Effective use of the hybrid emergency Department system in the treatment of non-traumatic critical care diseases.

BACKGROUND: The hybrid emergency room (ER) system can provide resuscitation, computed tomography imaging, endovascular treatment, and emergency surgery, without transferring the patient. However, although several reports have demonstrated the effectiveness of the hybrid ER for trauma conditions, only a few case reports have demonstrated its usefulness for non-traumatic critical diseases. In this observational cohort study, we aimed to identify endogenous diseases that may benefit from treatment in the hybrid ER. METHODS: We retrospectively reviewed the clinical characteristics of patients with non-traumatic conditions treated in a hybrid ER between August 2017 and July 2022 at our institution. Patients who underwent surgery, endoscopy, or interventional radiology (IR) in the hybrid ER were selected and pathophysiologically divided into a bleeding and non-bleeding group. The rate of shock or cardiac arrest, blood transfusion, and death within 24 h of admission or in-hospital death were compared among the groups using Fisher's exact test. Multivariable logistic regression analysis was performed to confirm the relationships among in-hospital mortality, transfusion, and hemorrhagic conditions in patients who underwent endoscopy and IR. RESULTS: Among the 726 patients with non-traumatic conditions treated in a hybrid ER system, 50 (6.9%) experienced cardiac arrest at or before admission to the hybrid ER, 301 (41.5%) were in shock, 126 (17.4%) received blood transfusions, 42 (5.8%) died within 24 h of admission to the hybrid ER, and 141 (19.4%) died in the hospital. Emergency surgery was performed in 39 patients (7 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the bleeding group (71.4% vs. 18.8%, P = 0.01); there were no significant differences in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Endoscopy was performed in 122 patients (80 in the bleeding group and 42 in the non-bleeding group). The bleeding group had a significantly higher rate of shock or cardiac arrest (87.5% vs. 66.7%, P = 0.008) and rate of blood transfusion (62.5% vs. 4.8%, P < 0.0001); there was no significant difference in death within 24 h and in-hospital death between groups. IR was performed in 100 patients (68 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the hemorrhage group (67.7% vs. 12.5%, P < 0.0001); there was no difference in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Multivariable analysis in patients who underwent endoscopy showed a trend toward more in-hospital deaths in non-hemorrhagic conditions than in hemorrhagic conditions (odds ratio = 3.8, 95% confidence interval: 0.88-17, P = 0.073); however, no significant relationship with in-hospital death was observed for any of the adjusted variables. CONCLUSION: Among endogenous diseases treated in the hybrid ER, there is a possible association between in-hospital mortality and hemorrhagic conditions. Future studies are needed to focus on diseases to demonstrate the effectiveness of the hybrid ER.

Hybrid emergency rooms reduce the requirement of blood transfusion in patients with severe trauma.

BACKGROUND: A hybrid emergency room (ER) is defined as an emergency unit with four functions-performing resuscitation, computed tomography (CT), surgery, and angiography. However, the safety and efficacy of performing CT in a hybrid ER are unclear in primary surveys. Therefore, this study aimed to evaluate the safety and clinical effects of hybrid ERs. METHODS: This retrospective observational study used data from the Shimane University Hospital Trauma Database from January 2016 to February 2019. Hospitalized patients with severe trauma and an injury severity score of ≥ 16 were divided into the non-hybrid ER group (n = 134) and the hybrid ER group (n = 145). The time from arrival to CT and interventions and the number of in-hospital survivors, preventable trauma deaths (PTD), and unexpected survivors (US) were assessed in both groups. Further, the amount of blood transfused was compared between the groups using propensity score matching. RESULTS: The time from arrival to CT and interventions was significantly reduced in the hybrid ER group compared to that in the non-hybrid ER group (25 vs. 6 min; p < 0.0001 and 101 vs. 41 min; p = 0.0007, respectively). There was no significant difference in the rate of in-hospital survivors (96.9% vs. 96.3%; p = 0.770), PTD (0% vs. 0%), and US (9.0 vs. 6.2%; p = 0.497) between the groups. The amount of blood transfused was significantly lower in the hybrid ER group than in the non-hybrid ER group (whole blood 14 vs. 8, p = 0.004; red blood cell 6 vs. 2, p = 0.012; fresh frozen plasma 9 vs. 6, p = 0.021). This difference was maintained after propensity score matching (whole blood 28 [10-54] vs. 6 [4-16.5], p = 0.015; RBC 8 [2.75-26.5] vs. 2 [0-8.5], p = 0.020, 18 [5.5-27] vs. 6 [3.5-7.5], p = 0.057). CONCLUSIONS: The study results suggest that trauma treatment in a hybrid ER is as safe as conventional treatment performed in a non-hybrid ER. Further, hybrid ERs, which can reduce the time for trauma surveys and treatment, do not require patient transfer and can reduce the amount of blood transfused during resuscitation.

