Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma.

BACKGROUND: The kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma. METHODS: The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation. RESULTS: A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends. CONCLUSION: In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury. LEVEL OF EVIDENCE: Guideline; systematic review, level III.

Comparative analysis of traumatic esophageal injury in pediatric and adult populations.

PURPOSE: Distribution and outcomes of traumatic injury of the esophagus (TIE) in pediatric versus adult populations are unknown. Our study sought to perform a descriptive analysis of TIE in children and adults. METHODS: We reviewed the National Trauma Data Bank (NTDB) for the years 2010-2015. Demographics, characteristics, and outcomes of pediatric (age < 16 years) and adult TIE patients were described and compared. RESULTS: Among 526,850 pediatric and 3,838,895 adult trauma patients, 90 pediatric (0.02%) and 1,411 (0.04%) adult TIE patients were identified. Demographics and esophageal injury severity did not differ. Children were more likely to sustain blunt trauma (63% versus 37%), with the most common mechanism being transportation-related accidents, were less-severely injured (median ISS 14 versus 22), and had fewer associated injuries (79% versus 95%) and complications (30% versus 51%) (all p < 0.001). Children had shorter hospitalizations (median 5 versus 10 days) and were more likely to be discharged home (84% versus 64%) (both p = 0.01). In-hospital mortality did not differ significantly between children and adults (10% versus 19%, p = 0.09). CONCLUSION: TIE in the pediatric population has unique characteristics compared to adults: it is more likely to be a result of blunt trauma, has lower injury burden, and has more favorable clinical outcomes.

Evaluating the Effectiveness of the Translated "A Matter of Balance" Fall Prevention Program Materials for Non-English-Speaking Participants.

A Matter of Balance (MOB) is an evidence-based fall prevention program shown to reduce fear of falling (FOF) in English-speaking participants. The effectiveness of translated (Chinese and Spanish) MOB materials in reducing FOF is unknown. The objective of this study was to evaluate whether MOB was associated with reduced FOF in Chinese- and Spanish-speaking participants and included an English-speaking comparison group. Participants were recruited from MOB classes in Massachusetts and Illinois. Investigators used the Falls Efficacy Scale-International (FES-I) and a demographic questionnaire to survey the participants at the first class (baseline), the last class, and 6 months after the MOB course. Of the 90 participants who enrolled, 77 (85.6%) completed the course (Chinese: n = 37; Spanish: n = 19; and English: n = 21) and 54 (60%) completed the 6-month survey (Chinese: n = 33; English: n = 21). Chinese FES-I scores significantly increased (FOF worsened) at the end of the course (+7.1, p = .009), and 6-month survey scores were also significantly above the baseline score (+6.7, p = .0088). FES-I scores decreased (FOF declined) in both the Spanish (-6.6, p = .016) and English groups (-2.7, p = .14) at the last class, and English 6-month FES-I scores were slightly lower than baseline scores (-0.4, p = .8). Participation in the MOB program did not reduce FOF in the Chinese population, but MOB did show promise in reducing FOF in both the Spanish and English groups. Future studies are warranted to explore the cultural, social, and education-related factors that may influence effectiveness of the MOB program.

Self-Inflicted Abdominal Stab Wounds Have a Higher Rate of Non-therapeutic Laparotomy/Laparoscopy and a Lower Risk of Injury.

BACKGROUND: The profile and management of self-inflicted abdominal stab wounds (SI-ASW) patients is still obscure. METHODS: The National Trauma Data Bank (2012) was queried for adults with abdominal stab wounds (n = 9544). Patients with SI-ASW (n = 1724) and non-SI-ASW (n = 7820) were compared. Predictors for non-therapeutic laparotomy/laparoscopy (non-TL) in SI-ASW patients were identified. RESULTS: SI-ASW patients were older, had more females and behavioral disorders, similar physiology, but a lower Injury Severity Score. They had more laparotomies overall (54 versus 48%, p < 0.0001) and more non-TL (42 versus 32%, p < 0.0001), but less injuries (43 versus 53%, p < 0.0001), although peritoneal violation rate was similar. Complications and mortality were similar. In the SI-ASW cohort, non-TL patients were more likely to be female and younger, and to have Glasgow Coma Scale (GCS) ≥13 and a higher systolic blood pressure. History of psychiatric, drug and alcohol disorders was associated with SI-ASW, but did not independently predict the need for treatment in adjusted models. CONCLUSION: Patients with SI-ASW underwent more non-TL than patients with non-SI-ASW. Female gender, younger age, and a higher GCS and systolic blood pressure predicted non-TL in this group.

