Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields.

BACKGROUND: Prophylactic intra-abdominal onlay mesh (IPOM) implantation has been shown to reduce the rate of fascial dehiscence and incisional hernia. However, surgical site infection (SSI) in presence of an IPOM remains a concern. The aim of this study was to assess predictors for SSI following IPOM placement in hernia and non-hernia abdominal surgery in clean and contaminated surgical fields. METHODS: Observational study including patients undergoing IPOM placement at a Swiss tertiary care hospital 2007-2016. IPOM implantation was performed in hernia and non-hernia elective and emergency abdominal surgery, including contaminated and infected surgical fields. The incidence of SSI was prospectively assessed by Swissnoso according to CDC criteria. The effect of disease- and procedure-related factors on SSI was assessed in multivariable regression analysis, adjusting for patient-related factors. RESULTS: A total of 1072 IPOM implantations were performed. Laparoscopy was performed in 415 patients (38.7%), laparotomy in 657 patients (61.3%). SSI occurred in 172 patients (16.0%). Superficial, deep, and organ space SSI were found in 77 (7.2%), 26 (2.4%), and 69 (6.4%) patients, respectively. Multivariable analysis revealed emergency hospitalization (OR 1.787, p = 0.006), previous laparotomy (1.745, p = 0.029), duration of operation (OR 1.193, p < 0.001), laparotomy (OR 6.167, p < 0.001), bariatric (OR 4.641, p < 0.001), colorectal (OR 1.941, p = 0.001), and emergency (OR 2.510, p < 0.001) surgery, wound class ≥ 3 (OR 3.878, p < 0.001), and non-polypropylene mesh (OR 1.818, p = 0.003) as independent predictors for SSI. Hernia surgery was independently associated with a lower risk for SSI (OR 0.165, p < 0.001). CONCLUSION: This study revealed emergency hospitalization, previous laparotomy, duration of operation, laparotomy, as well as bariatric, colorectal, and emergency surgery, abdominal contamination or infection, and usage of non-polypropylene mesh as independent predictors for SSI. In contrast, hernia surgery was associated with a lower risk for SSI. The knowledge of these predictors will help to balance benefits of IPOM implantation against the risk for SSI.

Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study.

BACKGROUND: Multiple acute care surgery (ACS) working models have been implemented. To optimize resources and on-call rosters, knowledge about work characteristics is required. Therefore, this study aimed to investigate the daily work characteristics of ACS surgeons at a Swiss tertiary care hospital. METHODS: Single-center prospective snapshot study. In February 2020, ACS fellows prospectively recorded their work characteristics, case volume and surgical case mix for 20 day shifts and 16 night shifts. Work characteristics were categorized in 11 different activities and documented in intervals of 30 min. Descriptive statistics were applied. RESULTS: A total of 432.5 working hours (h) were documented and characterized. The three main activities 'surgery,' 'patient consultations' and 'administrative work' ranged from 30.8 to 35.9% of the documented working time. A total of 46 surgical interventions were performed. In total, during day shifts, there were 16 elective and 15 emergency interventions, during night shifts 15 emergency interventions. For surgery, two peaks between 10:00 a.m.-02:00 p.m. and 08:00 p.m.-11:00 p.m. were observed. A total of 225 patient were consulted, with a first peak between 08:00 a.m. and 11:00 a.m. and a second, wider peak between 02:00 p.m. and 02:00 a.m. CONCLUSION: The three main activities 'surgery,' 'patient consultations' and 'administrative work' were comparable with approximately one third of the working time each. There was a bimodal temporal distribution for both surgery and patient consultations. These results may help to improve hospital resources and on-call rosters of ACS services.

LARS is Associated with Lower Anastomoses, but not with the Transanal Approach in Patients Undergoing Rectal Cancer Resection.

