Laparoscopy for emergency abdominal surgery is associated with reduced physical functional decline in older patients: a cohort study.

BACKGROUND: An increasing number of older patients require emergency abdominal surgery for acute abdomen. They are susceptible to surgical stress and lose their independence in performing daily activities. Laparoscopic surgery is associated with faster recovery, less postoperative pain, and shorter hospital stay. However, few studies have examined the relationship between laparoscopic surgery and physical functional decline. Thus, we aimed to examine the relationship between changes in physical function and the surgical procedure. METHODS: In this was a single-center, retrospective cohort study, we enrolled patients who were aged ≥ 65 years and underwent emergency abdominal surgery for acute abdomen between January 1, 2019, and December 31, 2021. We assessed their activities of daily living using the Barthel Index. Functional decline was defined as a decrease of ≥ 20 points in Barthel Index at 28 days postoperatively, compared with the preoperative value. We evaluated an association between functional decline and surgical procedures among older patients, using multiple logistic regression analysis. RESULTS: During the study period, 852 patients underwent emergency abdominal surgery. Among these, 280 patients were eligible for the analysis. Among them, 94 underwent laparoscopic surgery, while 186 underwent open surgery. Patients who underwent laparoscopic surgery showed a less functional decline at 28 days postoperatively (6 vs. 49, p < 0.001). After adjustments for other covariates, laparoscopic surgery was an independent preventive factor for postoperative functional decline (OR, 0.22; 95% CI, 0.05-0.83; p < 0.05). CONCLUSIONS: In emergency abdominal surgery, laparoscopic surgery reduces postoperative physical functional decline in older patients. Widespread use of laparoscopic surgery can potentially preserve patient quality of life and may be important for the better development of emergency abdominal surgery.

Persistent disparities between trauma center types in the management of children with high-grade blunt splenic injuries.

BACKGROUND: In the early 2000s, substantial variations were reported in the management of pediatric patients with blunt splenic injury (BSI). The purpose of this study was to assess the recent trends and disparities between different types of trauma centers. We hypothesized that there would be persistent disparities despite decreased trends in the rate of splenectomy. METHODS: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database. We included patients (age ≤18 years) with high-grade BSI (Abbreviated Injury Scale 3-5) between 2014 and 2021. The patients were divided into three groups based on trauma center types (adult trauma centers [ATCs], mixed trauma centers [MTCs], and pediatric trauma centers [PTCs]). The primary outcome was the splenectomy rate. Logistic regression was performed to evaluate the association between trauma center types and clinical outcomes. Additionally, the trends in the rate of splenectomy at ATCs, MTCs, and PTCs were evaluated. RESULTS: A total of 6601 patients with high-grade BSI were included in the analysis. Overall splenectomy rates were 524 (17.5%), 448 (16.3%), and 32 (3.7%) in the ATC, MTC, and PTC groups, respectively. ATCs and MTCs had significantly higher splenectomy rates compared to PTCs (ATCs: OR = 5.72, 95%CI = 3.78-8.67, and p < 0.001 and MTCs: OR = 4.50, 95%CI = 2.97-6.81, and p < 0.001), while decreased trends in the splenectomy rates were observed in ATCs and MTCs (ATCs: OR = 0.92, 95%CI = 0.87-0.97, and p = 0.003 and MTCs: OR = 0.92, 95%CI = 0.87-0.98, and p = 0.013). CONCLUSIONS: This study suggested persistent disparities between different trauma center types in the management of children with high-grade BSI.

Impact of resuscitative endovascular balloon occlusion of the aorta on gastrointestinal function with a matched cohort study.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control arterial hemorrhage in torso trauma; however, the abdominal visceral blood flow is also blocked by REBOA. The aim of this study was to evaluate the influence of REBOA on gastrointestinal function. Methods: A retrospective review identified all trauma patients admitted to our trauma center between 2008 and 2019. We used propensity score matching analysis to compare the gastrointestinal function between subjects who underwent REBOA and those who did not. Data on demographics, feeding intolerance (FI), time to feeding goal achievement, and complications were retrieved. Results: During the study period, 55 patients underwent REBOA. A total of 1694 patients met the inclusion criteria, 27 of whom were a subset of those who underwent REBOA. After 1:1 propensity score matching, the REBOA and no-REBOA groups were assigned 22 patients each. Patients in the REBOA group had a significantly higher incidence of FI (77% vs. 27%; OR, 9.1; 95% CI, 2.31 to 35.7; p=0.002) and longer time to feeding goal achievement (8 vs. 6 days, p=0.022) than patients in the no-REBOA group. Patients in the REBOA group also showed significantly prolonged durations of ventilator use (8 vs. 4 days, p=0.023). Furthermore, there was no difference in the mortality rate between the groups (9% vs. 9%, p=1.000). Conclusions: REBOA was associated with gastrointestinal dysfunction. Our study findings can be useful in providing guidance on managing nutrition in trauma patients who undergo REBOA. Level of evidence: Level IV. Study type: Care management.

