Eastern Association for the Surgery of Trauma (EAST) vs Western Trauma Association (WTA): How a Level 1 Trauma Center Splits the Difference in Resuscitative Thoracotomy.

Background Resuscitative thoracotomy (RT) is performed in severe trauma cases as a final lifesaving effort. Prominent, yet differing, practice management guidelines exist from Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA). This study evaluates all RTs performed from 2012 to 2019 at an urban Level 1 trauma center for management guideline indication and subsequent outcomes. Methods Our trauma registry was queried to identify RT cases from 2012 to 2019. Data was collected on patient demographics, prehospital presentation, cardiopulmonary resuscitation (CPR) requirements, and resuscitation provided. Survival to the operating room, intensive care unit, and overall were recorded. Information was compared with regard to EAST and WTA criteria. Results Eighty-seven patients who underwent RTs were included. WTA guidelines were met in 78/87 (89.7%) of cases, comparatively EAST guidelines were met in every case. Within the EAST criteria, conditional and strong recommendations were met in 70/87 (80.4%) and 17/87 (19.5%) of cases, respectively. In nine cases (10.3%) indications were discordant, each meeting conditional indication by EAST and no indication by WTA. All patients that survived to the operating room (OR), ICU admission, and overall met EAST criteria. Conclusion All RTs performed at our Level 1 trauma center met indications provided by EAST criteria. WTA guidelines were not applicable in nine salvaging encounters due to the protracted duration of CPR before proceeding to RT. Furthermore, more patients that survived to OR and ICU admission met EAST guidelines suggesting an improved potential for patient survivability. As increased data is derived, management guidelines will likely be re-established for optimized patient outcomes.

Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study.

INTRODUCTION: To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS: Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS: Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Timing of Gastrografin administration in the management of adhesive small bowel obstruction (ASBO): Does it matter?

BACKGROUND: Gastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge. METHODS: A retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality. RESULTS: One hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05). CONCLUSION: Gastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.

Parasitic leiomyoma of the greater omentum presenting as small bowel obstruction.

Parasitic leiomyomas (PL) are rare intra-abdominal tumors usually found in young women and are considered a type of uterine leiomyomas. They are usually reported in women who underwent laparoscopic morcellation of fibroids and frequently present with symptoms such as abdominal pain and distention. Treatment usually involves en bloc removal of the mass after dividing its blood supply from the host organ. In this case report, we describe the case of a middle-aged female who developed high-grade small bowel obstruction due to compression from a large PL with blood supply from the greater omentum. The patient underwent operative resection of the PL and subsequently fared very well. Meticulous attention to blood supply and attachments of PL to host organs is necessary for safe resection.

Abdominal compartment syndrome due to spontaneous rectus sheath hematoma with extension into the retroperitoneal space.

Rectus sheath hematoma (RSH) is an increasingly common clinical condition in our hospitals due to the increasing use of anticoagulant therapies for various purposes among our patients. Treatment of spontaneous RSH is generally conservative. For continued bleeding, interventional radiologic identification and subsequent embolization is an effective option. Surgery usually involves significant morbidity and is considered a technique of last resort. In this case report, we describe the case of middle aged female who developed abdominal compartment syndrome (ACS) from a large RSH that had extended into the retroperitoneum. The patient underwent abdominal decompression with removal of the hematoma and subsequently fared very well. Patients with large RSHs extending into the retroperitoneum should undergo constant monitoring of their abdominal pressures for early detection and treatment of potentially deadly condition of ACS.

Stapled versus hand-sewn: A prospective emergency surgery study. An American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. METHODS: The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. RESULTS: Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183-3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492-4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. CONCLUSION: EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. LEVEL OF EVIDENCE: Therapeutic study, level II.

The predictive value of initial serum lactate in trauma patients.

Trauma patients require early assessment of injury severity. Trauma scores, although well validated, can be unwieldy in the emergency clinical setting. We sought to evaluate the prognostic value of initial serum lactate (ISL) for mortality, operative intervention (OI), and intensive care unit admission (ICUA) in trauma patients. We conducted an institutional review board-approved retrospective study. We reviewed all trauma patients between January 2007 and June 2012 in our prospectively maintained database. We included only adults whose ISL had been drawn within the first 35 min after arrival. We included only those patients whose interval between injury and arrival was within 24 h. Survivors and nonsurvivors were compared using logistic regression, Mann-Whitney U, and chi-square tests. Discriminating ability of ISL for mortality was assessed with receiver operating characteristic analysis. Our secondary outcomes (ICUA and OI) were evaluated with logistic regression test and receiver operating characteristic analysis. A total of 1,941 patients were included. Overall mortality was 6.2%. Median ISL was 32 mg/dL (interquartile range, 17 - 62) for nonsurvivors versus 21 mg/dL (interquartile range, 14 - 32) for survivors (P < 0.001). In multivariate analysis, ISL was a significant covariate for mortality (P = 0.015). The odds ratio was 1.010 (95% confidence interval, 1.002 - 1.019). The area under the curve was 0.63. The ISL was a significant covariate for OI (P = 0.033). The ISL did not reach significance for ICUA. The ISL is an easily measured, rapid, and inexpensive test that can help to quickly stratify injury severity in trauma patients. We have found that ISL, when used in strictly selected patients, can predict OI and mortality.