BACKGROUND: Low anterior resection syndrome (LARS) is a defecation disorder that frequently occurs after a low anterior resection (LAR) with a total mesorectal excision (TME). The transanal (ta) TME for low rectal pathologies could potentially overcome some of the difficulties encountered with the abdominal approach in a narrow pelvis. However, the impact of the transanal approach on functional outcomes remains unknown. Here, we investigated the effect of the taTME approach on functional outcomes by comparing LARS scores between the LAR and taTME approaches in patients with colorectal cancer. METHODS: We conducted a retrospective cohort study including 80 patients (n = 40 LAR-TME, n = 40 taTME) with rectal adenocarcinoma. We reviewed medical charts to obtain LARS scores 6 months after the rectal resection or a reversal of the protective ileostomy. RESULTS: At the 6-month follow-up, 80% of patients exhibited LARS symptoms (44% minor LARS and 36% major LARS). LARS scores were not significantly associated with the T-stage, N-stage, or neo-adjuvant radiotherapy. The mean distance of the anastomosis from the anal verge was 4.0 ± 2.0 cm. The taTME group had significantly lower anastomoses compared with the LAR-TME group (median 4.0 cm [IQR1.8] vs. median 5.0 cm [IQR 2.0], p < 0.001). Univariable analysis revealed significantly higher LARS scores in the taTME group compared with the LAR-TME group (median LARS scores: 29 vs. 25, p = 0.040). However, multivariable regression analysis, adjusting for neo-adjuvant treatment, anastomosis distance from the anal verge, anastomotic leak rate, and body mass index, revealed no significant effect of taTME on the LARS score (adjusted regression coefficient: - 2.147, 95%CI: - 2.130 to 6.169, p = 0.359). We also found a significant correlation between LARS scores and the distance of the anastomosis from the anal verge (regression coefficient: - 1.145, 95%CI: - 2.149 to - 1.141, p = 0.026). CONCLUSION: Fifty percentage of patients in this cohort exhibited some LARS symptoms after a mid- or low-rectal cancer resection. As previously described, LARS scores were negatively correlated with the distance of the anastomosis from the anal verge. TaTME was after adjustment for the height of the anastomosis not associated with higher LARS at 6 months when compared with LAR-TME.

Impact of Inter-Hospital Transfer on Outcomes in Patients Undergoing Emergency Abdominal Surgery: A Tertiary Referral Center's Perspective.

BACKGROUND: In trauma patients, the impact of inter-hospital transfer has been widely studied. However, for patients undergoing emergency abdominal surgery (EAS), the effect of inter-hospital transfer on outcomes is largely unknown. METHODS: This is a single-center, retrospective observational study. Outcomes of transferred patients undergoing EAS were compared to patients primarily admitted to a tertiary care hospital from 01/2016 to 12/2018 using univariable and multivariable analyses. The primary outcome was in-hospital mortality. RESULTS: Some 973 patients with a median (IQR) age of 58.1 (39.4-72.2) years and a median body mass index of 25.8 (22.5-29.3) kg/m2 were included. The transfer group comprised 258 (26.3%) individuals and the non-transfer group 715 (72.7%). The population was stratified in three subgroups: (1) patients with low surgical stress (n = 483, 49.6%), (2) with hollow viscus perforation (n = 188, 19.3%) and (3) with potential bowel ischemia (n = 302, 31.1%). Neither in the low surgical stress nor in the hollow viscus perforation group was the transfer status associated with mortality. However, in the potential bowel ischemia group inter-hospital transfer was a predictor for mortality (OR 3.54, 95%CI 1.03-12.12, p = 0.045). Moreover, in the hollow viscus perforation group inter-hospital transfer was a predictor for reduced hospital length of stay (RC -10.02, 95%CI -18.14/-1.90, p = 0.016) and reduced severe complications (OR 0.38, 95%CI 0.18-0.77, p = 0.008). CONCLUSION: Other than in patients with low surgical stress or hollow viscus perforation, in patients with potential bowel ischemia inter-hospital transfer was an independent predictor for higher mortality. Taking into account the time sensitiveness of bowel ischemia, efforts should be made to avoid inter-hospital transfer in this vulnerable subgroup of patients.

The Impact of Accidental Hypothermia on Mortality in Trauma Patients Overall and Patients with Traumatic Brain Injury Specifically: A Systematic Review and Meta-Analysis.

