The role of diagnostic laparoscopy for trauma at a high-volume level one center.

BACKGROUND: The role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries. OBJECTIVE: While the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center. METHODS: All trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated. RESULTS: A total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4-18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05). CONCLUSION: In this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

Trimethyllysine, a trimethylamine N-oxide precursor, provides near- and long-term prognostic value in patients presenting with acute coronary syndromes.

AIMS: Trimethyllysine (TML) serves as a nutrient precursor of the gut microbiota-derived metabolite trimethylamine N-oxide (TMAO) and is associated with incident cardiovascular (CV) events in stable subjects. We examined the relationship between plasma TML levels and incident CV events in patients presenting with acute coronary syndromes (ACS). METHODS AND RESULTS: Plasma levels of TML were quantified in two independent cohorts using mass spectrometry, and its relationship with CV events was investigated. In a Cleveland Cohort (N = 530), comprised of patients presenting to the emergency department with chest pain and suspected ACS, TML was associated with major adverse cardiac events (MACE, myocardial infarction, stroke, need for revascularization, or all-cause mortality) over both 30 days [3rd tertile (T3), adjusted odds ratio (OR) 1.77, 95% confidence interval (CI) 1.04-3.01; P < 0.05] and 6 months (T3, adjusted OR 1.95, 95% CI 1.15-3.32; P < 0.05) of follow-up independent of traditional CV risk factors and indices of renal function. Elevated TML levels were also associated with incident long-term (7-year) all-cause mortality [T3, adjusted hazard ratio (HR) 2.52, 95% CI 1.50-4.24; P < 0.001], and MACE even amongst patients persistently negative for cardiac Troponin T at presentation (e.g. 30-day MACE, T3, adjusted OR 4.49, 95% CI 2.06-9.79; P < 0.001). Trimethyllysine in combination with TMAO showed additive significance for near- and long-term CV events, including patients with 'negative' high-sensitivity Troponin T levels. In a multicentre Swiss Cohort (N = 1683) comprised of ACS patients, similar associations between TML and incident 1-year adverse cardiac risks were observed (e.g. mortality, adjusted T3 HR 2.74, 95% CI 1.28-5.85; P < 0.05; and MACE, adjusted T3 HR 1.55, 95% CI 1.04-2.31; P < 0.05). CONCLUSION: Plasma TML levels, alone and together with TMAO, are associated with both near- and long-term CV events in patients with chest pain and ACS.

The Impact of Steroids and Inflammatory Bowel Disease in Colectomies in the Era of Enhanced Recovery.

INTRODUCTION: Enhanced recovery after surgery protocols are commonly used, but their utility in patients with inflammatory bowel disease and steroid use is poorly studied. We sought to examine influence of inflammatory bowel disease (IBD) and steroid use on hospital length of stay (LOS) and operative duration in patients undergoing colectomies in the era of ERAS. METHODS: We performed retrospective review of our institutional National Surgical Quality Improvement Program (NSQIP) registry (2016-2018) for colectomies. We performed 2 distinct analyses to examine influence of steroids and IBD on LOS and operative duration. Multivariable linear regression was used to predict outcomes after adjusting for relevant perioperative features. RESULTS: There were 366 patients in the cohort; 17.8% were on steroids and 16.4% had IBD. Patients using steroids had longer LOS (6 vs 4 days, P < .0001). IBD patients had a longer LOS (7 vs 5 days, P < .0001) and longer operative duration (383 min vs 335.5 minute, P = .01) compared to non-IBD patients. On multivariable analysis, steroid use was not associated with increased LOS or operative duration. Inflammatory bowel disease was associated with an increased hospital LOS and operative duration. DISCUSSION: Patients on steroids had longer LOS when compared to patients not on steroids. Inflammatory bowel disease regardless of steroid use was found to be a significant risk factor for both increased LOS and operative duration. A closer look at preoperative physiology may help to tailor ERAS protocols in patients with inflammatory conditions.

Difference in Presentation and Concomitant Intra-Abdominal Injury with Chance Fracture in Pediatric and Adult Populations.

BACKGROUND: Chance fracture (CFx) with concomitant intra-abdominal injury has variable occurrence rates ranging from 33 to 89%. No single study has compared the incidence of simultaneous abdominal injury between pediatric and adult populations. This study compares the rate of simultaneous intra-abdominal injury and chance fracture in these populations. METHODS: A retrospective review of pediatric and adult patients with chance fracture in comparable pediatric and adult trauma centers was performed. Patient demographics, mechanism of injury (MOI), and injury patterns were collected from 2002 to 2019 for pediatric patients and 2015 to 2018 for adults. Student t-test analyses were performed to determine statistical significance between the cohorts. RESULTS: The pediatric group had a similar incidence of abdominal solid organ injuries compared to adults (16 [20.5%] vs. 40 [19.7%], p<0.879), but the pediatric group had a greater number of total intra-abdominal (49 [62.8%] vs. 47 [23.1%], p < 0.001) and hollow organ injuries (40 [51.3%] vs. 17 [8.4%], p < 0.001). Motor vehicle collision was the most common mechanism of injury for both groups (72 pediatric [92.3%] vs. 85 adult [41.7%]) but adults suffered from more falls (3 pediatric vs. 81 adult, p < 0.001). Pediatric patients with CFx caused by MVCs had more intra-abdominal injuries (48 [66.7%] vs. 25[29.8%], p < 0.001) and hollow organ injuries compared to adults (39 [54.2%] vs. 8[9.5%], p < 0.001). CONCLUSION: In the setting of Chance fracture after trauma, pediatric patients are more likely to have a concomitant intra-abdominal organ injury (63% vs. 23%), especially hollow viscus injury (51.3% vs. 8.4%) compared with adults regardless of mechanism.

Sustained Clinical Performance During Surgical Rotations Predicts NBME Shelf Exam Outcomes.

OBJECTIVE: To determine if longitudinal, excellent clinical performance reflected in subjective evaluations during a surgery clerkship would be associated with a greater likelihood of National Board of Medical Examiners Surgery Shelf Exam ("shelf exam") success. DESIGN: We retrospectively reviewed medical students' surgical clerkship performance from 2014 to 2019. Clinical evaluations for each rotation were abstracted and students were stratified by performance: excellent performers and non-excellent performers. The rotation performance grades were then combined to classify overall clerkship performance: sustained excellent performers, improved performers, worsened performers, and sustained non-excellent performers. We compared the shelf exam scores between performer class for each clinical rotation and the overall clerkship. Using logistic regression, we also sought to determine if clinical performance predicted passing the shelf exam. SETTING: Emory University School of Medicine in Atlanta, Georgia. PARTICIPANTS: Third-year medical students (N = 674) who completed a surgery clerkship. RESULTS: Excellent performers scored higher than non-excellent performers on the shelf exam during both clinical rotations (all p < 0.01). Sustained excellent performers had the highest exam scores out of all the clerkship performance groups (p < 0.0001). Excellent performers for both rotations were associated with increased odds of passing the shelf exam. Sustained excellent performers had the greatest odds (OR 3, 95% confidence interval 1.5-6.3, p = 0.003) of passing the exam. CONCLUSIONS: Clinical performance during the surgical clerkship and individual rotations correlates with shelf exam scores. Students should be encouraged to excel on the wards to maximize the educational experience and improve their odds of passing the exam.