A mechanism to explain how regular exercise might reduce the risk for clinical prostate cancer.

Epidemiological studies report that regular physical activity can reduce the risk for prostate cancer. This study was conducted to investigate possible mechanisms to explain the epidemiological data. Serum from sedentary controls or men with regular (5 days/week) aerobic exercise was used to stimulate lymph node cancer of the prostate (LNCaP) tumor cells in vitro. Growth and apoptosis were assessed and cell lysate p53, p21 and Bcl-2 proteins measured. Tryphostin was used to block the insulin-like growth factor-I receptor. Exercise serum-stimulated growth was reduced at 2 and 4 days while apoptosis was increased. Tryphostin reduced growth in the control but not in the exercise serum-stimulated samples. Total cell lysate p53 protein was higher in the exercise serum-stimulated cells at both 2 and 4 days. The levels of p21 protein, a downstream effector of p53, were elevated at 2 days but were normal at 4 days. Bcl-2, an antiapoptotic protein, was significantly reduced at 2 days in the exercise serum-stimulated lysates. These results indicate that exercise training alters serum insulin-like growth factor axis factors in vivo that increase LNCaP cellular p53 protein content in vitro leading to reduced growth via p21 and induced apoptosis via the mitochondrial pathway.

Exercise alters the IGF axis in vivo and increases p53 protein in prostate tumor cells in vitro.

Epidemiological studies report that regular physical activity can reduce the risk for prostate cancer, the most common solid-tumor cancer in US men. Regular exercise alters the serum IGF axis in vivo and reduces cell proliferation while increasing apoptosis in serum-stimulated LNCaP prostate cancer cells in vitro. The present study tests the hypothesis that these effects on tumor cell lines are mediated by enhancement of the function of the p53 gene known to arrest cell growth and induce apoptosis. When LNCaP cells were cultured in exercise serum and compared with control serum, cell growth was reduced by 27%, and there was a similar 33% decrease in proliferating cell nuclear antigen protein, a marker for cell cycling. Apoptosis was increased by 371% with the exercise serum, and there was a 100% increase in p53 protein (75.2 +/- 2.0 vs. 38.2 +/- 2.0 pg/microg protein). When serum was used to stimulate LN-56 cells, a cell line with nonfunctional p53 derived from LNCaP, no significant reduction in cell growth or increase in apoptosis with the exercise serum was observed. These results indicate that exercise training alters serum factors in vivo that increase cellular p53 protein content and is associated with reduced growth and induced apoptosis in LNCaP prostate cancer cells in vitro.

A low-fat diet and/or strenuous exercise alters the IGF axis in vivo and reduces prostate tumor cell growth in vitro.

BACKGROUND: Prostate cancer is the most common solid-tumor cancer in US males but is rare in Asian males. When Asian men adopt the US lifestyle, clinical prostate cancer increases greatly. Epidemiological data from men in the US indicate that regular activity may reduce the risk for prostate cancer. METHODS: Serum was obtained from three groups of similar-aged men, Control, Diet and Exercise, and Exercise alone were used to stimulate LNCaP cells in culture. Growth and apoptosis of tumor cells were measured. Serum samples were also used to measure insulin, IGF-1, IGFBP-1. RESULTS: The Diet and Exercise and the Exercise alone groups had lower serum insulin and IGF-1 but higher IGFBP-1 compared to Controls. LNCaP cell growth was reduced in both groups compared to Control and there was a major increase in apoptosis of tumor cells. CONCLUSIONS: A low-fat diet and/or intensive exercise results in change in serum hormones and growth factors in vivo that can reduce growth and induce apoptosis of LNCaP prostate tumor cells in vitro.

Insulin-like growth factor I (IGF-I) and IGF binding protein-1 modulate prostate cancer cell growth and apoptosis: possible mediators for the effects of diet and exercise on cancer cell survival.

Previous studies showed that serum from men consuming a low fat diet and undergoing exercise intervention (DE) reduced LNCaP cell growth and induced apoptosis in vitro. DE also decreased serum IGF-I and increased serum IGF binding protein-1 (IGFBP-1). The present study evaluates the effects of IGF-I and IGFBP-1 on growth and apoptosis of prostate cancer cells in vitro. When IGF-I was added to the post-DE serum, the reduction in LNCaP cell growth and the induction of apoptosis in medium containing post-DE serum alone were reversed. When IGFBP-1 was added to the pre-DE serum samples, LNCaP cell growth was reduced, and apoptosis was induced. IGF-I, long-R(3)-IGF-I (only binds IGF-I receptor), AL(31)Leu(60)-IGF-I (only binds IGFBPs), antihuman IGF-I receptor antibodies, and IGFBP-1 were then added to LNCaP cultures to determine the independent effects of IGF-I and IGFBP-1 on cell growth. Collectively, the results using these agents show that IGF-I and IGFBP-1 exert opposing effects on LNCaP cell growth and apoptosis, and IGFBP-1 acts mainly through an IGF-dependent mechanism. DE results in a decrease in serum IGF-I with increased IGFBP-1 in vivo that is associated with apoptosis and reduced LNCaP and LAPC-4 prostate cancer cell growth in vitro.