BACKGROUND: Accidental hypothermia is a known predictor for worse outcomes in trauma patients, but has not been comprehensively assessed in a meta-analysis so far. The aim of this systematic review and meta-analysis was to investigate the impact of accidental hypothermia on mortality in trauma patients overall and patients with traumatic brain injury (TBI) specifically. METHODS: This is a systematic review and meta-analysis using the Ovid Medline/PubMed database. Scientific articles reporting accidental hypothermia and its impact on outcomes in trauma patients were included in qualitative synthesis. Studies that compared the effect of hypothermia vs. normothermia at hospital admission on in-hospital mortality were included in two meta-analyses on (1) trauma patients overall and (2) patients with TBI specifically. Meta-analysis was performed using a Mantel-Haenszel random-effects model. RESULTS: Literature search revealed 264 articles. Of these, 14 studies published 1987-2018 were included in the qualitative synthesis. Seven studies qualified for meta-analysis on trauma patients overall and three studies for meta-analysis on patients with TBI specifically. Accidental hypothermia at admission was associated with significantly higher mortality both in trauma patients overall (OR 5.18 [95% CI 2.61-10.28]) and patients with TBI specifically (OR 2.38 [95% CI 1.53-3.69]). CONCLUSIONS: In the current meta-analysis, accidental hypothermia was strongly associated with higher in-hospital mortality both in trauma patients overall and patients with TBI specifically. These findings underscore the importance of measures to avoid accidental hypothermia in the prehospital care of trauma patients.

Transthyretin at Admission and Over Time as a Marker for Clinical Outcomes in Critically Ill Trauma Patients: A Prospective Single-Center Study.

BACKGROUND: Transthyretin (TTR) has been described as a predictor for outcomes in medical and surgical patients. However, the association of TTR on admission and over time on outcomes has not yet been prospectively assessed in trauma patients. METHODS: This is a prospective observational study including trauma patients admitted to the intensive care unit (ICU) of a large Level I trauma center 05/2014-05/2015. TTR levels at ICU admission and all subsequent values over time were recorded. Patients were observed for 28 days or until hospital discharge. The association of outcomes and TTR levels at admission and over time was assessed using multivariable regression and generalized estimating equation (GEE) analysis, respectively. RESULTS: A total of 237 patients with TTR obtained at admission were included, 69 of whom had repeated TTR measurements. Median age was 40.0 years and median ISS 16.0; 83.1% were male. Below-normal TTR levels at admission (41.8%) were independently associated with higher in-hospital mortality (p = 0.042), more infectious complications (p = 0.032), longer total hospital length of stay (LOS) (p = 0.013), and ICU LOS (p = 0.041). Higher TTR levels over time were independently associated with lower in-hospital mortality (p = 0.015), fewer infections complications (p = 0.028), shorter total hospital and ICU LOS (both p < 0.001), and fewer ventilator days (0.004). CONCLUSIONS: In critically ill trauma patients, below-normal TTR levels at admission were independently associated with worse outcomes and higher TTR levels over time with better outcomes, including lower in-hospital mortality, less infectious complications, shorter total hospital and ICU LOS, and fewer ventilator days. Based on these results, TTR may be considered as a prognostic marker in this patient population.

Favourable long-term survival of patients with esophageal cancer treated with extended transhiatal esophagectomy combined with en bloc lymphadenectomy: results from a retrospective observational cohort study.

BACKGROUND: Although considered complex and challenging, esophagectomy remains the best potentially curable treatment option for resectable esophageal and esophagogastric junction (AEG) carcinomas. The optimal surgical approach and technique as well as the extent of lymphadenectomy, particularly regarding quality of life and short- and long-term outcomes, are still a matter of debate. To lower perioperative morbidity, we combined the advantages of a one-cavity approach with extended lymph node dissection (usually achieved by only a two-cavity approach) and developed a modified single-cavity transhiatal approach for esophagectomy. METHODS: The aim of this study was to evaluate the outcome of an extended transhiatal esophageal resection with radical bilateral mediastinal en bloc lymphadenectomy (eTHE). A prospective database of 166 patients with resectable cancers of the esophagus (including adenocarcinomas of the AEG types I and II) were analyzed. Patients were treated between 2001 and 2017 with eTHE at a tertiary care university center. Relevant patient characteristics and outcome parameters were collected and analyzed. The primary endpoint was 5-year overall survival. Secondary outcomes included short-term morbidity, mortality, radicalness of en bloc resection and oncologic efficacy. RESULTS: The overall survival rates at 1, 3 and 5 years were 84, 70, and 61.0%, respectively. The in-hospital mortality rate after eTHE was 1.2%. Complications with a Clavien-Dindo score of III/IV occurred in 31 cases (18.6%). A total of 25 patients (15.1%) had a major pulmonary complication. The median hospital stay was 17 days (interquartile range (IQR) 12). Most patients (n = 144; 86.7%) received neoadjuvant treatment. The median number of lymph nodes resected was 25 (IQR 17). The R0 resection rate was 97%. CONCLUSION: In patients with esophageal cancer, eTHE without thoracotomy resulted in excellent long-term survival, an above average number of resected lymph nodes and an acceptable postoperative morbidity and mortality.

Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer.

PURPOSE: Long-term outcomes in patients undergoing emergency versus elective resection for colorectal cancer (CRC) are discussed controversially. This study aims to assess long-term outcomes of emergency versus elective CRC surgery. METHODS: Single-center retrospective cohort study. Patients undergoing emergency or elective CRC surgery from July 2002 to January 2013 were included. Primary outcome was 5-year survival, secondary outcomes were in-hospital mortality and local tumor recurrence. RESULTS: Overall, 475 patients were included. Median age was 69.0 (IQR 59.0-77.0) years. A total of 141 patients (30%) were operated for rectal cancer and 334 patients (70%) for colon cancer. Median follow-up was 445 (IQR 67-1409) days. Emergency resection was performed in 105 patients (22%) due to obstruction, perforation, or bleeding. Stage IV tumors and ASA scores≥ 3 were significantly more frequent in the emergency than in the elective resection group (39.0% vs. 33.5%, p < 0.001; 75.5% vs. 61.3%, p = 0.003). The rate of patients with positive lymph nodes was similar in the two groups (46.2% vs. 46.3%, p = 1.000). In-hospital mortality was significantly higher in the emergency CRC versus the elective CRC group (8.4% vs. 3.0%, p = 0.023). Five-year survival (aHR 1.38; 95%CI 0.81-2.37, p = 0.237) or local tumor recurrence (aHR 1.48; 95%CI 0.47-4.66, p = 0.500) were not significantly different in patients undergoing emergency versus elective surgery for CRC. CONCLUSION: In-hospital mortality was increased in emergency versus elective CRC resections. However, 5-year survival and local recurrence after surgery for CRC were determined by the tumor stage, and not by the emergency versus elective setting of surgical resection.

Factors affecting the caloric and protein intake over time in critically ill trauma patients.

BACKGROUND: Major trauma leads to increased nutritional requirements. However, little is known about the actual amount of calories and protein administered and the factors affecting the intake over time in critically ill trauma patients. METHODS: Prospective study including 100 trauma patients admitted to the Los Angeles County + University of Southern California Medical Center intensive care unit between March 2014 and October 2014. Inclusion criteria were age > 16 y, surgery at admission, and no oral nutrition. The caloric and protein intake was recorded, and requirements were calculated daily for 28 d. The nutritional intake and the impact of clinical factors on the intake over time were assessed using mixed model analysis. RESULTS: The caloric and protein intake significantly increased over time, but the median intake did not meet the median calculated requirements at any time. Multivariable analysis revealed a smaller increase of the nutritional intake over time in patients with an injury severity score > 45, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Body mass index scores ≥ 30 kg/m2, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. CONCLUSIONS: The median nutritional intake did not meet the median calculated requirements over time. A smaller increase of the nutritional intake over time was found in patients with a higher injury burden, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Higher body mass index scores, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. These clinical factors can help to adjust the nutritional support in critically ill trauma patients.

Long-Term Follow-Up After Non-operative Management of Blunt Splenic and Liver Injuries: A Questionnaire-Based Survey.

