Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis.

BACKGROUND: International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis. METHOD: 1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery. RESULTS: 725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months. CONCLUSION: Patients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery. TRIAL REGISTRATION: Not applicable.

Trauma triage criteria as predictors of severe injury - a Swedish multicenter cohort study.

BACKGROUND: Adequate performance of trauma team activation (TTA) criteria is important in order to accurately triage trauma patients. The Swedish National Trauma Triage Criteria (SNTTC) consists of 29 criteria that trigger either a Trauma Alert, the highest level of TTA, or a Trauma Response. This study aimed to evaluate the SNTTC and its accuracy in predicting a severely injured patient in a multicenter setting. METHODS: A cohort study in Sweden involving six trauma receiving hospitals. Data was collected from the Swedish Trauma Registry. Some 626 patients were analyzed with regard to the specific criteria used to initiate the TTA, injury severity with New Injury Severity Score (NISS) and emergency interventions. Sensitivity, specificity, positive predictive value (PPV) and positive likelihood ratio (LR+) of the criteria were calculated, as well as undertriage and overtriage. RESULTS: All 29 criteria of SNTTC had a sensitivity > 80% for identifying a severely injured patient. The 16 Trauma Alert Criteria had a lower sensitivity of 62.6% but higher LR+ (3.5 vs all criteria 1.4), specificity (82.3 vs 39.1%) and PPV (55.4 vs 37.6%) and the highest accuracy (AUC 0.724). When using only the six physiological criteria, sensitivity (44.8%) and accuracy (AUC 0.690) decreased while LR+ (6.7), specificity (93.3%) and PPV (70.2%) improved. CONCLUSION: SNTTC is efficient in identifying severely injured patients. The current set of criteria exhibits the best sensitivity compared to other examined combinations and no additional criterion was found to improve the protocol enough to promote a change.

Effect of the COVID-19 pandemic on the care for acute cholecystitis: a Swedish multicentre retrospective cohort study.

OBJECTIVES: The present study aimed to investigate if and how the panorama of acute cholecystitis changed in 2020 in Sweden. Seven aspects were identified, the incidence of cholecystitis, the Tokyo grade, the timing of diagnosis and treatment, the proportion treated with early surgery, the proportion of patients treated with delayed surgery, and new complications from gallstones. DESIGN: Retrospective multicentre cohort study. SETTING: 3 hospitals in Sweden, covering 675 000 inhabitants. PARTICIPANTS: 1634 patients with cholecystitis. OUTCOMES: The incidence, treatment choice and diagnostic and treatment delay were investigated by comparing prepandemic and pandemic patients. RESULTS: Patients diagnosed with cholecystitis during the pandemic were more comorbid (American Society of Anesthesiologists 2-5, 86% vs 81%, p=0.01) and more often had a diagnostic CT (67% vs 59%, p=0.01). There were variations in the number of patients corresponding with the pandemic waves, but there was no overall increase in the number of patients with cholecystitis (78 vs 76 cases/100 000 inhabitants, p=0.7) or the proportion of patients treated with surgery during the pandemic (50% vs 50%, p=0.4). There was no increase in time to admission from symptoms (both median 1 day, p=0.7), or surgery from admission (both median 1 day, p=0.9). The proportion of grades 2-3 cholecystitis was not higher during the pandemic (46% vs 44%, p=0.9). The median time to elective surgery increased (184 days vs 130 days, p=0.04), but there was no increase in new gallstone complications (35% vs 39%, p=0.3). CONCLUSION: Emergency surgery for cholecystitis was not impacted by the pandemic in Sweden. Patients were more comorbid but did not have more severe cholecystitis nor was there a delay in seeking care. Fewer patients non-operatively managed had elective surgery within 6 months of their initial diagnosis but there was no corresponding increase in gallstone complications.

Validation of the Swedish Trauma Registry (SweTrau).

PURPOSE: Validation of registries is important to ensure accuracy of data and registry-based research. This is often done by comparisons of the original registry data with other sources, e.g. another registry or a re-registration of data. Founded in 2011, the Swedish Trauma Registry (SweTrau) consists of variables based on international consensus (the Utstein Template of Trauma). This project aimed to perform the first validation of SweTrau. METHODS: On-site re-registration was performed on randomly selected trauma patients and compared to the registration in SweTrau. Accuracy (exact agreement), correctness (exact agreement plus data within acceptable range), comparability (similarity with other registries), data completeness (1-missing data) and case completeness (1-missing cases) were deemed as either good ([Formula: see text] 85%), adequate (70-84%) or poor (< 70%). Correlation was determined as either excellent ([Formula: see text] 0.8), strong (0.6-0.79), moderate (0.4-0.59) or weak (< 0.4). RESULTS: The data in SweTrau had good accuracy (85.8%), correctness (89.7%) and data completeness (88.5%), as well as strong or excellent correlation (87.5%). Case completeness was 44.3%, however, for NISS > 15 case completeness was 100%. Median time to registration was 4.5 months, with 84.2% registered one year after the trauma. The comparability showed an accordance with the Utstein Template of Trauma of almost 90%. CONCLUSIONS: The validity of SweTrau is good, with high accuracy, correctness, data completeness and correlation. The data are comparable to other trauma registries using the Utstein Template of Trauma; however, timeliness and case completeness are areas of improvement.

