An international assessment of surgeon practices in abdominal wound closure and surgical site infection prevention by the European Society for Coloproctology.

AIM: The burden of abdominal wound failure can be profound. Recent clinical guidelines have highlighted the heterogeneity of laparotomy closure techniques. The aim of this study was to investigate current midline closure techniques and practices for prevention of surgical site infection (SSI). METHOD: An online survey was distributed in 2021 among the membership of the European Society of Coloproctology and its partner societies. Surgeons were asked to provide information on how they would close the abdominal wall in three specific clinical scenarios and on SSI prevention practices. RESULTS: A total of 561 consultants and trainee surgeons participated in the survey, mainly from Europe (n = 375, 66.8%). Of these, 60.6% identified themselves as colorectal surgeons and 39.4% as general surgeons. The majority used polydioxanone for fascial closure, with small bite techniques predominating in clean-contaminated cases (74.5%, n = 418). No significant differences were found between consultants and trainee surgeons. For SSI prevention, more surgeons preferred the use of mechanical bowel preparation (MBP) alone over MBP and oral antibiotics combined. Most surgeons preferred 2% alcoholic chlorhexidine (68.4%) or aqueous povidone-iodine (61.1%) for skin preparation. The majority did not use triclosan-coated sutures (73.3%) or preoperative warming of the wound site (78.5%), irrespective of level of training or European/non-European practice. CONCLUSION: Abdominal wound closure technique and SSI prevention strategies vary widely between surgeons. There is little evidence of a risk-stratified approach to wound closure materials or techniques, with most surgeons using the same strategy for all patient scenarios. Harmonization of practice and the limitation of outlying techniques might result in better outcomes for patients and provide a stable platform for the introduction and evaluation of further potential improvements.

Impact of easing COVID-19 lockdown restrictions on traumatic injuries in Riyadh, Saudi Arabia: one-year experience at a major trauma centre.

INTRODUCTION: Lockdown restrictions due to the COVID-19 pandemic have reduced the number of injuries recorded. However, little is known about the impact of easing COVID-19 lockdown restrictions on the nature and outcome of injuries. This study aims to compare injury patterns prior to and after the easing of COVID-19 lockdown restrictions in Saudi Arabia. METHOD: Data were collected retrospectively from the Saudi TraumA Registry for the period between March 25, 2019, and June 21, 2021. These data corresponded to three periods: March 2019-February 2020 (pre-restrictions, period 1), March 2020-June 2020 (lockdown, period 2), and July 2020-June 2021 (post easing of restrictions, period 3). Data related to patients' demographics, mechanism and severity of injury, and in-hospital mortality were collected and analysed. RESULTS: A total of 5,147 traumatic injury patients were included in the analysis (pre-restrictions n = 2593; lockdown n = 218; post easing of lockdown restrictions n = 2336). An increase in trauma cases (by 7.6%) was seen in the 30-44 age group after easing restrictions (n = 648 vs. 762, p < 0.01). Motor vehicle crashes (MVC) were the leading cause of injury, followed by falls in all the three periods. MVC-related injuries decreased by 3.1% (n = 1068 vs. 890, p = 0.03) and pedestrian-related injuries decreased by 2.7% (n = 227 vs. 143, p < 0.01); however, burn injuries increased by 2.2% (n = 134 vs. 174, p < 0.01) and violence-related injuries increased by 0.9% (n = 45 vs. 60, p = 0.05) post easing of lockdown restrictions. We observed an increase in in-hospital mortality during the period of 12 months after easing of lockdown restrictions-4.9% (114/2336) compared to 12 months of pre-lockdown period-4.3% (113/2593). CONCLUSION: This is one of the first studies to document trauma trends over a one-year period after easing lockdown restrictions. MVC continues to be the leading cause of injuries despite a slight decrease; overall injury cases rebounded towards pre-lockdown levels in Saudi Arabia. Injury prevention needs robust legislation with respect to road safety measures and law enforcement that can decrease the burden of traumatic injuries.

Ligation of injured subclavian vessels saved a young life: a case report.