A clinical prediction model for non-operative management failure in patients with high-grade blunt splenic injury.

Background: Nonoperative management (NOM) is the standard treatment for hemodynamically stable blunt splenic injury (BSI). However, NOM failure is a significant source of morbidity and mortality. We developed a clinical risk scoring system for NOM failure in BSI. Methods: Data from the Japanese Trauma Data Bank from 2008 to 2018 were analyzed. Eligible patients were restricted to those who underwent NOM with high-grade BSI (Organ Injury Scale ≥3). The primary outcome was a predictive score for NOM failure based on risk estimation. Results: There were 1651 patients included in this analysis, among whom 110 (6.7%) patients had NOM failure. Multivariate analysis identified seven variables associated with failed NOM: systolic blood pressure, Glasgow coma scale, Injury Severity Score, other concomitant abdominal injury, pelvic injury, high-grade BSI, and angioembolization. An eight-point predictive score was developed with a cut-off of greater than 5 points (specificity, 98.2%; sensitivity, 25.5%) with an area under the curve of 0.81. Conclusion: The clinical predictive score had good ability to predict NOM failure and may help surgeons to make better decisions for BSI.

Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis.

BACKGROUND: This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE. METHODS: Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90 mmHg, heart rate (HR) >120 bpm, or lowest SBP <90 mmHg within 1 h after admission, with ≥1 unit of blood transfused within 4 h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared. RESULTS: A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137 min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132 min, p < 0.001). CONCLUSION: Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.

Predictive value of total psoas muscle index for postoperative physical functional decline in older patients undergoing emergency abdominal surgery.

BACKGROUND: Older individuals increasingly require emergency abdominal surgeries. They are susceptible to surgical stress and loss of independence in performing daily activities. We hypothesized that the psoas muscle volume would be significantly associated with postoperative functional decline (FD) in older patients undergoing emergency abdominal surgery and aimed to evaluate the use of the psoas muscle volume on computed tomography (CT) scans. METHODS: A retrospective, single-center study of patients aged ≥ 65 years who had undergone emergency abdominal surgery between January 2019 and June 2021 was performed. We assessed patients' activities of daily living using the Barthel Index. FD was defined as a ≥ 5-point decrease between preoperative and 28-day postoperative values. The psoas muscle volume was measured by CT, which was used for diagnosis, and normalized by height to calculate total psoas muscle index (TPI). We evaluated associations between FD and TPI using receiver operating characteristics (ROC) analysis and multiple logistic regression analysis. RESULTS: Of 238 eligible patients, 71 (29.8%) had clinical postoperative FD. Compared to the non-FD group, the FD group was significantly older and had a higher proportion of females, higher Charlson Comorbidity Index, lower body mass index, higher American Society of Anesthesiology score, lower serum albumin level, and lower TPI. ROC analyses revealed that TPI had the highest area under the curve (0.802; 95% confidence interval [CI], 0.75-0.86). A multivariable logistic regression model revealed that low TPI was an independent predictor of postoperative FD (odds ratio, 0.14; 95% CI, 0.06-0.32). CONCLUSIONS: TPI can predict postoperative FD due to emergency abdominal surgery. Identification of patients who are at high risk of FD before surgery may be useful for enhancing the regionalized system of care for emergency general surgery.

Recent trends in the management of isolated high-grade splenic injuries: A nationwide analysis.