Damage control surgery for spontaneous perforation of pyometra with septic shock: a case report.

BACKGROUND: Although spontaneous perforation of pyometra is very rare, it sometimes causes severe peritonitis, leading to lethal conditions. Damage control surgery reportedly improves the survival of critically ill patients; however, there has been no report describing damage control surgery for ruptured pyometra. CASE PRESENTATION: An 83-year-old postmenopausal woman with generalized peritonitis and septic shock was admitted and underwent emergency laparotomy. Abbreviated surgery was carried out because of progressing septic shock, and planned reoperation was carried out 2 days after the initial surgery. Histopathological examination revealed the perforation of pyometra with no evidence of malignancy. The patient was discharged on the 32nd postoperative day in stable condition. CONCLUSION: We report a case of spontaneous perforation of pyometra with severe septic shock successfully treated by damage control surgery. Damage control surgery is a useful treatment option for hemodynamically unstable patients with diseases in the field of obstetrics and gynecology.

Delayed massive hemothorax due to diaphragm injury with rib fracture: A case report.

INTRODUCTION: Delayed massive hemothorax after blunt trauma is rare, although associated with significant morbidity and mortality. In most cases, the intercostal artery is the main bleeding source. We report a rare case of delayed massive hemothorax due to a diaphragm injury with a lower rib fractures. PRESENTATION OF CASE: A 58-year-old man, transported to our hospital four hours after a 2-meter fall from a ladder, had left-sided fractures to ribs 11 and 12, thoracic and lumbar vertebral fractures, and traumatic subarachnoid hemorrhage. On admission, no left hemothorax was documented; however, 17 h post-injury he developed hypovolemic shock. Plain chest radiographs showed a massive left hemothorax with a mediastinal shift. Chest contrast-enhanced computed tomography revealed extravasation of the contrast agent in the chest cavity. No intercostal arterial bleeding was evident on emergency angiography. A left anterolateral thoracotomy through the 6th intercostal space revealed rib fractures and active bleeding from the dorsal side of the left hemidiaphragm. Suture hemostasis was performed for the diaphragm injury and the disrupted ribs were repaired. DISCUSSION: Embolization of diaphragm-feeding arteries is not a simple or fast procedure. Clinically, predicting delayed hemothorax is challenging, and careful observation of trauma patients with lower rib fractures is needed. Thoracotomy should be considered for immediate hemostasis in patients with sudden shock, with complete hematoma drainage and repair of the disrupted rib. CONCLUSION: Diaphragmatic injury with lower rib fractures can result in delayed hemothorax, requiring thoracotomy.

Damage control surgery for unstable thoracic wall injury.

Damage control surgery (DCS) consists of three steps: an abbreviated initial operation, resuscitation in the ICU, and a planned reoperation. Although DCS for lung and heart injury have been established, there is no concept of DCS for the chest wall. We experienced a successful case, in which a DCS of chest wall lifting procedure and internal pneumatic stabilization were performed on the flail chest accompanied by a remarkable destruction of chest wall. As a result, the patient's abnormal breathing improved. Surgical fixations using KANI plate were performed at a later date. We suggest that the chest wall lifting procedure may be suitable as a DCS for thoracic cage destruction from severe chest wall injury.

