Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS: This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS: Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS: SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.

Use of super-thin anterolateral thigh flap in intra-oral reconstruction of soft tissue defects.

BACKGROUND: Traditional sub-fascial anterolateral thigh (ALT) flaps are bulky and often give unsatisfactory outcomes in several head and neck reconstructions where thin pliable flaps are required. As a result, despite high incidence of donor site complications, radial forearm flap is still commonly used for tongue, buccal mucosa and lip defects where a traditional ALT flap would be too bulky. The objective of this report was to evaluate the usefulness of super-thin ALT flap as an alternative to radial forearm flap for intra-oral reconstruction. PATIENTS AND METHODS: Retrospective evaluation was done of all head and neck reconstructions performed by a single surgeon between December 2021 and May 2022. Twenty-two patients who had undergone super-thin ALT flaps for intra-oral reconstruction of soft tissue defects were included in the report. These included buccal mucosa (n = 11), tongue (n = 8), and buccal mucosa with neck skin defects (n = 3). All patients had undergone wide excision of oral squamous cell carcinoma, and had history of chewing tobacco. Average age of patients was 54 years, 16 were males and 6 were females. Mean BMI of the patients was 25.2 kg/m2 (Range: 20.5-31.0 kg/m2 ). Super-thin ALT flap was elevated in the plane of superficial fascia of the thigh, thus leaving behind the deeper fat. The flaps were shaped as per the measurements obtained from the specimen as well as the defect and intra-oral inset was done prior to vascular anastomosis. RESULTS: Mean flap dimension was 8.3 × 6.7 cm (range: 6 × 5 to 20 × 7 cm). Mean flap thickness was 9 mm (range: 4-20 mm). Mean flap elevation time was 70.9 min (Range: 48-105 min). None of the flaps needed a re-exploration. All flaps survived completely. One patient had surgical site infection at the flap donor site which was managed conservatively. Mean follow up was 5 months (range: 3-10 months). All patients were able to take soft oral diet at the last follow up. CONCLUSIONS: Super-thin ALT flaps raised in superficial fascia plane are reliable and provide thin, pliable tissue for head and neck reconstruction. Unlike other thin flaps, these are not limited by donor site morbidity and flap dimension.

Protocolized approach saves the limb in peripheral arterial injury: A decade experience.

PURPOSE: Outcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The aim of this study was to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients. METHODS: This is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas). RESULTS: Out of 716 patients with PAI, the majority (92%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2-7 h). Brachial artery (28%) was the most common injured vessel followed by popliteal artery (18%) and femoral artery (17%). Limb salvage rate was 78%. Out of them, 158 (22%) patients needed amputation, and 53 (7%) had undergone primary amputation. The majority (86%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation. CONCLUSION: Over all limb salvage rates was 78% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.

Train-Associated Injuries Pose a Significant Burden on Trauma Care Systems of Emerging Economies.

BACKGROUND: The Indian railway system is the fourth largest in the world and causes about 15 deaths every day, due to intentional or unintentional reasons. This study presents a 5-year retrospective analysis of patients injured due to train-associated events, managed at a level-1 trauma center in India. MATERIALS AND METHODS: Hospital-based trauma registry data of train-associated injuries presenting between 2012 and 2016 were analyzed. Data from 726 patients were analyzed for demographics, injury events, injury regions, their management and outcomes. ISS and NISS were used to quantify the injury severity. RESULTS: Mean age was 33 years, with male-to-female ratio 86 to 14%. The majority of patients (62%) were between 20-40 years. The median ISS was 9 (IQR 4-16), median hospital stays 11 days (IQR6-23), with in-hospital mortality of 17.4%. Presence of head injury; ISS > 9 and CPR in ED were independent risk factors of mortality. Trespassers on the rail track had significantly more severe injuries compared to passengers (Median ISS 13 vs. 9, p = 0.012; Median NISS 22 vs.17, p = 0.015); however, mortality and hospital length of stay were not significantly different. Location of injury event (on platform or tracks) showed no difference between the severity of injuries, mortality and hospital length of stay. CONCLUSIONS: Current study reports comprehensive injury patterns and outcomes of train-associated injuries from a low- and middle-income country (LMIC). Apart from the mortality, there is a high incidence of permanent disabilities from extremity amputations. No significant difference was noted in the severity and outcomes among patients injured on or off train platforms, emphasizing the need for comprehensive safety measures including enforcement and promoting safe behavior not only on locations like train tracks but equally at platforms.

Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study.

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty-six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer-generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In-hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train-associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.

Impact of bariatric surgery on obstructive sleep apnoea-hypopnea syndrome in morbidly obese patients.

BACKGROUND: Obstructive sleep apnea (OSA) is commonly associated with morbid obesity. Weight loss following bariatric surgery results in resolution or improvement of OSA. However, few studies have done objective assessment of the impact of bariatric surgery on OSA. OBJECTIVE: The aim of this study was to assess the outcome of bariatric surgery on OSA. SETTING: The study was conducted in the teaching institution of a tertiary care centre. METHODS: Twenty-seven morbidly obese patients seeking bariatric surgery were administered Epworth Sleepiness Scale (ESS) health questionnaire and subjected to overnight polysomnography. Repeat assessment using ESS and polysomnography was done at 3-6 months after surgery. RESULTS: Mean age was 42.4 ± 10.5 years, and majority (77.8%) were female. The mean pre-operative weight and body mass index (BMI) were 126.4 ± 24.9 kg and 48.4 ± 8.2 kg/m2, respectively. Nearly 29.6% patients had symptoms of excessive daytime somnolence based on ESS score and overnight polysomnography detected the presence of OSA in 96.3% patients, of which 51.9% had severe OSA. At mean follow-up of 5.2 ± 2.5 months after surgery, mean weight and BMI decreased to 107.4 ± 24.5 kg and 41.2 ± 8.2 kg/m2, respectively. Mean ESS score and mean apnoea-hypopnea index declined from 8.9 ± 3.2 to 4.03 ± 2.15 (P < 0.001) and from 31.8 ± 20.4 to 20.2 ± 23.1 (P = 0.007), respectively. Number of patients requiring continuous positive airway pressure (CPAP) therapy declined from 15 to 3 and average CPAP requirement came down from 11.3 cm of H2O to 6 cm of H2O. CONCLUSION: OSA was present in a significant proportion of patients undergoing bariatric surgery. Bariatric surgery resulted in significant improvement in both subjective and objective parameters of OSA.

Outcome predictors of patients who underwent limb amputation/s following trauma at a level I trauma center in North India.

PURPOSE: Limb amputation is one of the oldest medical operations, dating back over 2500 years to Hippocrates' time. In developing countries like India, most of the patients are young, and trauma is the primary cause of limb amputation. The objectives of this study were to investigate the factors that can predict the outcome of patients who underwent upper or lower limb amputations. MATERIALS AND METHODS: This was a retrospective analysis of the prospectively collected data of patients who underwent limb amputations from January 2015 to December 2019. RESULTS: From January 2015 to December 2019, 547 patients underwent limb amputations. Males predominated (86%). Road traffic injuries (RTI) were the most common (323, 59%) mechanism of injury. Hemorrhagic shock was present in 125 (22.9%) patients. Above-knee amputation was the most common (33%) amputation procedure performed. The correlation of hemodynamic status at presentation with the outcome was statistically significant (p-0.001). Outcome measures like delayed presentation, hemorrhagic shock, Injury severity scores (ISS), and the new injury severity scores (NISS) were statistically significant (p-0.001) when compared to the outcome. There were 47 (8.6%) mortalities during the study period. CONCLUSION: Factors that affected the outcome were delayed presentation, hemorrhagic shock, higher ISS, NISS, MESS scores, surgical-site infection, and associated injuries. Overall mortality during the study was 8.6%.

Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial.

BACKGROUND: Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD. METHODS: This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma. RESULTS: Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay. CONCLUSION: The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema. LEVEL OF EVIDENCE: Therapeutic Study, Level II TRIAL REGISTRATION: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403.

Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center.

Introduction: Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous. Methods: Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate. Results: The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality. Conclusion: VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

Revisiting the Role of Amniotic Membrane Dressing in Acute Large Traumatic Wounds: A Randomized Feasibility Study at a Level 1 Trauma Centre.