BACKGROUND: Non-operative management (NOM) of blunt splenic or liver injuries (solid organ injury, SOI) has become the standard of care in hemodynamically stable patients. However, the incidence of long-term symptoms in these patients is currently not known. The aim of this study was to assess long-term symptoms in patients undergoing successful NOM (sNOM) for SOI. METHODS: Long-term posttraumatic outcomes including chronic abdominal pain, irregular bowel movements, and recurrent infections were assessed using a specifically designed questionnaire and analyzed by univariable analysis. RESULTS: Eighty out of 138 (58%) patients with SOI undergoing sNOM) responded to the questionnaire. Median (IQR) follow-up time was 48.8 (28) months. Twenty-seven (34%) patients complained of at least one of the following symptoms: 17 (53%) chronic abdominal pain, 13 (41%) irregular bowel movements, and 8 (25%) recurrent infections. One female patient reported secondary infertility. No significant association between the above-mentioned symptoms and the Injury Severity Score, amount of hemoperitoneum, or high-grade SOI was found. Patients with chronic pain were significantly younger than asymptomatic patients (32.1 ± 14.5 vs. 48.3 ± 19.4 years, p = 0.002). Irregular bowel movements were significantly more frequent in patients with severe pelvic fractures (15.4 vs. 0.0%, p = 0.025). A trend toward a higher frequency of recurrent infections was found in patients with splenic injuries (15.9 vs. 2.8%, p = 0.067). CONCLUSION: A third of patients with blunt SOI undergoing sNOM reported long-term abdominal symptoms. Younger age was associated with chronic abdominal symptoms. More studies are warranted to investigate long-term outcomes immunologic sequelae in patients after sNOM for SOI.

Early Surgery in Prone Position for Associated Injuries in Patients Undergoing Non-operative Management for Splenic and Liver Injuries.

BACKGROUND: In patients undergoing non-operative management (NOM) of blunt splenic and/or liver injuries, no data exist on the safety of same-admission surgery in prone position for concomitant injuries. METHODS: Retrospective study including adult trauma patients with blunt splenic/liver injuries and attempted NOM from 01/2009 to 06/2015 was conducted. Patient and injury characteristics as well as outcomes [failed (f)NOM, mortality] of patients with/without surgery in prone position were compared ('prone' vs. 'non-prone' group). RESULTS: A total of 244 patients with blunt splenic/liver injury and attempted NOM were included. Forty patients (16.4%) underwent surgery in prone position on median post-injury day 2.0 [interquartile range (IQR) 3.0]. Surgery in prone position was mostly performed for associated spinal or pelvic injuries. The ISS was significantly higher, and the proportion of patients with high-grade injuries (OIS ≥ 3) was significantly less frequent in the 'prone' group (30.0 ± 14.5 vs. 23.9 ± 13.2, p = 0.009 and 27.5 vs. 53.9%, p = 0.002). In-hospital mortality as well as NOM failure rates were not significantly different between the 'prone' and 'non-prone' group (2.5 vs. 2.9%, p = 1.000; 0.0 vs. 4.4%, p = 0.362). Eleven patients with high-grade injuries were operated in prone position at median day 3 (IQR 3.0). None of these patients failed NOM. However, one patient with a grade IV splenic injury required immediate splenectomy after being operated in right-sided position on the day of admission. CONCLUSION: In this single-center analysis, surgery in prone position was performed in a substantial number of patients with splenic/liver injuries without increasing the fNOM rate. However, caution should be used in patients with grade IV/V splenic injuries.

Thromboembolic Prophylaxis with Heparin in Patients with Blunt Solid Organ Injuries Undergoing Non-operative Treatment.