Incidence, Demographics, and Outcomes of Penetrating Trauma in Sweden During the Past Decade.

Trauma injury is the sixth leading cause of death worldwide, and interpersonal violence is one of the major contributors in particular regarding injuries to the head and neck. The incidence, demographics, and outcomes of penetrating trauma reaching hospitals in Sweden are not known. We report the largest, nationwide epidemiological study of penetrating injuries in Sweden, using the Swedish Trauma Registry (SweTrau). A multi-center retrospective descriptive study of 4,776 patients was conducted with penetrating injuries in Sweden, between 2012 and 2018. Due to the increase in coverage of the SweTrau registry during the same period, we chose to analyze the average number of cases for the time intervals 2013-2015 and 2016-2018 and compare those trends to the reports of the Swedish National Council for Crime Prevention (Brå) as well. A total of 663 patients had Injury Severity Score (ISS) ≥ 15 at admission and were included in the study. Three hundred and sixty-eight (55.5%) were stab wounds (SW), 245 (37.0%) gunshot wounds (GSW), and 50 (7.5%) other traumas. A majority of the cases involved injuries to the head, neck, and face. SW increased from 145 during 2013-2015 to 184 during the second period of 2016-2018. The increase was greater for GSW from 92 to 141 during the same respective periods. This trend of increase over time was also seen in head, neck, and face injuries. The 30-day mortality was unaffected (48-47%) in GSW and trended toward lower in SW (24-21%) when comparing 2013-2015 with 2016-2018. Patients with head trauma had 45% mortality compared to 18% for non-head trauma patients. Head trauma also resulted in worse outcomes, only 13% had Glasgow outcome score (GOS) 5 compared to 27% in non-head trauma. The increasing number of cases of both SW and GSW corresponded well with reports from Brå although further studies also are needed to address deaths outside of hospitals and not registered at the SweTrau. The majority of cases had injuries to the head, neck, and face and were associated with higher mortality and poor outcomes. Further studies are needed to understand the contributing factors to these worse outcomes in Sweden and whether more targeted trauma care of these patients can improve outcomes.

Better compliance with triage criteria in trauma would reduce costs with maintained patient safety.

OBJECTIVE: To evaluate trauma triage criteria in terms of compliance, undertriage, and overtriage and identify risk factors for mistriage. METHODS: In a retrospective cohort study, all consecutive trauma patients at a University Hospital in Sweden in 2012 were included. Patients were stratified into three groups on the basis of trauma team activation (full trauma team, limited trauma team, and no trauma team). Case records were reviewed for mechanism of injury, vital signs, and injuries. Compliance with alert criteria was evaluated and injury severity score combined with the Matrix method was used for assessment of overtriage and undertriage. RESULTS: A total of 1424 trauma patients were included in the study. Seventy-three (5.1%) patients activated a full trauma team, 732 (51.4%) a limited trauma team, and 619 (43.5%) did not activate any trauma team. Undertriage was 2.7% [95% confidence interval (CI): 1.9-3.8%] and overtriage was 34.2% (95% CI: 23.5-46.3%) in the complete cohort. Compliance with 'trauma triage criteria' was assessed by comparing actual alerts with what was estimated to be the correct alert levels on the basis of prehospital case records. Compliance with full trauma team criteria was 80% (68-88%), limited trauma team was 54% (51-58%), and no trauma team was 79% (76-82%). Assuming full compliance with trauma criteria, the Matrix method resulted in an undertriage of 2.3% (95% CI: 1.6-3.3%) and an overtriage of 42.6% (95% CI: 32.4-53.2%). CONCLUSION: The overtriage and undertriage in this study is in line with the recommendations of the American College of Surgeons Committee on Trauma. However, better compliance with trauma alert criteria would result in fewer trauma team activations without affecting patient safety.

A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden - the TRAUMALERT study.

BACKGROUND: Trauma triage based on prehospital information facilitates correct allocation of in-hospital resources. The Swedish national two-tier trauma team activation (TTA) criteria were revised in 2016. The current study aimed to evaluate the safety and efficacy of the new criteria. METHODS: Five centres covering trauma care for 1.2 million inhabitants registered all trauma patients prospectively in the Swedish trauma registry (SweTrau) prior to and after stepwise introduction of new TTA criteria within the cohort (a prospective stepped-wedge cohort study design; period August 2016-November 2017). Evaluation of full- and limited-TTA frequency, under- and overtriage were performed at equal duration before and after this change. RESULTS: The centres registered 1948 patients, 1882 (96.6%) of which were included in the study. With new criteria, frequency of full-TTA was unchanged, while limited-TTA decreased with 46.3% (from 988 to 531). 30-day trauma mortality was unchanged. The overtriage was 107/150 (71.3%) with former criteria, and 104/144 (72.2%) with new criteria, p = 0.866. Undertriage was 50/1037 (4.8%) versus 39/551 (7.1%), p = 0.063. Undertriage was consistently > 20% in patients with fall injury. Among patients with Injury Severity Score (ISS) > 15, 50/93 (53.8%) did not initiate full-TTA with former, vs 39/79 (49.4%) with new criteria, p = 0.565. Age > 60-years was a risk factor for undertriage (OR 2.89, p < 0.001), while low fall injuries indicated a trend (OR 2.70, p = 0.051). CONCLUSIONS: The newly implemented Swedish TTA criteria result in a reduction in limited TTA frequency, indicating an increased efficiency in use of resources. The over- and undertriage is unchanged compared to former criteria, thus upholding patient safety.