Introduction: Acute large traumatic wounds require temporary dressing prior to the definitive soft tissue reconstruction, as the physiological derangement during the immediate postinjury period delays the definitive surgical intervention. Selecting an ideal dressing material from numerous available synthetic dressings and skin substitutes poses a challenge. Although amniotic membrane (AM) scaffold has a definitive role in promoting wound healing in burns and chronic wounds, however, its efficacy in acute large traumatic wound is lacking. The present trial aimed to evaluate the safety and efficacy of AM in wound bed preparation before the definitive soft-tissue reconstruction in acute large traumatic wounds. Methods: Sixty patients with acute large traumatic wounds (>10 cm × 10 cm) were divided into two groups (conventional dressing and AM dressing) using simple mixed block randomization. Wounds were assessed using the Bates Jensen Score at various timelines for the signs of early wound healing. The primary outcome was to evaluate the time taken for the wound bed preparation for definitive soft-tissue reconstruction. The secondary outcome was the pain assessment and complications, if any. Results: There was significant reduction in the wound exudate as well as peripheral tissue edema in the intervention group (P = 0.01). AM dressing was significantly less painful (P = 0.01). The incidence of wound infection and need for debridement was decreased in the intervention group. However, the time interval to definitive soft-tissue coverage was statistically insignificant and comparable in both the groups. No adverse reactions were seen in either group. Conclusion: AM dressings are safe and efficacious with significant reduction in wound exudates and peripheral edema. However, these dressings do not hasten the wound maturation as compared to conventional dressings. AM dressings can be used as a less painful alternative to conventional dressing in the management of large acute posttraumatic wounds.

No role of antibiotics in patients with chest trauma requiring inter-costal drain: a pilot randomized controlled trial.

PURPOSE: To study the role of prolonged prophylactic antibiotic therapy (PAT) in the prevention of Inter-costal drain (ICD) related infectious complications in patients with Blunt Trauma Chest (BTC). METHODS: Patients of age 15 years and above with BTC requiring ICD were included. Patients with penetrating chest injuries, associated injuries/illnesses requiring antibiotic administration, need for mechanical ventilation, known pulmonary disease or immuno-compromised status and need for open thoracotomy were excluded. 120 patients were randomized equally to two groups; no prolonged PAT group (Group A) and prolonged PAT group (group B). Both group patients received one shot of injectable antibiotic prior to ICD insertion. Primary outcome measure was comparison of ICD related infectious complications (pneumonia, empyema and SSI) and secondary outcome measures included the duration of ICD, Length of Hospital stay (LOS) and in-hospital mortality in both the groups. RESULTS: Infectious complications (pneumonia, empyema and SSI) were seen in only one patient in antibiotic group, and none in no antibiotic group (p value = 0.500). Other complications such as post ICD pain scores, respiratory failure requiring ventilatory support, retained hemothorax or recurrent pneumothorax, did not show any statistical difference between both groups. Also, no significant difference was seen in both the groups in terms of mean duration of ICD (p value = 0.600) and LOS (p value = 0.259).m CONCLUSION: Overall prevalence of ICD related infectious complications are low in BTC patients. Definitive role of prolonged prophylactic antibiotics in reducing infectious complications and other associated co morbidities in BTC patients with ICDs could not be established. TRIAL REGISTRY DETAILS: Clinical Trial Registry, India (Trial registered at ctri.nic.in/clinical trials/login.php, number REF/2019/021704 dated 18/10/2019).

Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial.

PURPOSE: Penetrating abdominal trauma was traditionally managed by mandatory exploration, which led to high rates of non-therapeutic surgery and prolonged hospital stay. Diagnostic laparoscopy (DL) is a less-invasive alternative; however, it requires general anaesthesia and carries a potential risk of iatrogenic injuries. Contrast-enhanced computed tomography (CECT)-guided selective non-operative management (SNOM) may avoid surgery altogether, but there is apprehension of missed injury. Randomised trials comparing these two modalities are lacking. This study is aimed at comparing outcomes of these two management approaches. METHODS: Hemodynamically stable patients with penetrating trauma to anterior abdominal wall were randomised in 1:1 ratio to DL or CECT-based management. Primary outcome was length of hospital stay (LOS). Secondary outcomes were rate of non-therapeutic surgery, complications, and length of intensive care unit (ICU) stay. RESULTS: There were 52 patients in DL group and 54 patients in CECT group. Mean LOS was comparable (3 vs 3.5 days; p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (65.4 vs 17.4%, p = 0.0001). Rate of complications and length of ICU stay were similar. Selective non-operative management based on CECT findings was successful in 93.8% of patients; 2 patients had delayed surgery. CONCLUSION: In patients with penetrating trauma to anterior abdominal wall, DL and CECT-based management led to comparable hospital stay. Significant reduction in non-therapeutic surgery could be achieved using a CECT-based approach. TRIAL REGISTRATION: Clinical trials registry-India (CTRI/2019/04/018721, REF/2019/01/023400).