BACKGROUND: Patients with blunt solid organ injuries (SOI) are at risk for venous thromboembolism (VTE), and VTE prophylaxis is crucial. However, little is known about the safety of early prophylactic administration of heparin in these patients. METHODS: This is a retrospective study including adult trauma patients with SOI (liver, spleen, kidney) undergoing non-operative management (NOM) from 01/01/2009 to 31/12/2014. Three groups were distinguished: prophylactic heparin (low molecular weight heparin or low-dose unfractionated heparin) ≤72 h after admission ('early heparin group'), >72 h after admission ('late heparin group'), and no heparin ('no heparin group'). Patient and injury characteristics, transfusion requirements, and outcomes (failed NOM, VTE, and mortality) were compared between the three groups. RESULTS: Overall, 179 patients were included; 44.7% in the 'early heparin group,' 34.6% in the 'late heparin group,' and 20.8% in the 'no heparin group.' In the 'late heparin group,' the ISS was significantly higher than in the 'early' and 'no heparin groups' (median 29.0 vs. 17.0 vs. 19.0; p < 0.001). The overall NOM failure rate was 3.9%. Failed NOM was significantly more frequent in the 'no heparin group' compared to the 'early' and 'late heparin groups' (10.8 vs. 3.2 vs. 1.3%; p = 0.043). In the 'early heparin group' 27.5% patients suffered from a high-grade SOI; none of these patients failed NOM. Mortality did not differ significantly. Although not statistically significant, VTE were more frequent in the 'no heparin group' compared to the 'early' and 'late heparin groups' (10.8 vs. 4.8 vs. 1.3%; p = 0.066). CONCLUSION: In patients with SOI, heparin was administered early in a high percentage of patients and was not associated with an increased NOM failure rate or higher in-hospital mortality.

Insulin-Treated Patients with Diabetes Mellitus Undergoing Emergency Abdominal Surgery Have Worse Outcomes than Patients Treated with Oral Agents.

BACKGROUND: Diabetes mellitus (DM) is a known risk factor for worse outcomes after emergency abdominal surgery (EAS). However, it is unclear if the type of diabetes treatment (insulin or oral agents) has any effect on outcomes after EAS. METHODS: Matched cohort study utilizing the ACS NSQIP database. Patients with DM undergoing EAS were divided into insulin and oral agent treatment groups. A 1:1 cohort matching of insulin-treated and oral agent-treated patients was performed (matched for sex, age, ASA score, BMI category, operative procedure, and preoperative acute renal failure, pneumonia, SIRS, sepsis, septic shock, and corticosteroid use). Outcomes of matched insulin- and oral agent-treated patients were compared with univariable and multivariable regression analysis. RESULTS: A total of 7401 patients with DM underwent EAS, 3182 (43 %) of which were insulin treated and 4219 (57 %) were treated with oral agents. Matching resulted in 2280 matched cases, which formed the basis of this analysis. Insulin-treated patients were more likely to have postoperative complications (OR 1.279, CI 1.119-1.462), had a higher 30-day mortality rate in patients with sepsis at hospital admission (OR 3.421, CI 1.959-5.974), and a longer total hospital length of stay (RC 1.115, CI 1.065-1.168) and postoperative LOS (RC 1.082, CI 1.031-1.135). CONCLUSIONS: In patients with DM undergoing emergency abdominal surgery, insulin-treated patients have worse outcomes than oral agent-treated patients. Insulin-treated patients with DM therefore should be monitored and treated more intensively in anticipation of potential complications after emergency abdominal surgery.

Longitudinal analysis of caloric requirements in critically ill trauma patients: a retrospective cohort study.

PURPOSE: Nutrition is of paramount importance in critically ill trauma patients. However, adequate supply is difficult to achieve, as caloric requirements are unknown. This study investigated caloric requirements over time, based on indirect calorimetry, in critically ill trauma patients. METHODS: Retrospective cohort study at a tertiary trauma center including critically ill trauma patients who underwent indirect calorimetry 2012-2019. Caloric requirements were assessed as resting energy expenditure (REE) during the intensive care unit stay up to 28 days and analyzed in patient-clustered linear regression analysis. RESULTS: A total of 129 patients were included. Median REE per day was 2376 kcal. The caloric intake did not meet REE at any time with a median daily deficit of 1167 kcal. In univariable analysis, ISS was not significantly associated with REE over time (RC 0.03, p = 0.600). Multivariable analysis revealed a significant REE increase (RC 0.62, p < 0.001) and subsequent decrease (RC - 0.03, p < 0.001) over time. Age < 65 years (RC 2.07, p = 0.018), male sex (RC 4.38, p < 0.001), and BMI ≥ 35 kg/m2 (RC 6.94, p < 0.001) were identified as independent predictors for higher REE over time. Severe head trauma was associated with lower REE over time (RC - 2.10, p = 0.030). CONCLUSION: In critically ill trauma patients, caloric requirements significantly increased and subsequently decreased over time. Younger age, male sex and higher BMI were identified as independent predictors for higher caloric requirements, whereas severe head trauma was associated with lower caloric requirements over time. These results support the use of IC and will help to adjust nutritional support in critically ill trauma patients.