We describe a rare life-saving case of penetrating subclavian vessel injury that was managed successfully at King Saud Medical City, a major trauma center in Riyadh, Saudi Arabia. The patient was a healthy 21-year-old Saudi male who was presented initially at Al-Aflaj Hospital, 300 km away from King Saud Medical City, following a stab with a knife to the left side of his lower neck. He was transferred to King Saud Medical City for definitive surgical management after having temporary bleeding control at Al-Aflaj Hospital. The patient was successfully managed with a median sternotomy, left supraclavicular extension, and clavicular division. Hemostasis was achieved by ligating the injured subclavian vessels in a situation of extremes to save a life. His postoperative course was uneventful. He was discharged on the eleventh postoperative day with an intact neurovascular condition of the left upper limb.

Trauma Resuscitation Training: An Evaluation of Nurses' Knowledge.

BACKGROUND: Trauma resuscitation in the emergency department involves coordinated, well-equipped, and trained health care providers to make essential, prudent, and expedient management decisions. During resuscitation, health care providers' knowledge and skills are critical in minimizing the potential risks of mortality and morbidity. OBJECTIVE: This study aimed to evaluate the impact of training on nurses' knowledge and confidence regarding trauma resuscitation and whether there was any difference between participants with and without previous trauma training. METHODS: This study used a pre- and posttraining test study design to evaluate the effects of an intensive 8-hr trauma resuscitation training program on nurses' knowledge from January 2018 to August 2021. The training program consisted of lectures and patient scenarios covering initial assessment, resuscitation, and management priorities for trauma patients in life-threatening situations, stressing the principles of the trauma team approach. RESULTS: A total of 128 nurses participated in 16 courses conducted during the study period. This study found significant improvement in nurses' knowledge after the training (pre- and posttraining median [interquartile range, IQR] test scores 5 [4-6] vs. 9 [8-9], p < .001). There was no significant difference in pretraining test scores between the participants with previous trauma training and those without training (median [IQR] test scores 5 [4-6] vs. 4 [4-5], p = .751). CONCLUSIONS: Trauma resuscitation training affects nurses' knowledge improvement, emphasizing the need for training trauma care professionals to provide adequate care.

Outcomes of Trauma Patients Present to the Emergency Department with a Shock Index of ≥1.0.

Introduction: The study aimed primarily to evaluate the association between the initial shock index (SI) ≥1.0 with blood transfusion requirement in the emergency department (ED) after acute trauma. The study's secondary aim was to look at the outcomes regarding patients' disposition from ED, intensive care unit (ICU) and hospital length of stay, and deaths. Methods: It was a retrospective, cross-sectional study and utilized secondary data from the Saudi Trauma Registry (STAR) between September 2017 and August 2020. We extracted the data related to patient demographics, mechanism of injuries, the intent of injuries, mode of arrival at the hospital, characteristics on presentation to ED, length of stay, and deaths from the database and compared between two groups of SI <1.0 and SI ≥1.0. A P < 0.05 was statistically considered significant. Results: Of 6667 patients in STAR, 908 (13.6%) had SI ≥1.0. With SI ≥1.0, there was a significantly higher incidence of blood transfusion in ED compared to SI <1.0 (8.9% vs. 2.4%, P < 0.001). Furthermore, SI ≥ 1.0 was associated with significant ICU admission (26.4% vs. 12.3%, P < 0.001), emergency surgical intervention (8.5% vs. 2.8%, P < 0.001), longer ICU stay (5.0 ± 0.36 vs. 2.2 ± 0.11days, P < 0.001), longer hospital stays (14.8 ± 0.61 vs. 13.3 ± 0.24 days, P < 0.001), and higher deaths (8.4% vs. 2.8%, P < 0.001) compared to the patient with SI <1.0. Conclusions: In our cohort, a SI ≥ 1.0 on the presentation at the ED carried significantly worse outcomes. This simple calculation based on initial vital signs may be used as a screening tool and therefore incorporated into initial assessment protocols to manage trauma patients.

Development of the Saudi Arabian trauma system.