Bicyclist Safety Behaviors in an Urban Northeastern, United States City: An Observational Study.

Bicycling is gaining popularity in the United States, and laws and safety recommendations are being established to keep bicyclists safer. To improve road safety for bicyclists, there is a need to characterize their compliance with road laws and safety behaviors. Adult bicyclists were observed at three high-traffic intersections in Boston, MA, with state recommendations of wearing a helmet and riding in a bike lane. State law compliance for displaying reflectors during the day and of a front light and a rear light/reflector at night, obeying traffic signals, and giving pedestrians the right of way was also observed. Variables were compared between personal and shared/rented bicyclists and analyzed by time of day. A total of 1,685 bicyclists were observed. Because of the speed of the bicyclists and obstructed views, only a sampling of 802 bicyclists was observed for reflectors/front light. Overall, 74% wore a helmet, 49% had reflectors/front lights, 95% rode in bike lanes, 87% obeyed traffic signals, and 99% gave the right of way to pedestrians. Compared with shared bicyclists (n = 122), personal bicyclists (n = 1563) had a higher helmet-wearing behaviors (77% vs. 39%, p = .0001). Shared bicyclists had a higher (p = .0001) compliance with reflectors/lights (100%) than personal bicyclists (39%, n = 265). Boston bicyclists ride in bike lanes, obey traffic signals, give pedestrians the right of way, and wear helmets while having suboptimal compliance with light/reflector use. Educational programs and stricter law enforcement aimed at these safety behaviors should be part of the effort to improve safety for all road users.

Blood pressure regulation to prevent progression of blunt traumatic intracranial hemorrhage in stable patients.

BACKGROUND: Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients. METHODS: A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval. RESULTS: Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD. CONCLUSIONS: A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated. LEVEL OF EVIDENCE III: Prognostic, Level II study.

Is implementation of robotic-assisted procedures in acute care general surgery cost-effective?

Over the past 2 decades, the use and importance of robotic surgery in minimally invasive surgery has increased. Across various surgical specialties, robotic technology has gained popularity through its use of 3D visualization, optimal ergonomic positioning, and precise instrument manipulation. This growing interest has also been seen in acute care surgery, where laparoscopic procedures are used more frequently. Despite the growing popularity of robotic surgery in the acute care surgical realm, there is very little research on the utility of robotics regarding its effects on health outcomes and cost-effectiveness. The current literature indicates some value in utilizing robotic technology in specific urgent procedures, such as cholecystectomies and incarcerated hernia repairs; however, the high cost of robotic surgery was found to be a potential barrier to its widespread use in acute care surgery. This narrative literature review aims to determine the cost-effectiveness of robotic-assisted surgery (RAS) in surgical procedures that are often done in urgent settings: cholecystectomies, inguinal hernia repair, ventral hernia repair, and appendectomies.

A Cost-Effectiveness Analysis of Wittmann Patch-Assisted Abdominal Closure Compared to Planned Ventral Hernia in Management of the Open Abdomen.

BACKGROUND: Inability to achieve primary fascial closure after damage control laparotomy is a frequently encountered problem by acute care and trauma surgeons. This study aims to compare the cost-effectiveness of Wittmann patch-assisted closure to the planned ventral hernia closure. METHODS: A literature review was performed to determine the probabilities and outcomes for Wittmann patch-assisted primary closure and planned ventral hernia closure techniques. Average utility scores were obtained by a patient-administered survey for the following: rate of successful surgeries (uncomplicated abdominal wall closure), surgical site infection, wound dehiscence, abdominal hernia and enterocutaneous fistula. A visual analogue scale (VAS) was utilized to assess the survey responses and then converted to quality-adjusted life years (QALYs). Total cost for each strategy was calculated using Medicare billing codes. A decision tree was generated with rollback and incremental cost-utility ratio (ICUR) analyses. Sensitivity analyses were performed to account for uncertainty. RESULTS: Wittmann patch-assisted closure was associated with higher clinical effectiveness of 19.43 QALYs compared to planned ventral hernia repair (19.38), with a relative cost reduction of US$7777. Rollback analysis supported Wittmann patch-assisted closure as the more cost-effective strategy. The resulting negative ICUR of -156,679.77 favored Wittmann patch-assisted closure. Monte Carlo analysis demonstrated a confidence of 96.8% that Wittmann patch-assisted closure was cost-effective. CONCLUSIONS: This study demonstrates using the Wittmann patch-assisted closure strategy as a more cost-efficient management of the open abdomen compared to the planned ventral hernia approach.