Pre-injury stimulant use in isolated severe traumatic brain injury: effect on outcomes.

PURPOSE: The aim of this study was to assess the impact of pre-injury stimulant use (amphetamine, cocaine, methamphetamine and/or ecstasy) on outcomes after isolated severe traumatic brain injury (TBI). METHODS: Retrospective 2017 TQIP study, including adult trauma patients (≥16 years old) who underwent drug and alcohol screening on admission and sustained an isolated severe TBI (head AIS ≥3). Patients with significant extracranial trauma (AIS ≥3) were excluded. Epidemiological and clinical characteristics, procedures and outcome variables were collected. Patients with isolated stimulant use were matched 1:1 for age, gender, mechanism of injury, head AIS and overall comorbidities, with patients with negative toxicology and alcohol screen. Outcomes in the two groups were compared with univariable and multivariable regression analysis. RESULTS: 681 patients with isolated TBI and stimulant use were matched with 681 patients with negative toxicology and alcohol screen. The incidence of hypotension and CGS <9 was similar in the two groups. In multivariable regression analysis, stimulant use was not independently associated with mortality (OR 0.95, 95% CI 0.61-1.49). However, stimulant use was associated with longer hospital length of stay (HLOS) (RC 1.13, 95%CI 1.03-1.24). CONCLUSION: Pre-injury stimulant use is common in patients admitted for severe TBI, but was not independently associated with mortality when compared to patients with negative toxicology. However, stimulant use was associated with a significant longer HLOS.

Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis.

BACKGROUND: After the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies. METHODS: Systematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores. RESULTS: A total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, -0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, -0.18; 95% confidence interval, -0.29 to -0.06). CONCLUSION: This meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Increased hospital treatment volume of splenic injury predicts higher rates of successful non-operative management and reduces hospital length of stay: a Swiss Trauma Registry analysis.

PURPOSE: First time analysis of the epidemiology, management and outcomes of patients with splenic injuries in Switzerland. This study aims to assess the effect of hospital treatment volume on successful non-operative management (NOM) in splenic injuries. METHODS: A multicentric registry-based study including all patients with splenic injuries entered into the Swiss Trauma Registry from 2015 to 2018 was conducted. Patients were stratified according to the hospitals treatment volume of splenic injuries. Primary outcome was the rate of successful NOM. RESULTS: During the 4-year study period, 652 patients with splenic injury were included in the study. Median age of the study population was 42 (IQR 27-59) years, and median ISS was 26 (20-34). The overall rate of successful NOM was 86.5%. Median HLOS was 13 (8-21) days. In-hospital mortality was 7.2% (n = 47). The mean number of patients with splenic injuries per center and year was 14. Five out of 12 Level I trauma centers treating more patients than the mean (≥ 15/year) were defined as high-volume centers. Multivariable analysis adjusting for differences in baseline and injury characteristics revealed treatment in a high-volume center as an independent predictor for successful NOM (OR 2.15, 95% CI 1.28-3.60, p = 0.004) and shorter HLOS (RC - 2.39, 95% CI - 4.91/- 0.48, p = 0.017), however, not for reduced in-hospital mortality (OR 0.92, 95% CI 0.39-2.18, p = 0.845). CONCLUSION: Higher hospital treatment volume was associated with a higher rate of NOM and shorter HLOS, but not lower mortality. These results constitute the basis for further quality improvement in the care of splenic injury patients within the trauma system in Switzerland.

[Resuscitative endovascular balloon occlusion of the aorta in severely injured patients in the emergency trauma room: a case series]. / "Resuscitative endovascular balloon occlusion of the aorta" bei schwer verletzten Patienten im Schockraum: eine Fallserie.