A dedicated network-based trauma system ensures optimal care to injured patients. Considering the significant burden of trauma, the Kingdom of Saudi Arabia is striving to develop a nationwide trauma system. This article describes the recent design, development, and implementation of the Saudi Arabian trauma system in line with Vision 2030. The basis of our strategy was the find, organize, clarify, understand, select-plan, do, check, and act (FOCUS-PDCA) model, developed by engaging key stakeholders, including patients. More than 300 healthcare professionals and patients from around the Riyadh region assessed the current system with three solutions and roadmap workshops. Subsequently, the national clinical advisory group (CAG) for trauma was formed to develop the Saudi Arabian trauma system, and CAG members analyzed and collated internationally recognized trauma systems and guidelines. The guidelines' applicability in the kingdom was discussed and reviewed, and an interactive document was developed to support socialization and implementation. The CAG team members agreed on the guiding principles for the trauma pathway, identified the challenges, and finalized the new system design. They also developed a trauma care standard document to support and guide the rollout of new trauma networks across the kingdom. The CAG members and other stakeholders are at the forefront of implementing the trauma system across the Riyadh region. Recent trauma system development in Saudi Arabia is the first step in improving national trauma care and may guide development in other locations, regionally and internationally, to improve outcomes.

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants' demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group's time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6-20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury.

Transformation of health care and the new model of care in Saudi Arabia: Kingdom's Vision 2030.

The Kingdom of Saudi Arabia espoused "Vision 2030" as a strategy for economic development and national growth. The vision demonstrated the Kingdom's objectives to become a pioneer nation globally by achieving three main goals: a vibrant society, a thriving economy, and an ambitious nation. To fulfill this, the Kingdom launched a national transformation program (NTP) as outlined in "vision 2030" in June 2016. The health care transformation is one of the eight themes of the NTP's. The history of health care facilities in the Kingdom is almost a century. Although the Kingdom has made notable progress in improving its population's health over recent decades, it needs to modernize the health care system to reach the "vision 2030" goal. This article aims to describe the new Model of Care (MOC) according to the recent Saudi health care transformation under the Kingdom's vision 2030. The MOC concept started with understanding the current state and collecting learnings. It is based on the six systems of care (SOC)- keeping well, planned procedure, women & children, urgent problems, chronic conditions, and the last phase of life. The SOC is cut across different "service layers" to support people's stay well and efficiently get them healthy again when they need care. The new MOC describes a total of forty-two interventions, of which twenty-seven split across the six SOC and the rest fifteen cut-across the multiple SOC. Implementation of all MOC interventions will streamline the Saudi health care system to embrace the Kingdom's "vision 2030".

Incidence and Nature of Lower-Limb Deep Vein Thrombosis in Patients with Polytrauma on Thromboprophylaxis: A Prospective Cohort Study.

PURPOSE: Deep vein thrombosis (DVT) is common among the severely injured and may lead to pulmonary embolism (PE), which can be life threatening. Thromboprophylaxis may reduce the incidence of venous thromboembolism (VTE); it does not guarantee complete protection. This study's primary aim was to determine the incidence and nature of lower-limb DVT in polytrauma patients taking prophylaxis. The secondary objective was to assess the incidence of DVT-related complications, including the development of PE and death. PATIENTS AND METHODS: This prospective observational study included patients age 18 years or older who presented with polytrauma directly from the scene and were admitted into the trauma unit between March 1, 2020 and August 31, 2020. All patients underwent lower-limb ultrasound during their hospital course to diagnose DVT. RESULTS: A total of 169 patients underwent extremity Doppler ultrasound to detect DVT. Of these, 69 patients (40.8%) were considered at the highest-risk for VTE development. For VTE prophylaxis, 115 patients (68%) received pharmacologic agents, and 54 patients (32%) had intermittent pneumatic compression on admission. Three patients (1.8%) developed DVT despite prophylaxis. Four patients (2.4%) developed PE during the index presentation and were diagnosed between days 3 and 13 after injury. Early DVT was not detected in any patients with diagnosed PE. Overall, nine patients (5.33%) died, but no in-hospital deaths were related to DVT and/or PE. CONCLUSION: The incidence of DVT in polytrauma patients remains low in our small series, perhaps because of the mandatory VTE risk assessment for all hospitalized patients and the early initiation of prophylaxis. Using a trauma center registry to measure DVT and PE incidence regularly is recommended to improve trauma care quality.