Mediastinal, retroperitoneal, and subcutaneous emphysema due to sigmoid colon penetration: A case report and literature review.

INTRODUCTION: Mediastinal and subcutaneous emphysema usually result from spontaneous rupture of the alveolar wall. We present an extremely rare case of massive mediastinal, retroperitoneal, and subcutaneous emphysema due to the penetration of the colon into the mesentery. PRESENTATION OF CASE: A 57-year-old man presented to our institution with a history of chest pain. The patient's medical history included malignant rheumatoid arthritis during the use of steroids and an immunosuppressive agent. The patient had no signs of peritoneal irritation or abdominal pain. A chest radiography revealed subcutaneous emphysema of the neck, mediastinal emphysema, as well as subdiaphragmatic free air. Computed tomography showed extensive retroperitoneal, mediastinal, and mesenteric emphysema of the sigmoid colon without pneumothorax. Diagnostic laparoscopy was performed and revealed perforation into the sigmoid mesentery. Segmental resection of the sigmoid colon and end-colostomy were performed. The diverticulum was communicating with the outside of the mesentery via the mesentery. The mediastinal emphysema disappeared a few days after the surgery. DISCUSSION: Colonic perforation generally results in free perforation. Colonic gas may spread via various anatomical pathways when perforation of the colon occurs in the retroperitoneum; thus, diverse atypical clinical symptoms may be present. Signs of peritoneal irritation can be hidden in cases of retroperitoneal colonic perforation. The atypical manifestation of a retroperitoneal colonic perforation can cause difficulties in making a diagnosis. CONCLUSIONS: Massive mediastinal and retroperitoneum emphysema are rare signs of colonic perforation. Emergency laparotomy should be considered in colonic penetration of the diverticulitis where the emphysema expands to the mediastinum extensively.

First establishment of a new table-rotated-type hybrid emergency room system.

The hybrid emergency room (hybrid ER) system was first established in 2011 in Japan. It is defined as an integrated system including an ER, emergency computed tomography (CT) and interventional radiology (IVR) rooms, and operating rooms. Severe trauma patients can undergo emergency CT examinations and therapies (surgeries) without being transferred. The hybrid ER system is attracting attention because trauma resuscitation using this system has been reported to potentially improve the mortality rate in severe trauma patients. In August 2017, we established a new table-rotated-type hybrid ER to facilitate surgical functions. Herein, we introduce a new table-rotated-type hybrid ER consisting of an IVR-CT-operating room system and discuss its efficiency and feasibility for trauma resuscitation, including surgery and IVR. This system includes four new concepts: (1) to secure a wide working space during trauma resuscitation by reconsidering the arrangement of the C-arm, (2) ensure an air-conditioned operating room in the hybrid ER, (3) adopt an operating table but not interventional radiology table, and (4) prepare a trauma bay with three additional beds for multiple victims. This hybrid ER system also adopted the rotated-type table to secure a wide working space during the resuscitation phase. The C-arm was located away from the patients and placed on the wall opposite to the CT gantry, in contrast to that in previous systems. If patients needed an emergency IVR, the table was just rotated, and the IVR could be conducted immediately. This improvement can secure a wide working space in the hybrid ER. Moreover, the patient table was also a surgical operating table, and the hybrid ER system had an air-conditioned operating room (class 10,000). In the anticipation of many trauma patients being transported to the ER, a new trauma bay with three additional beds next to the hybrid ER was established, which also had an air-conditioned operating room. This new rotated-type hybrid ER system facilitates efficient surgical functions during trauma resuscitation and can secure a wide working space for the medical team to immediately perform resuscitative procedures and IVRs without delay.

Safe and simple gastric conduit pull-through procedure through the posterior mediastinal route using echo probe cover in thoracoscopic subtotal esophagectomy.

