Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis.

BACKGROUND: Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave's syndrome (BS). METHODS: We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. RESULTS: Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8-5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2-7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2-6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1-3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1-3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. CONCLUSIONS: This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome.

Recidivism rates following firearm injury as determined by a collaborative hospital and law enforcement database.

BACKGROUND: Recidivism is a key outcome measure for injury prevention programs. Firearm injury recidivism rates are difficult to determine because of poor longitudinal follow-up and incomplete, disparate databases. Reported recidivism rates from trauma registries are 2% to 3%. We created a collaborative database merging law enforcement, emergency department, and inpatient trauma registry data to more accurately determine rates of recidivism in patients presenting to our trauma center following firearm injury. METHODS: A collaborative database for Jefferson County, Kentucky, was constructed to include violent firearm injuries encountered by the trauma center or law enforcement from 2008 to 2019. Iterative deterministic data linkage was used to create the database and eliminate redundancies. From patients with at least one hospital encounter, raw recidivism rates were calculated by dividing the number of patients injured at least twice by the total number of patients. Cox proportional hazard models were used to evaluate risk factors for recidivism. The cumulative incidence of recidivism over time was estimated using a Kaplan-Meier survival model. RESULTS: There were 2, 363 assault-type firearm injuries with at least 1 hospital encounter, approximately 9% of which did not survive their initial encounter. The collaborative database demonstrated raw recidivism rates for assault-type firearm injuries of 9.5% compared with 2.5% from the trauma registry alone. Risk factors were young age, male sex, and African American race. The predicted incidence of recidivism was 3.6%, 5.6%, 11.4%, and 15.8% at 1, 2, 5, and 10 years, respectively. CONCLUSION: Both hospital and law enforcement data are critical for determining reinjury rates in patients treated at trauma centers. Recidivism rates following violent firearm injury are four times higher using a collaborative database compared with the inpatient trauma registry alone. Predicted incidence of recidivism at 10 years was at least 16% for all patients, with high-risk subgroups experiencing rates as high as 26%. LEVEL OF EVIDENCE: Epidemiological, level III.

Operative Management of Thoracic Gunshot Wounds: More Aggressive Treatment Has Been Required over Time.

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.

Randomized Controlled Trial Evaluating the Efficacy of Peritoneal Resuscitation in the Management of Trauma Patients Undergoing Damage Control Surgery.

BACKGROUND: Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery. These data represent the outcomes of a single institution randomized controlled trial into the efficacy of PR as a management option in these patients. STUDY DESIGN: From 2011 to 2015, one hundred and three patients were enrolled in a prospective randomized controlled trial evaluating the use of PR in the treatment of patients undergoing damage control surgery compared with conventional resuscitation (CR) alone. Patient demographics, clinical variables, and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. RESULTS: After initial screening, 52 patients were randomized to the PR group and 51 to the CR group. Age, sex, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared with the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days; p ≤ 0.002). Volume of resuscitation and blood products transfused in the initial 24 hours was not different between the groups. Primary fascial closure rate was higher in the PR group (83% vs 66%; p ≤ 0.05). Intra-abdominal complications were lower in the PR compared with the CR group (8% vs 18%), with abscess formation rate (3% vs 14%; p < 0.05) being significant. Patients in the PR group had a lower 30-day mortality rate, despite similar Injury Severity Scores (13% vs 28%; p = 0.06). CONCLUSIONS: Peritoneal resuscitation enhances management of damage control surgery patients by reducing time to definitive abdominal closure, intra-abdominal infections, and mortality rates.

Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged.

BACKGROUND: Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. STUDY DESIGN: All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. RESULTS: Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n = 513), compared with intubated level 1 patients (n = 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. CONCLUSIONS: When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care.

Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions.

BACKGROUND: Tube thoracostomy is a common procedure used in the management of thoracic trauma. Traditional teaching suggests that chest tubes should be directed in specific locations to improve function. Common examples include anterior and superior placement for pneumothorax, inferior and posterior placement for hemothorax, and avoidance of the pulmonary fissure. The purpose of this study was to examine the effect of specific chest tube position on subsequent chest tube function. METHODS: A retrospective review of all patients undergoing tube thoracostomy for trauma from January 1, 2010, to September 30, 2012, was performed. Only patients undergoing computed tomography scans following chest tube insertion were included so that positioning could be accurately determined. Rib space insertion level and positioning of the tube relative to the lung parenchyma were recorded. The duration of chest tube drainage and the need for secondary interventions were determined and compared for tubes in different rib spaces and locations. For purposes of comparison, tubes placed above the sixth rib space were considered "high," and those at or below it were considered "low." RESULTS: A total of 291 patients met criteria for inclusion. Forty-eight patients (16.5%) required secondary intervention. Neither high chest tube placement nor chest tube location relative to lung parenchyma was associated with an increased need for secondary interventions. On multivariate analysis, only chest Abbreviated Injury Scale (AIS) scores, mechanism, and volume of hemothorax were found to be significant risk factors for the need for secondary interventions. CONCLUSION: Chest tube location does not influence the need for secondary interventions as long as the tube resides in the pleural space. The severity of chest injury is the most important factor influencing outcome in patients undergoing tube thoracostomy for trauma. Tube thoracostomy technique should focus on safe insertion within the pleural space and not on achieving a specific tube location. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review.