BACKGROUND: The feasibility of nonoperative management for high-grade blunt splenic injuries (BSIs) has been suggested in recent studies. The purpose of this study was to assess nationwide trends in the management of isolated high-grade BSIs. We hypothesized that isolated high-grade BSIs are more frequently being managed nonoperatively. METHODS: The American College of Surgeons Trauma Quality Improvement Program database was queried to identify patients (16 years or older) with isolated high-grade BSIs (Abbreviated Injury Scale, ≥3) between 2013 and 2019. Patients were divided into two groups based on their hemodynamic status (hemodynamically stable [HS] and hemodynamically unstable [HU]). The primary outcome was the rate of total splenectomy each year, and the secondary outcome was the use of splenic angioembolization (SAE). Multiple regression models were created to estimate annual trends in splenectomy and SAE. RESULTS: A total of 6,747 patients with isolated high-grade BSIs were included: 5,714 (84.7%) and 1,033 (15.3%) in HS and HU groups, respectively. In the HS group, the rate of overall splenectomy was significantly decreased (from 22.9% in 2013 to 12.6% in 2019; odds ratio [OR] for 1-year increment, 0.850; 95% confidence interval [CI], 0.815-0.886; p < 0.001), and the use of SAE was significantly increased (from 12.5% in 2013 to 20.9% in 2019; OR, 1.107; 95% CI, 1.065-1.150; p < 0.001). In the HU group, the overall splenectomy rate was unchanged (from 69.8% in 2013 to 50.8% in 2019; OR, 0.931; 95% CI, 0.865-1.002; p = 0.071), whereas SAE was significantly increased (from 12.7% in 2013 to 28.8% in 2019; OR, 1.176; 95% CI, 1.079-1.284; p < 0.001). CONCLUSION: We observed significant trends toward more frequent use of nonoperative management in high-grade BSIs with hemodynamic stability. Further studies are warranted to define the role of SAE, especially in patients with hemodynamic instability. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Angioembolization versus preperitoneal packing for severe pelvic fractures: A propensity matched analysis.

BACKGROUND: Whether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial. STUDY DESIGN: This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3-5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis. RESULTS: A total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321). CONCLUSIONS: Though patients' characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy.

Factors associated with prolonged procedure time of embolization for trauma patients.

Aim: Limited information exists on the factors associated with prolonged procedural time in embolization for trauma patients. We clarified the clinical application of embolization in trauma patients and factors associated with a prolonged procedure time. Methods: Medical records of 162 trauma patients who underwent embolization between January 2007 and December 2020 at a regional trauma care center were reviewed retrospectively. Patients were divided into four embolized body regions: chest, abdomen, pelvis, and other. Patient demographics, trauma mechanism, physiology, trauma severity, embolization procedures, and 30-day mortality were examined. The outcomes were identifying an embolized body region, embolized arteries, and procedure time. Multiple regression model was created to investigate the factors associated with prolonged procedural time in embolization. Results: Embolization was mainly undertaken in pelvic fractures (n = 96, 59%) and abdominal organ injuries (n = 57, 35%) and extended to the chest (n = 17, 10%), and other (n = 20, 12%). Approximately 13% (n = 21) of patients underwent embolization in two or more regions. Embolization was more strictly performed in minor artery injuries, for example, external iliac (n = 15, 16%) and lumbar artery (n = 22, 23%) branches in pelvic fractures, and inferior phrenic artery (n = 2, 3.5%) branches in liver injuries. Multiple regression model indicated that the number of embolized arteries (P = 0.021) and number of embolized regions (P < 0.001) were associated with prolonged procedural time in embolization. Conclusions: Embolization for trauma patients extended to various trauma regions. In time-sensitive embolization, emergency interventional radiologists showed superior knowledge of expected embolizing arteries and factors associated with procedure time.

Extensive rib resection followed by thoracic wall reconstruction using polytetrafluoroethylene mesh and titanium plates for refractory intercostal artery bleeding induced by severe blunt thoracic injury: report of a case.

Massive hemothorax due to multiple rib fractures and intercostal artery (ICA) injuries is one of the most lethal forms of chest trauma. Urgent thoracotomy is required; however, suturing is sometimes difficult owing to the limited operative field in the thoracic cavity and because the transected ICA retracts between the surrounding intercostal muscles. We present a patient with refractory ICA bleeding induced by severe blunt thoracic injury successfully treated with extensive rib resection followed by thoracic wall reconstruction using GORE® DUALMESH® and titanium plates. A 66-year-old woman attempted suicide by diving into the path of a train. She incurred massive left hemothorax associated with multiple rib fractures and severe trauma to her extremities; both upper limbs and left leg at the thigh were nearly disconnected. Initially, she underwent urgent left anterolateral thoracotomy followed by partial lung resection and suture hemostasis of the thoracic wall. Subsequently, interventional radiology was performed for the ICA bleeding, and her extremities except her right leg were amputated. However, because hemothorax persisted, and because of the comminuted fractures, we removed the fifth to eighth ribs, and the ICA vascular sheath was ligated. Resecting multiple ribs caused deformities and lung herniations, although hemostasis was achieved. On the third postoperative day, thoracic reconstruction using Gore-Tex® Dual Mesh and titanium plates was performed. Although a small empyema occurred, it was controlled with antibiotics and drainage. Paradoxical respiration and atelectasis did not occur, and the patient was moved to the hospital for continued care in a lucid state.