A gastric conduit is commonly used to reconstruct the alimentary tract after esophagectomy. When the posterior mediastinum is applied to a reconstruction route, the gastric conduit created has been protected by an echo probe cover and, then blindly elevated to the neck. However, using this elevation method, the gastric conduit has the potential to catch on the vessels and nerves, posing a risk of major bleeding. We report a safe method of gastric conduit pull-through procedure to avoid unexpected technical complications. Two approximately 60-cm-long polyester tapes are prepared and ligated at both ends forming a loop. A 50-cm-long echo probe cover of 10 cm in diameter is prepared, and the closed end of the echo probe cover is cut to make an open-ended echo probe cover. A line parallel to the long axis of the echo probe cover is drawn across the echo probe cover with a sterile surgical marking pen. The looped polyester tape is inserted into the echo probe cover. The looped polyester tape and echo probe cover are ligated with 2-0 silk, approximately 5 cm in front of the knots on both sides. After dissection is carried out according to practice, the previously crafted polyester tape is inserted into the chest cavity. The echo probe cover is placed to connect the distal and proximal ends of the esophagus, and its torsion is corrected using the line marked with the pen and a crease, both of which are parallel to the long axis of the echo probe cover. One end of polyester tape is fixed to the distal esophageal stump by using the clips, with the opposite end fixed to the proximal esophageal stump. Either one of the 2 lengths of polyester tape is connected to the gastric conduit. By pulling up this length of polyester tape from the neck, the gastric conduit can pass through the echo probe cover and be elevated to the neck.

Reconstruction of the gastrointestinal tract by hemi-double stapling method for the esophagus and jejunum using EEA OrVil in laparoscopic total gastrectomy and proximal gastrectomy.

We report the method of anastomosis based on a hemi-double stapling technique (hereinafter, HDST) using a trans-oral anvil delivery system (EEA OrVil) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection. As a basic technique, end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum. After the gastric lymph node dissection, the esophagus was cut off obliquely to the long axis using an automated stapler. EEA OrVil was orally, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, HDST-based anastomosis was completed. The method may safe laparoscopic anastomosis between the esophagus and reconstructed intestine.

Overexpression of macrophage migration inhibitory factor induces angiogenesis and deteriorates prognosis after radical resection for hepatocellular carcinoma.

BACKGROUND: Macrophage migration inhibitory factor (MIF) is a pivotal cytokine that regulates inflammatory and immune responses. Recently, many investigators reported that MIF is expressed highly in several tumors, including hepatocellular carcinoma (HCC). However, the role of MIF in tumor angiogenesis and patient prognosis has not been examined in patients with HCC. METHODS: The authors evaluated MIF expression in 56 samples of HCC by Western blot analysis, and the results were correlated with clinicopathologic factors and patient prognosis. MIF localization was determined by immunohistochemical methods, and the results were compared with tumor microvessel density (MVD), as assessed by anti-CD34 antibody. Furthermore, to validate the role of MIF in angiogenesis, both MIF expression during culture of HCC cells (using the Hep3B, HepG2, and Huh7 cell lines) under hypoxic condition and the angiogenic potential of recombinant MIF in an in vitro angiogenic model were examined. RESULTS: Tumors with high MIF expression had high alpha-fetoprotein levels (P = 0.049) and frequent intrahepatic recurrence (P = 0.043). Immunohistochemical MIF scores had a significant correlation with MVD (P = 0.007). Patients who had tumors with high MIF expression levels had a significantly worse (P = 0.025) disease-free survival, and this finding remained significant as an independent prognostic factor in the multivariate analysis. Hep3B cells had high expression of MIF at 6 hours and 12 hours after hypoxic stress and exogenous MIF stimulated endothelial tube formation in in vitro angiogenesis. CONCLUSIONS: The current findings suggest that MIF expression may play a pivotal role in the dismal prognosis of patients with HCC that may be attributable to the modulation of angiogenesis.