Liver Transplant After Severe Liver Trauma: The First Report in a Korean Adult.

Following a motor-vehicle accident, a 57-year-old man was diagnosed with a grade 4 liver injury (American Association for the Surgery of Trauma organ injury scale) with multiple contrast extravasations. He initially underwent nonoperative management, which included transcatheter arterial embolization. However, he experienced a hemorrhage after the first embo-lization procedure, and so the procedure was repeated. Thereafter, he was diagnosed with liver failure based on findings from computed tomography and liver function tests. On day 28 of hospitalization, the patient underwent deceased donor liver transplant. He experienced several complications, including acute renal failure, pneumonia, and bile leak. These were managed successfully, and the patient was discharged 4 months after the transplant. Although liver transplant procedure for hepatic trauma is technically challenging and risky, it should be considered a viable treatment option in some patients (such as patients with severe liver injury). This is the first reported case, to our knowledge, of a liver transplant performed successfully in a patient with severe hepatic trauma in Korea.

National Follow-up Survey of Preventable Trauma Death Rate in Korea.

BACKGROUND: The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea. METHODS: From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident. CONCLUSION: The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.

Implementation of a massive transfusion protocol: A single trauma center experience from South Korea.

BACKGROUND: Massive transfusion (MT) is traditionally defined as transfusion of more than 10 units of red blood cells (RBCs) within the first 24 h after admission. The aim of this study is to analyze the trend of MT in regional trauma center including ratio of fresh frozen plasma (FFP) and packed RBC. METHODS: Retrospective data were driven from 2014 to 2016. A total of 185 patients who received more than 10 packed RBC units within the first 24 h after admission were included in the study. We analyzed transfusion requirements for each time interval 4 h and 24 h after admission. Moreover, we compared transfusion characteristics between survival and non-survival group, between high FFP: RBC group (≥1: 2) and low FFP: RBC group (<1: 2), and between the first half and latter half period. RESULTS: There was a trend for improvement in the FFP: RBC ratio after applying the MT protocol. The FFP: RBC ratio increased from 1: 1.7 to 1: 1.4 within 24 h after arrival. The time to first transfusion was shortened (137-106 min). Mortality was lower in high FFP: RBC group than that of low FFP: RBC group. CONCLUSION: In our study, the MT protocol improved the FFP: RBC ratio. A higher FFP: RBC ratio also led to an improvement in the mortality rate in MT patients.

Use of venovenous extracorporeal membrane oxygenation in trauma patients with severe adult respiratory distress syndrome: A retrospective study.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) has increased, although its survival benefit in trauma patients with severe adult respiratory distress syndrome (ARDS) remains controversial. We investigated the effect of veno-venous (VV)-ECMO on the clinical outcomes of trauma patients with severe ARDS. METHODS: This was a retrospective study at a single center comprising trauma patients admitted between January 2013 and December 2017, diagnosed with severe ARDS using the Berlin definition (PaO2/FiO2 ratio ⩽100), in the 7 days following trauma. Patients were managed with VV-ECMO or conventional mechanical ventilation (CMV). The primary outcome was in-hospital mortality (mortality at 60 days); secondary outcomes comprised 28-day mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, ICU-free days, duration of mechanical ventilation (MV), and MV-free days. Propensity score matching was performed to adjust for the baseline differences. RESULTS: Sixteen patients (22.5%) were managed with VV-ECMO and 55 were managed with CMV. After matching, the in-hospital mortality rate (43.8% vs 53.1%; p = 0.760), 28-day mortality rate (37.5% vs 31.3%; p = 0.750), median hospital LOS (39.5 vs 36.5 days; p = 0.533), ICU-free days (0 vs 0 days; p = 0.241), and MV-free days (0 vs 0 days; p = 0.272) did not significantly differ between the VV-ECMO and CMV groups. CONCLUSION: In-hospital mortality (mortality at 60 days) did not differ significantly between the VV-ECMO and CMV groups. Although the safety of ECMO in trauma patients requires further investigation, VV-ECMO may be considered as a rescue therapy.

Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures.

Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092-3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB.

Current status of initial antibiotic therapy and analysis of infections in patients with solitary abdominal trauma: a multicenter trial in Korea.

PURPOSE: Proper use of antibiotics during emergency abdominal surgery is essential in reducing the incidence of surgical site infection. However, no studies have investigated the type of antibiotics and duration of therapy in individuals with abdominal trauma in Korea. We aimed to investigate the status of initial antibiotic therapy in patients with solitary abdominal trauma. METHODS: From January 2015 to December 2015, we retrospectively analyzed the medical records of patients with solitary abdominal trauma from 17 institutions including regional trauma centers in South Korea. Both blunt and penetrating abdominal injuries were included. Time from arrival to initial antibiotic therapy, rate of antibiotic use upon injury mechanism, injured organ, type, and duration of antibiotic use, and postoperative infection were investigated. RESULTS: Data of the 311 patients were collected. The use of antibiotic was initiated in 96.4% of patients with penetrating injury and 79.7% with blunt injury. Initial antibiotics therapy was provided to 78.2% of patients with solid organ injury and 97.5% with hollow viscus injury. The mean day of using antibiotics was 6 days in solid organ injuries, 6.2 days in hollow viscus. Infection within 2 weeks of admission occurred in 36 cases. Infection was related to injury severity (Abbreviated Injury Scale of >3), hollow viscus injury, operation, open abdomen, colon perforation, and RBC transfusion. There was no infection in cases with laparoscopic operation. Duration of antibiotics did not affect the infection rate. CONCLUSION: Antibiotics are used extensively (84.2%) and for long duration (6.2 days) in patients with abdominal injury in Korea.

Antibiotic use in patients with abdominal injuries: guideline by the Korean Society of Acute Care Surgery.

PURPOSE: A task force appointed by the Korean Society of Acute Care Surgery reviewed previously published guidelines on antibiotic use in patients with abdominal injuries and adapted guidelines for Korea. METHODS: Four guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. Five topics were considered: indication for antibiotics, time until first antibiotic use, antibiotic therapy duration, appropriate antibiotics, and antibiotic use in abdominal trauma patients with hemorrhagic shock. RESULTS: Patients requiring surgery need preoperative prophylactic antibiotics. Patients who do not require surgery do not need antibiotics. Antibiotics should be administered as soon as possible after injury. In the absence of hollow viscus injury, no additional antibiotic doses are needed. If hollow viscus injury is repaired within 12 hours, antibiotics should be continued for ≤ 24 hours. If hollow viscus injury is repaired after 12 hours, antibiotics should be limited to 7 days. Antibiotics can be administered for ≥7 days if hollow viscus injury is incompletely repaired or clinical signs persist. Broad-spectrum aerobic and anaerobic coverage antibiotics are preferred as the initial antibiotics. Second-generation cephalosporins are the recommended initial antibiotics. Third-generation cephalosporins are alternative choices. For hemorrhagic shock, the antibiotic dose may be increased twofold or threefold and repeated after transfusion of every 10 units of blood until there is no further blood loss. CONCLUSION: Although this guideline was drafted through adaptation of other guidelines, it may be meaningful in that it provides a consensus on the use of antibiotics in abdominal trauma patients in Korea.

Effects of the establishment of a trauma center and a new protocol on patients with hemodynamically unstable pelvic fractures at a single institution in Korea.