Can Surgeons Reliably Identify Non-cirrhotic Liver Disease During Laparoscopic Bariatric Surgery?

INTRODUCTION: Identification of liver disease during bariatric operations is an important task given the patients risk for occult fatty liver disease. Surgeon's accuracy of assessing for liver disease during an operation is poorly understood. The objective was to measure surgeons' performance on intra-operative visual assessment of the liver in a simulated environment. METHODS: Liver images from 100 patients who underwent laparoscopic bariatric surgery and pre-operative ultrasound elastography between July 2020 and July 2021 were retrospectively evaluated. The perception of 15 surgeons regarding the degree of hepatic steatosis and fibrosis was collected in a simulated clinical environment by survey and compared to results determined by ultrasonographic exam. RESULTS: The surgeons' ability to correctly identify the class of steatosis and fibrosis was poor (accuracy 61% and 59%, respectively) with a very weak correlation between the surgeon's predicted class and its true class (r = 0.17 and r = 0.12, respectively). When liver disease was present, surgeons completely missed its presence in 26% and 51% of steatosis and fibrosis, respectively. Digital image processing demonstrated that surgeons subjectively classified steatosis based on the "yellowness" of the liver and fibrosis based on texture of the liver, despite neither correlating with the true degree of liver disease. CONCLUSION: Laparoscopic visual assessment of the liver surface for identification of non-cirrhotic liver disease was found to be an inaccurate method during laparoscopic bariatric surgery. While validation studies are needed, the results suggest the clinical need for alternative approaches.

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.

Warfarin, not direct oral anticoagulants or antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: Implications in this new era of novel anticoagulants: An EAST multicenter study.

INTRODUCTION: This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use. METHODS: A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 2.8-13.9]), medical history, and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR, 1.3 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were. CONCLUSION: Despite ongoing concerns about the increase in DOAC use and lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease and comorbidities rather than type of AP or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Tranexamic Acid and Pulmonary Complications: A Secondary Analysis of an EAST Multicenter Trial.

BACKGROUND: Anti-inflammatory effects of tranexamic acid (TXA) in reducing trauma endotheliopathy may protect from acute lung injury. Clinical data showing this benefit in trauma patients is lacking. We hypothesized that TXA administration mitigates pulmonary complications in penetrating trauma patients. MATERIALS AND METHODS: This is a post-hoc analysis of a multicenter, prospective, observational study of adults (18+ years) with penetrating torso and/or proximal extremity injury presenting at 25 urban trauma centers. Tranexamic acid administration in the prehospital setting or within three hours of admission was examined. Participants were propensity matched to compare similarly injured patients. The primary outcome was development of pulmonary complication (ARDS and/or pneumonia). RESULTS: A total of 2382 patients were included, and 206 (8.6%) received TXA. Of the 206, 93 (45%) received TXA prehospital and 113 (55%) received it within three hours of hospital admission. Age, sex, and incidence of massive transfusion did not differ. The TXA group was more severely injured, more frequently presented in shock (SBP < 90 mmHg), developed more pulmonary complications, and had lower survival (P < 0.01 for all). After propensity matching, 410 patients remained (205 in each cohort) with no difference in age, sex, or rate of shock. On logistic regression, increased emergency department heart rate was associated with pulmonary complications. Tranexamic acid was not associated with different rate of pulmonary complications or survival on logistic regression. Survival was not different between the groups on logistic regression or propensity score-matched analysis. CONCLUSIONS: Tranexamic acid administration is not protective against pulmonary complications in penetrating trauma patients.

Readmissions after emergent incisional ventral hernia repair: a retrospective review of the nationwide readmissions database.