Routine whole body CT of high energy trauma patients leads to excessive radiation exposure.

BACKGROUND: Whole body computed tomography (WBCT) is an important adjunct in trauma care, which is often part of standard protocol in initial management of trauma patients. However, WBCT exposes patients to a significant dose of radiation. The use of WBCT was assessed in a modern trauma cohort in Sweden. METHODS: A two-center retrospective cohort study was performed. All consecutive trauma alert patients at a university hospital (July-December 2008), and a rural county hospital (January 2009- December 2010) were included. Patients were stratified into three groups (high, intermediate and low risk) based on documented suspected injuries at primary survey at the site of accident or at the emergency department. Injury severity score (ISS) was calculated. Case records were reviewed for clinical and radiological findings at the time of trauma, and during a ≥36 months of follow-up period to identify possible missed injuries. RESULTS: A total of 523 patients were included in the study (university hospital n = 273; rural county hospital n = 250), out of which 475 patients (91.0 %) underwent radiological examinations, 290 patients (55.4 %) underwent WBCT, which identified trauma related findings in 125 patients (43.1 % of those examined). The high-risk group (n = 62) had a mean age of 38.5 years (21.1 SD). Mean ISS was 16.48 (18.14 SD). In this group, WBCT resulted in a positive finding in 38 (74.5 %) patients. In the intermediate-risk group (n = 322; mean age 37.66, 20.24 SD) ISS was 4.42 (6.30 SD). A positive finding on WBCT was found in 87 of the intermediate group patients (44.8 %). The low-risk group (n = 139; mean age 32.5 years; 21.4 SD) had a mean ISS of 0.84 (1.57 SD) with no positive findings on WBCT and no missed injuries in medical records at ≥36 months. DISCUSSION: The risk of developing radiation induced cancer is significant for young people if exposed to relatively high dose radiation as is the case in WBCT. WBCT in high-energy trauma is important for planning of treatment in severely injured patients while it can be questioned in the seemingly not injured where it is used mainly to permit early discharge from the ED. CONCLUSIONS: Risk stratification criteria could in this retrospective study identify high energy trauma patients not in need of radiological imaging. WBCT in high-energy trauma does not affect patient care if the patient is mentally alert, not intoxicated nor shows signs of other than minor injuries when evaluated by a trauma-team. The risk of missing important traumatic findings in these patients is very low. Observation of the patient with reexamination instead of imaging may be considered in this group of often young patients where radiation dose is an issue.

Bilateral adrenalectomy for ectopic Cushing's syndrome-discussions on technique and indication.

BACKGROUND: Tumors producing adrenocorticotropic hormone (ACTH) or corticotropin releasing hormone (CRH) often remain undiagnosed until severe Cushing's syndrome appears, and it may be difficult to distinguish from Cushing's syndrome due to pituitary tumors. Many patients suffer from disease spread, with metastases in the liver or other locations, and the main symptoms may be mineral disturbances, diabetes mellitus, or psychological symptoms from the severe hypercortisolism. Bilateral adrenalectomy may alleviate this situation, but is sometimes a troublesome procedure in these severely ill patients. METHODS: We have retrospectively investigated 8 patients with ectopic Cushing's syndrome who have undergone bilateral adrenalectomy at the University Hospital in Uppsala. In addition, another 5 patients who underwent bilateral adrenalectomy for other reasons (recurrent pituitary Mb Cushing or bilateral hyperplasia) were scrutinized for technical considerations. Indications, timing of surgery, and operative procedures were studied to identify signs that may support our approach to management in the future. RESULTS: Curative surgery was not possible in any of the cases with ectopic Cushing's syndrome. Of the 13 operated patients, handport-assisted laparoscopic adrenalectomy was successfully performed bilaterally in 5 patients and unilaterally in combination with contralateral open surgery in 1 patient; conventional open surgery was performed on 7 patients, 3 of which were conversions from intitial handport-assisted procedures. Non-fatal complications occurred in 4 out of 10 patients. CONCLUSIONS: We conclude that bilateral handport-assisted laparoscopic adrenalectomy is safe, and that all surgical techniques in these severely ill patients may be troublesome and technically demanding. Early surgical intervention may reduce the technical disadvantages. Moreover, bilateral adrenalectomy can substantially reduce the symptoms of Cushing's syndrome, although effects on mortality are not obvious.