PURPOSE: Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. METHODS: A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. RESULTS: There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. CONCLUSION: Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Use of computed tomography findings and contrast extravasation in predicting the need for embolization with pelvic fractures.

Transarterial embolization (AE) can be a lifesaving procedure for severe hemorrhage associated with pelvic fractures. The purpose of this study was to identify demographic and radiographic findings that predict the need for embolization. We performed a retrospective review of all patients with at least one pelvic fracture and admission to the intensive care unit over a 35-month period. Computed tomography (CT) and pelvic radiographs were reviewed. Patient demographics, outcomes, time to angiography, and whether or not embolization was performed were determined. Statistical analysis was used to determine factors associated with the need for AE. Of the 327 total patients with pelvic fractures, 317 underwent CT scanning. Forty-four patients (13.5%) underwent angiography and 25 (7.6%) required therapeutic embolization. There were 39 total deaths (11.6%) with five deaths related to pelvic hemorrhage (1.5%). Multivariate analysis revealed that age older than 55 years (odds ratio [OR], 1.06; P < 0.001), systolic blood pressure less than 90 mmHg in the emergency department (OR, 11.64; P = 0.0008), and CT extravasation (OR, 147.152; P < 0.0001) were significantly associated with the need for embolization. Contrast extravasation was not present in 25 per cent of patients requiring therapeutic AE. The presence of contrast extravasation is highly associated with the need for pelvic embolization in patients with pelvic fractures, but its absence does not exclude the need for pelvic angiography.

Open repair of blunt thoracic aortic injury remains relevant in the endovascular era.

BACKGROUND: Thoracic endovascular aneurysm repair (TEVAR) has been a major advance in the treatment of blunt thoracic aortic injury (BTAI), although many patients still undergo open repair. This study was undertaken to evaluate outcomes with open repair and TEVAR for BTAI. STUDY DESIGN: A retrospective review of all patients with BTAI at a single Level I trauma center from 2001 through 2009 was performed. Patients were grouped according to treatment modality, ie, open repair, TEVAR, or medical management. Direct comparison using standard statistical methods was made between patients undergoing open repair and TEVAR since late 2006 when TEVAR began at our institution using standard statistical methods. Outcomes variables included mortality, paraplegia, length of stay, ICU stay, and ventilator requirements. RESULTS: There were 69 patients in the study, with 36 (52.2%) undergoing open repair, 10 receiving TEVAR (14.5%), 10 patients managed medically (14.5%), and 13 (18.8%) who died during triage. Overall mortality in the pre-TEVAR era was 29.6%. Since the introduction of TEVAR, there have been 8 open repairs. Patients undergoing open repair were significantly younger (32 vs 58 years; p = 0.002) and had smaller aortic diameter (18 mm vs 24.5 mm; p < 0.001) than those undergoing TEVAR. Overall mortality since the introduction of TEVAR has dropped to 12.0% (p = 0.097). CONCLUSIONS: TEVAR and open repair should be viewed as complementary rather than competing modalities for the treatment of BTAI. Having both available allows selection of the most appropriate management technique for each patient, with subsequent improvement in outcomes.

Statewide experience with Clostridium difficile colitis in academic and non-academic medical centers.

BACKGROUND: Clostridium difficile colitis is a nosocomial infection that can present as minor, readily treated symptoms or as fulminant colitis leading to death. Risk factors for C. difficile colitis have been defined, and certain populations of hospitalized patients appear to be particularly susceptible. However, most information on C. difficile colitis is from large tertiary-care medical centers. Whether the community hospital experience is similar to that of large referral centers is unknown. METHODS: We abstracted all cases of C. difficile colitis (ICD-9-CM 008.45) for 2003-2005 from a state database and divided the hospitals into academic and nonacademic centers. Cases were stratified according to whether the colitis was listed as the primary presenting diagnosis or a secondary diagnosis. Demographic information, associated diagnoses, length of stay, and deaths were analyzed. RESULTS: The incidence of C. difficile colitis increased from 2003 to 2005, and the majority of cases occurred at nonacademic centers. Patients in nonacademic centers more frequently had C. difficile colitis as the primary diagnosis, had a shorter length of stay, were older, and were more frequently women. The mortality rate was higher for secondary (8.5%) than for primary (2.6%; p < 0.05) C. difficile colitis, but there was no difference between academic and nonacademic centers. CONCLUSIONS: The incidence of C. difficile colitis is increasing in this statewide database. Compared with academic medical centers, nonacademic centers deal with a higher rate of primary C. difficile colitis that is associated with a lower mortality rate and shorter stay than secondary colitis.