Emergent ventral hernia repair (eVHR) is associated with significant morbidity, yet there is no consensus regarding optimal surgical approach. We hypothesized that eVHR with synthetic mesh would have a higher readmission rate compared to primary eVHR or biologic mesh repair. Retrospective analysis of the Nationwide Readmissions Database (NRD) was conducted for patient entries between 2016 and 2018. Adult patients who underwent eVHR were included. Patient demographics, comorbidities, and surgical techniques were compared between readmitted and non-readmitted patients. Predictors of readmission were assessed using multivariate analysis with propensity weighting for various eVHR techniques. Secondary outcomes included hospital length of stay and readmission diagnoses. 43,819 patients underwent eVHR; of the 22,732 with 6 months of follow-up, 6382 (28.1%) were readmitted. The majority of readmissions occurred within the first 30 days (51.8%). Over half of the readmissions were related to surgical complications (50.6%), the most common being superficial surgical site infection (30.1%) and bowel obstruction/ileus (12.2%). In the multivariate analysis, predictors of 30-day readmission included use of synthetic mesh (OR 1.07, 95% CI 1.00-1.14), biologic mesh (OR 1.26, 95% CI 1.06-1.49), and need for concomitant large bowel resection (OR 1.46, 95% CI 1.30-1.65). eVHR is associated with high rates of readmission. Primary repair had favorable odds for readmission and lower risk of surgical complications compared to synthetic and biologic mesh repairs. Synthetic repair had lower odds of readmission than biologic repair. Given the inherent limitations of the NRD, further institutional prospective studies are required to confirm these findings.

Longitudinal study evaluating post-ICU syndrome differences between acute care surgery and trauma SICU survivors.

BACKGROUND: Post-intensive care unit (ICU) syndrome (PICS) occurs at an exorbitant rate in surgical ICU (SICU) survivors. It remains unknown if critical illness due to trauma versus acute care surgery (ACS) may represent different pathophysiologic entities. In this longitudinal study, we determined if admission criteria in a cohort of trauma and ACS patients were associated with differences in the occurrence of PICS. METHODS: Patients were 18 years or older, admitted to a Level I trauma center to the trauma or ACS services, remained in the SICU for ≥72 hours, and were seen in an ICU Recovery Center at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. Post-ICU syndrome sequelae were diagnosed by dedicated specialist staffing using clinical criteria and screening questionnaires. The PICS symptoms were distilled into physical, cognitive, and psychiatric categories. Preadmission histories, hospital courses, and recovery data were collected via retrospective chart review. RESULTS: One hundred twenty-six patients were included: 74 (57.3%) trauma patients and 55 (42.6%) ACS patients. Prehospital psychosocial histories were similar between groups. Acute care surgery patients had a significantly longer hospital course, higher APACHE II and III scores, were intubated for longer, and had higher rates of sepsis, acute renal failure, open abdomen, and hospital readmissions. At the 2-week follow-up visit, ACS patients had higher rates of PICS sequelae (ACS, 97.8% vs. trauma 85.3%; p = 0.03), particularly in the physical (ACS, 95.6% vs. trauma 82.0%, p = 0.04), and psychiatric domains (ACS, 55.6% vs. trauma 35.0%, p = 0.04). At the 12-week and 24-week visits, rates of PICS symptoms were comparable between groups. CONCLUSION: The occurrence of PICS is extraordinarily high in both trauma and ACS SICU survivors. Despite entering the SICU with similar psychosocial histories, the two cohorts have different pathophysiologic experiences, which are associated with a higher rate of impairment in the ACS patients during early follow-up. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Duration of antimicrobial treatment for complicated intra-abdominal infections after definitive source control: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Recent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. METHODS: A working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs. long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Noninferiority of short compared with long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and to formulate recommendations. RESULTS: Sixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1 day to 28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.56-1.44), rate of surgical site infection (OR, 0.88; 95% CI, 0.56-1.38); persistent/recurrent abscess (OR, 0.76; 95% CI, 0.45-1.29); unplanned interventions (OR, 0.53; 95% CI, 0.12-2.26); hospital length of stay (mean difference, -2.62 days; CI, -7.08 to 1.83 days); or readmissions (OR, 0.92; 95% CI, 0.50-1.69). The level of evidence was assessed as very low. CONCLUSION: The group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

Grade 1 Internal Carotid Artery Blunt Cerebrovascular Injury Persistence Risks Stroke With Current Management: An EAST Multicenter Study.

BACKGROUND: Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics. METHODS: A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only. RESULTS: From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury. DISCUSSION: While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization. METHODS: A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated. RESULTS: Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity. CONCLUSION: We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level IV.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury.

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS: This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS: 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION: DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.