Hemorrhage is the cause of death in 30-40% of severely injured patients due to trauma and the most frequent avoidable cause of death. In civilian emergency medical services, the majority of life-threatening hemorrhages are found in incompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a lifesaving procedure for temporary bleeding control in multiple trauma patients. Since August 2020 REBOA is implented in the treatment of seriously injured patients in the emergency department of the University Hospital of Bern. In this case series we report on our experiences in all seven patients in whom we performed this procedure during the first year.

Performance of quick sequential organ failure assessment and modified age disease adjusted qadSOFA for the prediction of outcomes in emergency general surgery patients.

BACKGROUND: Sepsis is a highly prevalent condition and is associated with a reported in-hospital mortality rate up to 40% in patients with abdominal sepsis requiring emergency general surgery (EGS). The quick sequential organ failure assessment score (qSOFA) has not been studied for EGS patients. METHODS: Retrospective cohort study in adult patients undergoing abdominal EGS at a university tertiary care center from 2016 to 2018. The primary outcome was mortality. The effect of clinical variables on outcomes was assessed in univariable and multivariable logistic regression analyses. Based on these results, the qSOFA score was modified. The performance of scores was assessed using receiver operating characteristics. RESULTS: Five hundred seventy-eight patients undergoing abdominal EGS were included. In-hospital mortality was 4.8% (28/578). Independent predictors for mortality were mesenteric ischemia (odds ratio [OR] 15.9; 95% confidence interval [CI] 5.2-48.6; p < 0.001), gastrointestinal tract perforation (OR 4.9; 95% CI 1.7-14.0; p = 0.003), 65 years or older (OR 4.1; 95% CI 1.5-11.4; p = 0.008), and increasing qSOFA (OR 1.8; 95% CI 1.2-2.8; p = 0.007). The modified qSOFA (qadSOFA) was developed. The area under the receiver operating characteristic curve of the qSOFA and qadSOFA for mortality was 0.715 and 0.859, respectively. Optimal cutoff value was identified as qadSOFA ≥ 3 (Youden Index 64.1%). CONCLUSION: This is the first study investigating the qSOFA as a predictor for clinical outcomes in EGS. Compared with the qSOFA, the new qadSOFA revealed an excellent predictive power for clinical outcomes. Further validation of qadSOFA is warranted. LEVEL OF EVIDENCE: Diagnostic test/criteria; Level II.

Biologic mesh implantation is associated with serious abdominal wall complications in patients undergoing emergency abdominal surgery: A randomized-controlled clinical trial.

BACKGROUND: Open, emergency abdominal surgery is associated with a high incidence of fascial dehiscence and incisional hernia. Implantation of biologic meshes potentially reinforces the abdominal wall and therefore decreases such complications. The aim of this prospective randomized study was to compare the outcome after prophylactic intraperitoneal implantation of a biologic Strattice mesh (Allergan, Dublin, Ireland) with standard abdominal closure in patients undergoing emergency abdominal surgery. METHODS: A two-arm randomized clinical trial was performed in patients undergoing emergency abdominal surgery at Bern University Hospital, University of Bern, Switzerland, from April 2016 to March 2019. Patients were randomly assigned to prophylactic implantation of a biological intraperitoneal mesh using Strattice, Allergan (mesh group), or standard abdominal closure using a single, continuous running suture (no-mesh group). Because of safety concerns, patient enrollment was closed prematurely. RESULTS: Eligibility for inclusion was assessed in 61 patients. A total of 48 patients were randomized (21 in the mesh group, 28 in the no-mesh group). No differences in baseline characteristics were found. Abdominal wall complications requiring reoperations were more frequent in the mesh group compared to the no-mesh group (5 [83.3%] of 13 vs. 1 [14.3%] of 13 patients, p = 0.026). Mesh-associated abdominal wall complications included nonintegration of the mesh into the abdominal wall, dissolution of the mesh, and mesh-related infections. CONCLUSION: In patients undergoing emergency abdominal surgery, intraperitoneal biologic Strattice mesh implantation is associated with significantly more frequent abdominal wall complications requiring reoperation. Therefore, the use of such meshes cannot be recommended in the contaminated environment of emergency abdominal surgery. LEVEL OF EVIDENCE: Therapeutic, level I.