Traumatic chylothorax: a dilemma to surgeons and interventionists.

Chylothorax is generally seen due to iatrogenic injury to the thoracic duct during thoracic or neck surgery. It can also be encountered secondary to chest trauma either blunt or penetrating. Percutaneous thoracic duct embolisation is an alternative to surgical treatment and is considered an effective and safe minimally invasive treatment option for chylothorax with a success rate of about 80%. We present a case of blunt trauma to the chest with chylothorax, which was successfully managed with transvenous retrograde thoracic duct embolisation.

Down a wrong path - A nasogastric tube in the lung.

Nasogastric tube insertion is a common bedside procedure. In an awake patient, unexpected passage into airway is easily noticeable due to the gag reflex; however, in the case of ventilated patients false cannulation is liable to be missed, unless insertion is carried out under direct visualization. We present a case of passage of nasogastric tube into peripheral bronchiole of the right lung, which was initially missed on chest radiography. This case report highlights the fallacy of relying on a chest radiograph.

Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial.

BACKGROUND: The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma. METHODS: In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate. RESULTS: Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups. CONCLUSION: ERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications. LEVEL OF EVIDENCE: Level 1, randomized controlled trial, care management. TRIAL REGISTRATION NUMBER: Clinical Trials Registry of India (CTRI/2019/06/019533).

Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial.

BACKGROUND: Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial. MATERIALS AND METHODS: After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge. RESULTS: Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits. CONCLUSION: Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.

Post-traumatic bronchobiliary fistula.

Post-traumatic bronchobiliary fistula (BBF) is a rare entity, with only a few cases reported worldwide. Bilioptysis is pathognomonic of the condition, however, bronchoscopy and bronchoalveolar lavage along with CT are used for confirmation. We describe this condition in a young woman who presented to us with bilioptysis following a laparotomy for blunt torso trauma. Diagnosis was made of BBF, followed by surgical management and complete recovery. We emphasise the signs of early diagnosis, confirmatory tests, individualised treatment and advocate surgical management as the gold standard of treatment.

Comparative study of outcomes following laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in morbidly obese patients: A case control study.

AIM: To compare the impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on weight loss and obesity related comorbidities over two year follow-up via case control study design. METHODS: Forty patients undergoing LRYGB, who completed their two year follow-up were matched with 40 patients undergoing LSG for age, gender, body mass index and presence of type 2 diabetes mellitus (T2DM). Data of these patients was retrospectively reviewed to compare the outcome in terms of weight loss and improvement in comorbidities, i.e., T2DM, hypertension (HTN), obstructive sleep apnea syndrome (OSAS), hypothyroidism and gastroesophageal reflux disease (GERD). RESULTS: Percentage excess weight loss (EWL%) was similar in LRYGB and LSG groups at one year follow-up (70.5% vs 66.5%, P = 0.36) while it was significantly greater for LRYGB group after two years as compared to LSG group (76.5% vs 67.9%, P = 0.04). The complication rate after LRYGB and LSG was similar (10% vs 7.5%, P = 0.99). The median duration of T2DM and mean number of oral hypoglycemic agents were higher in LRYGB group than LSG group (7 years vs 5 years and 2.2 vs 1.8 respectively, P < 0.05). Both LRYGB and LSG had significant but similar improvement in T2DM, HTN, OSAS and hypothyroidism. However, GERD resolved in all patients undergoing LRYGB while it resolved in only 50% cases with LSG. Eight point three percent patients developed new-onset GERD after LSG. CONCLUSION: LRYGB has better outcomes in terms of weight loss two years after surgery as compared to LSG. The impact of LRYGB and LSG on T2DM, HTN, OSAS and hypothyroidism is similar. However, LRYGB has significant resolution of GERD as compared to LSG.