Comparison of trauma management between two major trauma services in Riyadh, Kingdom of Saudi Arabia and Melbourne, Australia.

INTRODUCTION: The burden of injury in the Kingdom of Saudi Arabia (KSA) has increased in recent years, but the country has lacked a consistent methodology for collecting injury data. A trauma registry has been established at a large public hospital in Riyadh from which these data are now available. OBJECTIVES: We aimed to provide an overview of trauma epidemiology by reviewing the first calendar year of data collection for the registry. Risk-adjusted analyses were performed to benchmark outcomes with a large Australian major trauma service in Melbourne. The findings are the first to report the trauma profile from a centre in the KSA and compare outcomes with an international level I trauma centre. METHODS: This was an observational study using records with injury dates in 2018 from the registries at both hospitals. Demographics, processes and outcomes were extracted, as were baseline characteristics. Risk-adjusted endpoints were inpatient mortality and length of stay. Binary logistic regression was used to measure the association between site and inpatient mortality. RESULTS: A total of 2436 and 4069 records were registered on the Riyadh and Melbourne databases, respectively. There were proportionally more men in the Saudi cohort than the Australian cohort (86% to 69%). The Saudi cohort was younger, the median age being 36 years compared with 50 years, with 51% of injuries caused by road traffic incidents. The risk-adjusted length of stay was 4.4 days less at the Melbourne hospital (95% CI 3.95 days to 4.86 days, p<0.001). The odds of in-hospital death were also less (OR 0.25; 95% CI 0.15 to 0.43, p<0.001). CONCLUSIONS: This is the first hospital-based study of trauma in the kingdom that benchmarks with an individual international centre. There are limitations to interpreting the comparisons, however the findings have established a baseline for measuring continuous improvement in outcomes for KSA trauma services.

Vertebral artery injury in major trauma patients in Saudi Arabia: A retrospective cohort study.

Blunt vertebral artery injury (VAI) is associated with severe cervicocephalic trauma and may have devastating consequences. This study aimed to determine the incidence and nature of VAI in polytrauma patients. The secondary objective was to assess the association of VAI with previously suggested risk factors. It was a retrospective observational study of all polytrauma patients admitted to the trauma unit between April 2018 and July 2019, who had CT neck angiography to diagnose blunt VAI according to modified Denver criteria. Out of 1084 admitted polytrauma patients, 1025 (94.6%) sustained blunt trauma. Of these, 120 (11.7%) underwent screening CT neck angiography. VAI was detected in 10 (8.3%; 95% CI 4.1-14.8) patients. There were three patients with Grade I injury, two with Grade II, and five with Grade IV injury. Among all trauma admissions, the incidence of diagnosed VAI was 0.9% (95% CI 0.5-1.8). Among patients suspected of VAI, there was no univariable association of VAI with C-Spine fracture: OR 4.2 (95% CI 0.51-34.4; p = 0.18). There were two (20%) deaths related to VAI. Traumatic VAI was uncommonly detected in this major trauma service in Saudi Arabia. High suspicion and liberal screening by CT angiography in cases where VAI is possible should be considered to avoid missed injuries.

Thoracic endovascular aortic repair in a case of grade III blunt aortic injury with aberrant vertebral artery origin.

Aberrant origin of the left vertebral artery (LVA) can pose a challenge during thoracic endovascular aortic repair. We encountered such a patient who was involved in a motor vehicle accident in whom computed tomography angiography revealed a grade IIIB blunt aortic injury with an anomalous origin of the LVA distal to the origin of the left subclavian artery. On-table aortography confirmed dominance of the LVA. Hence, an open left carotid-vertebral and then left carotid-subclavian artery bypass was performed, followed by thoracic endovascular aortic repair. The patient recovered well and was discharged home 3 days later.

The World Health Organization trauma checklist versus Trauma Team Time-out: A perspective.