PURPOSE: The aim of this study was to determine whether the outcomes of patients with hemodynamically unstable pelvic bone fractures changed after the introduction of a protocol including extraperitoneal pelvic packing (EPP) and the establishment of a trauma center. METHODS: We analyzed data of adult patients (≥ 18 years old) with hemodynamically unstable pelvic bone fractures who visited a single trauma center from February 2009 to October 2016. In July 2014, a new protocol for pelvic fractures was implemented, and a trauma center was established. Therefore, patient outcomes were compared by period (period I: pre-protocol vs. period II: post-protocol). RESULTS: Seventy-nine patients with hemodynamically unstable pelvic bone fractures were recruited. The time to angiographic embolization after arrival at the emergency room decreased significantly in period II when compared to period I (182.9 vs. 268.9 min, respectively, p < 0.001). The time required to intervention, including EPP, also decreased, from 268.9 ± 132.4 min in period I to 141.9 ± 79.9 min in period II (p < 0.001). The overall mortality rate decreased from 47.2% in period I to 23.3% in period II (p = 0.033), and mortality related to hemorrhagic shock in particular, was significantly lowered, from 27.8% in period I to 4.7% in period II (p = 0.009). CONCLUSIONS: The establishment of a trauma center and the implementation of a new protocol that included EPP were effective in the treatment of patients with hemodynamically unstable pelvic fractures.

Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). METHODS: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. RESULTS: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. CONCLUSIONS: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

Multivariate Analysis of Risk Factors Associated With the Nonreversal Ileostomy Following Sphincter-Preserving Surgery for Rectal Cancer.

PURPOSE: A loop ileostomy is used to protect an anastomosis after anal sphincter-preserving surgery, especially in patients with low rectal cancer, but little information is available concerning risk factors associated with a nonreversal ileostomy. The purpose of this study was to identify risk factors of ileostomy nonreversibility after a sphincter-saving resection for rectal cancer. METHODS: Six hundred seventy-nine (679) patients with rectal cancer who underwent sphincter-preserving surgery between January 2004 and December 2011 were evaluated retrospectively. Of the 679, 135 (19.9%) underwent a defunctioning loop ileostomy of temporary intent, and these patients were divided into two groups, that is, a reversal group (RG, 112 patients) and a nonreversal group (NRG, 23 patients) according to the reversibility of the ileostomy. RESULTS: In 23 of the 135 rectal cancer patients (17.0%) that underwent a diverting ileostomy, stoma reversal was not possible for the following reasons; stage IV rectal cancer (11, 47.8%), poor tone of the anal sphincter (4, 17.4%), local recurrence (2, 8.7%), anastomotic leakage (1, 4.3%), radiation proctitis (1, 4.3%), and patient refusal (4, 17.4%). The independent risk factors of the nonreversal group were anastomotic leakage or fistula, stage IV cancer, local recurrence, and comorbidity. CONCLUSION: Postoperative complications such as anastomotic leakage or fistula, advanced primary disease (stage IV), local recurrence and comorbidity were identified as risk factors of a nonreversal ileostomy. These factors should be considered when drafting prudential guidelines for ileostomy closure.

Comparison of long-term oncologic outcomes of stage III colorectal cancer following laparoscopic versus open surgery.

PURPOSE: The oncologic outcomes after performing laparoscopic surgery (LS) compared to open surgery (OS) are still under debate and a concern when treating patients with colon cancer. The aim of this study was to compare the long-term oncologic outcomes of LS and OS as treatment for stage III colorectal cancer patients. METHODS: From January 2001 to December 2007, 230 patients with stage III colorectal cancer who had undergone LS or OS in this single center were assessed. Data were analyzed according to intention-to-treat. The primary endpoints were disease-free survival and overall survival. RESULTS: A total of 230 patients were entered into the study (114 patients had colon cancer-33 underwent LS and 81 underwent OS; 116 patients had rectal cancer-44 underwent LS and 72 underwent OS). The median follow-up periods for the colon and rectal cancer groups were 54 and 53 months, respectively. The overall conversion rate was 12.1% (n = 4) for colon cancer, and 4.5% (n = 2) for rectal cancer. Disease-free 5-year survival of colon cancer was 84.3% and 90% in LS group (LG) and OS group (OG), respectively, and that of rectal cancer was 83% and 74.6%, respectively (P > 0.05). Overall 5-year survival for colon cancer was 72.2% and 71.3% for LG and OG, respectively, and that for rectal cancer was 67.6% and 59.2%, respectively (P > 0.05). CONCLUSION: The long-term analyses for oncologic aspects of our study may confirm the safety of LS compared to OS in stage III colorectal cancer patients.

