiscences. A total of 30% of the patients died in the hospital, and an additional six patients died 6 months after discharge. Patients in the oldest age stratum were more likely to die at 6 months than those in the lower strata. CONCLUSION: Older patients were more likely to die by 6 months, the median hospital stay was 3 weeks, and there were multiple indications for OA management. With a 6-month mortality of 36% and 70% of survivors requiring postdischarge care, this population represents a critically ill population meriting additional study. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Readmission after treatment of Grade 3 and 4 renal injuries at a Level I trauma center: Statewide assessment using the Comprehensive Hospital Abstract Reporting System.

BACKGROUND: One criticism of the existing renal trauma research is the limited outpatient follow-up after index hospitalization. We assessed readmission rates following treatment for American Association for the Surgery of Trauma (AAST) Grade 3 and 4 renal injury using the Comprehensive Hospital Abstract Reporting System (CHARS). METHODS: We evaluated all patients with AAST Grade 3 and 4 renal injuries admitted to Harborview Medical Center (HMC) between 1998 and 2010, the only Level 1 trauma center in Washington state. Grade 4 renal injuries were stratified by collecting system laceration (CSL) or segmental vascular injury. Data were abstracted from the CHARS database for readmissions to any Washington state hospital within 6 months of renal injury. Clinical variables, diagnoses, and procedures were queried based on DRG International Classification of Diseases-9th Rev. codes. RESULTS: A total of 477 Grade 3 and 159 Grade 4 renal injuries were initially treated at HMC. On admission, 111 patients required intervention: 75 (16%) of 477 Grade 3 and 36 (23%) of 159 Grade 4 injuries. Within 6 months of index hospitalization, 86 (18%) of 477 Grade 3 and 38 (24%) of 159 Grade 4 patients were readmitted to any Washington state hospital. Eighty percent of Grade 3 injuries and 66% of Grade 4 injuries returned to HMC compared with secondary hospitals (p = 0.08). At readmission, 19 (22%) of 86 Grade 3 and 16 (42%) of 38 Grade 4 injuries had a urologic diagnosis. Subsequent procedural intervention was required on readmission in 6 (7%) of 86 Grade 3 and 5 (13%) of 38 Grade 4 renal injuries (all CSL injuries). CONCLUSION: A subset of patients treated for Grade 3 and 4 renal trauma will be readmitted for further management. While urologic diagnoses and additional procedures may be low overall, readmission to outside hospitals may preclude accurate determination of renal trauma outcomes. Based on these data, patients with Grade 4 CSL injuries seem to be at the highest risk for readmission and to require a subsequent urologic procedure. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Abdominal gunshot wounds-a comparative assessment of severity measures.

BACKGROUND: Penetrating abdominal trauma is a common feature of trauma treated in low- and middle-income countries (LMICs). The penetrating abdominal trauma index (PATI) and the injury severity score (ISS) are severity-measures most often used to gauge injury severity. It remains unclear which measure better accounts for the severity of sustained injuries. This study compares the predictive ability of both injury severity measures in patients presenting to an LMIC in South Asia. METHODS: All isolated gunshot wounds to the abdomen presenting to a university hospital between 2011 and 2012 were included. ISS and PATI were calculated for each case. Primary outcome measures included all-cause mortality and complications. Multivariable analysis adjusting for age, sex, referral status, hypotension, tachycardia, and injury severity measures was performed. The area under the receiver operating characteristic (AUROC) curve were further calculated to compare the respective abilities of ISS and PATI at predicting death and complications. RESULTS: A total of 70 patients were included. The average age on presentation was 34.5 y (±11.4) within a predominantly male (n = 68, 97.1%) cohort. Most gunshot wounds were intentionally inflicted (n = 67, 95.7%). The crude rates of death and complications were 34.3% and 15.7%, respectively. The median ISS was 14 (interquartile range: 11-21), and the median PATI was 16 (interquartile range: 9-26). AUROC analysis revealed that ISS was comparable with PATI at predicting mortality (AUROC [95% confidence interval]: 0.952 [0.902-1.00] versus 0.934 [0.860-1.00]) and complications (AUROC [95% confidence interval]: 0.868 [0.778-0.959] versus 0.895 [0.815-0.975]). CONCLUSIONS: The predictive ability of ISS and PATI severity measures was found to be comparable. The results suggest that both measures can be used to risk-stratify patients with isolated abdominal gunshot wounds in an LMIC.