Time-out protocols have reportedly improved team dynamics and patients' safety in various clinical settings - particularly in the operating room. In 2016, the World Health Organization (WHO) introduced a Trauma Care checklist, which outlines steps to follow immediately after the primary and secondary surveys and prior to the team leaving the patient. The WHO Trauma Care checklist's main perceived benefit is the prompting of clinicians to complete trauma admissions as per evidence-based guidelines. The WHO Trauma Care checklist, while likely to be successful in reducing errors of omission related to hospital admission, may be limited in its ability to reduce errors that occur in the initial 30 min of trauma reception - when most of the life-saving decisions are made. To address this limitation a Trauma Team Time-out protocol is proposed for initial trauma resuscitation, targeting the critical first 30 min of hospital reception.

Surgical site infections after trauma laparotomy. An observational study from a major trauma center in Saudi Arabia.

OBJECTIVES: To determine the incidence of surgical site infection (SSI) after trauma laparotomy and evaluate variables on presentation to the emergency department (ED) associated with the development of SSI. Methods: A retrospective cohort study was undertaken of patients presenting directly from the scene who underwent trauma laparotomy between January 2016 and December 2017. The primary outcome variable was SSI, as defined by the Centers for Disease Control and Prevention guideline. A univariate assessment with demographics, vital signs, and acute management was reported. Results: A total of 70 patients were included for data analysis. Of these, 9 (12.9%; 95% confidence interval (CI): 6.9-22.7%) patients developed SSI, including 5 patients with bowel injury (small bowel; n=3, colonic injuries; n=2). Most cases were diagnosed after 7 days in the hospital. All patients developed superficial incisional (skin and subcutaneous tissue) SSI. No predetermined variables, including bowel injury (p=0.08) or duration of surgery (p=0.09), demonstrated a statistically significant association with the development of SSI. Conclusion: Rates of SSI after trauma laparotomy were similar to previous reports from other centers. Surgical site infection after trauma laparotomy was diagnosed at a delayed time point after surgery, and patient demographics, injury characteristics, and acute surgical management did not appear to be associated with subsequent diagnosis of SSI.

Right main bronchus rupture due to blunt chest trauma.

Bronchial rupture following major blunt chest trauma should be suspected in every case of massive and persistent air leak through the intercostal drain tube. Chest radiogram offers indirect signs, while chest CT scan demonstrates specific signs highly suggestive for this extremely rare tracheobronchial injury. Bedside bronchoscopy confirms the diagnosis.

Selective nonoperative management of liver gunshot injuries.

PURPOSE: Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. METHODS: A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. RESULTS: During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. CONCLUSION: The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.

Incidental right-sided diaphragmatic eventration after blunt thoracoabdominal trauma.

[No Abstract Available].

Significant bleeding from Meckel's diverticulum after blunt abdominal trauma: a case report.

BACKGROUND: Meckel's diverticulum, with an incidence of 2%, is the most common congenital anomaly in the gastrointestinal tract. Its main complications are perforation, obstruction, and bleeding. A few studies have reported that blunt abdominal trauma may result in perforation or obstruction to Meckel's diverticulum. However, reports of significant major intestinal bleeding from Meckel's diverticulum as a complication of blunt abdominal trauma is rare. This paper present what we believe to be the first reported case of significant intestinal bleeding from a Meckel's diverticulum following blunt abdominal trauma. CASE PRESENTATION: A 12-year-old Saudi boy of Arab ethnicity presented to the King Saud Medical City emergency department with bleeding per rectum and mild abdominal pain following blunt trauma to his abdomen. On examination, his abdomen was slightly tender, bowel sounds were present, and he was hemodynamically stable. During admission, rectal bleeding was ongoing. On day 3 he deteriorated with decreasing blood pressure and hemoglobin, and increasing pulse rate with fever. After resuscitation and stabilization, he was urgently taken to the operating room for further diagnostic management and treatment. His nasogastric tube revealed bile without blood, and an intraoperative colonoscopy revealed altered blood within his whole colon and terminal ileum without a definite bleeding site. A laparotomy was performed, and an injured branch of the mesenteric artery supplying the Meckel's diverticulum was identified as the source of the significant arterial bleeding. Suture ligation controlled the bleeding, and the Meckel's diverticulum was resected. The patient remained stable after that until discharge without any further intestinal bleeding. CONCLUSION: Identifying bleeding as a complicated Meckel's diverticulum following blunt trauma to the abdomen can be challenging due to its low incidence and difficulties while making the diagnosis.