Fabrication of electroless nickel plated aluminum freeform mirror for an infrared off-axis telescope.

Freeform mirrors can be readily fabricated by a single point diamond turning (SPDT) machine. However, this machining process often leaves mid-frequency errors (MFEs) that generate undesirable diffraction effects and stray light. In this work, we propose a novel thin electroless nickel plating procedure to remove MFE on freeform surfaces. The proposed procedure has a distinct advantage over a typical thick plating method in that the machining process can be endlessly repeated until the designed mirror surface is obtained. This is of great importance because the sophisticated surface of a freeform mirror cannot be optimized by a typical SPDT machining process, which can be repeated only several times before the limited thickness of the nickel plating is consumed. We will also describe the baking process of a plated mirror to improve the hardness of the mirror surface, which is crucial for minimizing the degradation of that mirror surface that occurs during the polishing process. During the whole proposed process, the changes in surface figures and textures are monitored and cross checked by two different types of measurements, as well as by an interference pattern test. The experimental results indicate that the proposed thin electroless nickel plating procedure is very simple but powerful for removing MFEs on freeform mirror surfaces.

Comparison of the surgical outcomes of laparoscopic versus open surgery for colon perforation during colonoscopy.

PURPOSE: Colonoscopy is a safe and commonly used method for the screening of colon cancer, but sometimes major complications, such as, colonic perforation or hemorrhage occur during the procedure. The aim of this study was to compare the surgical outcomes of laparoscopic and open surgery for colon perforation after colonoscopy. METHODS: A retrospective review of patient records was performed on 25 patients with iatrogenic colon perforation during colonoscopy during the 7-year period from January 2005 to June 2012. Demographic data, operative procedures, operation times, postoperative complications, hospital course, and morbidities in the laparoscopic surgery group (LG) and open surgery group (OG) were compared. RESULTS: Seventeen of the 25 patients underwent laparoscopic surgery (68%) and 8 patients open surgery (32%). The most common surgical methods were primary repair in the LG, and Hartmann's operation in the OG. Average time to first flatus was 2.9 days in the LG and 4.5 days in the OG, and average times to first meals were 4.5 days and 5 days, respectively. Mean hospital stays were 10.8 days in the LG and 17 days in the OG. After surgery, complications occurred in two patients in the LG, but no complication occurred in the OG. CONCLUSION: Laparoscopic repair for iatrogenic colonic perforation during colonoscopy seems to be useful and safe surgical method in early period after perforation. However, open surgery is also needed for the delayed cases after perforation.

Comparison of short-term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer.

PURPOSE: The aim of this study was to compare short-term morbidities and mortalities of elective surgery after stent insertion and emergency surgery in obstructive colorectal cancer. METHODS: We retrospectively reviewed 77 patients with obstructive colorectal cancer that underwent elective surgery after stenting (stent group: SG, n = 49) or emergent surgery (emergency group: EG, n = 28) from January 2000 to July 2010. RESULTS: The American Society of Anesthesiologists (ASA) score of SG was lower than that of EG (p = 0.015). The percentages of open and laparoscopic surgery in SG were 73.5% (36/49) and 26.5% (13/49), respectively, whereas surgery in EG was performed using an open technique (p = 0.003). The rate of primary anastomosis, without constructing a stoma, was 87.8% in SG and 42.9% in EG (p < 0.001). There was no difference in a postoperative complication. Anastomotic leakage according to time between stent placement and surgery in SG were 3 cases for 1-9 days and 0 for more than 10 days (p = 0.037). Three-year overall survival rates were 68.8% and 51.3% (p = 0.430), respectively. CONCLUSION: Preoperative stent insertion in obstructive colorectal cancer seems to be safe and feasible, and may decrease second stage procedure. Waiting 10 days after stent placement may be a more optimal time for surgical intervention. Further prospective randomized studies are needed to determine the proper time bridge to surgery following stent insertion in obstructive colorectal cancer.