Cell salvage in emergency trauma surgery.

BACKGROUND: Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also known as intraoperative blood salvage (IBS)) have been used as an alternative to blood products from other individuals during surgery because of the risk of transfusion-related infections such as hepatitis and human immunodeficiency virus (HIV). In this review, we sought to assess the effects and cost of cell salvage in individuals undergoing abdominal or thoracic surgery. OBJECTIVES: To compare the effect and cost of cell salvage with those of standard care in individuals undergoing abdominal or thoracic trauma surgery. SEARCH METHODS: We ran the search on 25 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, EMBASE Classic + EMBASE (OvidSP), PubMed, and ISI Web of Science (SCI-Expanded & CPSI-SSH). We also screened reference lists and contacted principal investigators. SELECTION CRITERIA: Randomised controlled trials comparing cell salvage with no cell salvage (standard care) in individuals undergoing abdominal or thoracic trauma surgery. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data from the trial reports. We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Only one small study (n = 44) fulfilled the inclusion criteria. Results suggested that cell salvage did not affect mortality overall (death rates were 67% (14/21 participants) in the cell salvage group and 65% (15/23) in the control group) (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.31 to 3.72). For individuals with abdominal injury, mortality was also similar in both groups (OR 0.48, 95% CI 0.11 to 2.10).Less donor blood was needed for transfusion within the first 24 hours postinjury in the cell salvage group compared with the control group (mean difference (MD) -4.70 units, 95% CI -8.09 to -1.31). Adverse events, notably postoperative sepsis, did not differ between groups (OR 0.54, 95% CI 0.11 to 2.55). Cost did not notably differ between groups (MD -177.81, 95% CI -452.85 to 97.23, measured in GBP in 2002). AUTHORS' CONCLUSIONS: Evidence for the use of cell salvage in individuals undergoing abdominal or thoracic trauma surgery remains equivocal. Large, multicentre, methodologically rigorous trials are needed to assess the relative efficacy, safety and cost-effectiveness of cell salvage in different surgical procedures in the emergency context.

A prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy is associated with high survivability and low rates of fecal diversion.

OBJECTIVE: This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization. BACKGROUND: Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial. METHODS: We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality. RESULTS: Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%). CONCLUSIONS: Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.

Selective non operative management of gunshot wounds to the abdomen: a collective review.

BACKGROUND: Over the past four decades there has been a shift from operative to selective conservatism in trauma. Selective nonoperative management (SNOM) of stab wounds to the abdomen is widely accepted in trauma centres. However, selective conservatism with gunshot wounds to the abdomen is controversial. This collective review assesses the evidence of SNOM of gunshot wounds to the abdomen. METHODS: A Medline search between 1 January 1960 and 31 July 2013 was conducted identifying studies that investigated SNOM of gunshot wounds to the abdomen. Case reports, review articles and editorials were excluded. All other studies that investigated SNOM of gunshot wounds to the abdomen and its outcomes were included. RESULTS: A total of 37 studies were included of which 22 were prospective, 14 were retrospective and 1 case series. A total of 21330 patients with gunshot wounds to the abdomen were included, of which 6468 (30.3%) were managed nonoperatively. Successful SNOM was possible in 5510 (85.18%) patients and 958 (14.8%) failed SNOM and underwent delayed laparotomies. SNOM reduces rates of non-therapeutic laparotomies and the associated morbidity. Special aspects reviewed include the prehospital and nursing involvement in this modality of care. CONCLUSIONS: Current evidence supports SNOM of gunshot wounds to the abdomen. It is associated with a decreased rate of non therapeutic laparotomy. Careful patient selection and specially designed protocols should be established and adhered to.