Delayed embolization associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival.

BACKGROUND: Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture. METHODS: A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0-30, 30-60, 60-90, 90-120, 120-150, and 150-180 min). We compared the adjusted 30-day mortality rate according to time to embolization. RESULTS: We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48-79) years and 55% were male. The median injury severity score was 26 (18-38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran-Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0-30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2-23.9) for the 150-180 min group. CONCLUSION: Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.

Stanford Type A Aortic Dissection caused by veno-arterial extracorporeal membrane oxygenation.

Extracorporeal cardiopulmonary resuscitation (E-CPR) has attracted interest in the area of resuscitation, with its utilization in refractory cardiac arrest having recently increased. However, E-CPR has a high complication rate of approximately 30% and life-threatening complications can occur. We present a case who experienced an acute aortic dissection caused by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Specifically, the aortic dissection was caused by an adjustment in the position of return cannula.

Hybrid emergency room management of a ruptured abdominal aortic aneurysm.

Patients with a ruptured abdominal aortic aneurysm (rAAA) still have high mortality. Rapid diagnosis and treatment are vital for improving survival outcomes. rAAA management has evolved regarding these factors. We have reported the case of a 70-year-old man with an rAAA that was rapidly diagnosed and treated in a hybrid emergency room (ER). A hybrid ER is an integrated ER capable of computed tomography scanning, interventional radiology, and surgery in one place. In the present case, the door-to-intervention time was 35 minutes. The use of hybrid ERs has the potential to enhance the speed and quality of diagnostic and definitive treatment of rAAAs.

Near-fatal negative pressure pulmonary oedema successfully treated with venovenous extracorporeal membrane oxygenation performed in the hybrid emergency room.

We report a rare case of negative pressure pulmonary oedema (NPPE), a life-threatening complication of tracheal intubation. A 41-year-old obese man was admitted to a previous hospital for neck surgery. After extubation, he developed respiratory distress followed by haemoptysis and desaturation. The patient was reintubated and brought to our hospital where we introduced venovenous extracorporeal membrane oxygenation (ECMO) to prevent cardiac arrest, which is an unusual clinical course for NPPE. He returned to his routine without any sequelae. This is the first case report of NPPE successfully resolved with venovenous ECMO in the hybrid emergency room (hybrid ER), which is a resuscitation room equipped with interventional radiology features and a sliding CT scanner. Since the hybrid ER serves as a single move for patients where all necessary procedures are performed, it has the potential to lower the incidence of cannulation complications, beyond the delay in ECMO initiation.

Comparison of the Clinical Course of COVID-19 Pneumonia and Acute Respiratory Distress Syndrome in 2 Passengers from the Cruise Ship Diamond Princess in February 2020.

BACKGROUND Patients with coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 can rapidly progress to acute respiratory distress syndrome (ARDS). Because clinical diagnosis of ARDS includes several diseases, understanding the characteristics of COVID-19-related ARDS is necessary for precise treatment. We report 2 patients with ARDS due to COVID-19-associated pneumonia. CASE REPORT Case 1 involved a 72-year-old Japanese man who presented with respiratory distress and fever. Computed tomography (CT) revealed subpleural ground-glass opacities (GGOs) and consolidation. Six days after symptom onset, reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis of COVID-19-associated pneumonia. He was intubated and received veno-venous extracorporeal membrane oxygenation (ECMO) 8 days after symptom onset. Follow-up CT revealed large diffuse areas with a crazy-paving pattern and consolidation, which indicated progression of COVID-19-associated pneumonia. Following treatment with antiviral medications and supportive measures, the patient was weaned off ECMO after 20 days. Case 2 involved a 70-year-old Asian man residing in Canada who presented with cough, malaise, nausea, vomiting, and fever. COVID-19-associated pneumonia was diagnosed based on a positive result from RT-PCR testing. The patient was then transferred to the intensive care unit and intubated 8 days after symptom onset. Follow-up CT showed that while the initial subpleural GGOs had improved, diffuse GGOs appeared, similar to those observed upon diffuse alveolar damage. He was administered systemic steroid therapy for ARDS and extubated after 6 days. CONCLUSIONS Because the pattern of symptom exacerbation in COVID-19-associated pneumonia cases seems inconsistent, individual treatment management, especially the CT-based treatment strategy, is crucial.