Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen.

INTRODUCTION: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. METHODS: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. RESULTS: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RH, followed by the LH and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70.5% of lumbar, 66.5% of epigastric, 62% of flank, and 59% of RH penetrating SW could have been managed without a laparotomy. CONCLUSIONS: SNOM of penetrating SW in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RH regions.

Important learning points arising from the focused issue dedicated to the Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management.

The Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management was formulated in Germany by military medical personnel, who have been deployed to conflict areas, but also work in hospitals open for the lay public. In this manuscript we discuss different concepts and ideas taught in this course as these are described in a focused issue recently published in the European Journal of Trauma and Emergency Surgery. We provide reinforcement for some of the ideas conveyed. We provide alternative views for others. Injuries following explosions are different from blunt and penetrating trauma and at times demand a different approach. There are probably several ways to manage a mass casualty incident depending on the setup of the organization. An open discussion on the topics presented in the manuscripts included in the focused issue on military and disaster surgery should enrich everyone.

Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study.

PURPOSE: Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. METHODS: A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. RESULTS: The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. CONCLUSION: Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Relevance of pneumoperitoneum in the conservative approach to complicated acute diverticulitis. A retrospective study identifying risk factors associated with treatment failure.

BACKGROUND: The aim of this study is to evaluate the relevance of pneumoperitoneum on the success rate of non-operative management (NOM) of patients with complicated acute diverticulitis (AD), and the risk factors associated with failure. METHODS: Observational retrospective cohort study of patients attended at the emergency department for AD from January 2015-August 2019. Patient demographics, blood tests, radiological data and initial treatment strategies were registered. NOM, based on intravenous antibiotics (ATB) and bowel rest, was defined as unsuccessful when emergency surgery (ES) and/or infection-related death took place. Patients initially treated with ES were excluded. Analysis was done with the IBM SPSS statistics 23.0.0.2 software. RESULTS: According to modified Hinchey and WSES criteria, 99 (12%) of 826 AD episodes were complicated, with pneumoperitoneum on the CT scan in 89 (90.5%). NOM was undertaken in 93 (94%) cases, with a 91.5% success rate. Multivariate analysis revealed ASA class III-IV, and the presence of fluid collections >3 cm in diameter, but not distant free air, to be associated with NOM failure. However, the success rate of NOM was significantly higher in patients with pericolic pneumoperitoneum (98.5%) than in those with distant free air (80%) (P=0.02). Risk factors of NOM failure were an advanced age, high CRP and WBC values, and the presence of free fluid in >2 abdominal quadrants. CONCLUSIONS: NOM in hemodynamically stable patients with complicated AD is a safe and feasible approach, even in the context of distant free air. Nevertheless, patients with isolated pericolic air did better in our series.

Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen. / Relación entre la localización anatómica y el manejo selectivo no operatorio de las heridas por arma blanca penetrantes en abdomen.

INTRODUCTION: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. METHODS: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. RESULTS: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy. CONCLUSIONS: SNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions.

Emergency surgery and trauma care during COVID-19 pandemic. Recommendations of the Spanish Association of Surgeons / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients

La infección por el nuevo coronavirus SARS-COV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados

Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos / Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]. / Atención de la urgencia quirúrgica durante la pandemia COVID-19. Recomendaciones de la Asociación Española de Cirujanos.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugía-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.

Prehospital triage for mass casualty incidents using the META method for early surgical assessment: retrospective validation of a hospital trauma registry.

BACKGROUND: In mass casualty incidents (MCI), death usually occurs within the first few hours and thus early transfer to a trauma centre can be crucial in selected cases. However, most triage systems designed to prioritize the transfer to hospital of these patients do not assess the need for surgery, in part due to inconclusive evidence regarding the value of such an assessment. Therefore, the aim of the present study was to evaluate the capacity of a new triage system-the Prehospital Advanced Triage Method (META)-to identify victims who could benefit from urgent surgical assessment in case of MCI. METHODS: Retrospective, descriptive, observational study of a multipurpose cohort of patients included in the severe trauma registry of the Gregorio Marañón University General Hospital (Spain) between June 1993 and December 2011. All data were prospectively evaluated. All patients were evaluated with the META system to determine whether they met the criteria for urgent transfer. The META defines patients in need of urgent surgical assessment: (a) All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee, (b) Open pelvic fracture, (c) Closed pelvic fracture with mechanical or haemodynamic instability and (d) Blunt torso trauma with haemodynamic instability. Patients who fulfilled these criteria were designated as "Urgent Evacuation for Surgical Assessment" (UESA) cases; all other cases were designated as non-UESA. The following variables were assessed: patient status at the scene; severity scales [RTS, Shock index, MGAP (Mechanism, Glasgow coma scale, Age, pressure), GCS]; need for surgery and/or interventional procedure to control bleeding (UESA); and mortality. The two groups (UESA vs. non-UESA) were then compared. RESULTS: A total of 1882 cases from the database were included in the study. Mean age was 39.2 years and most (77%) patients were male. UESA patients presented significantly worse on-scene hemodynamic parameters (systolic blood pressure and heart rate) and greater injury severity (RTS, shock index, and MGAP scales). No differences were observed for respiratory rate, need for orotracheal intubation, or GCS scores. The anatomical injuries of patients in the UESA group were less severe but these patients had a greater need for urgent surgery and higher mortality rates. CONCLUSION: These findings suggest that the META triage classification system could be beneficial to help identify patients with severe trauma and/or in need of urgent surgical assessment at the scene of injury in case of MCI. These findings demonstrate that, in this cohort, the META fulfils the purpose for which it was designed.

Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados / Pelvic fractures with associated retroperitoneal hematoma: time until angioembolization and results

Introducción: El tratamiento de las fracturas de pelvis con hematoma retroperitoneal (HRP) es controvertido. Especialmente la necesidad de angioembolización (AE) cuando no hay extravasación de contraste (EC) en la tomografía computarizada (TC) o angiografía. Otro aspecto relevante es el retraso hasta la misma. Nuestro objetivo ha sido determinar si existen diferencias en el tiempo hasta la AE entre los pacientes admitidos durante el horario laboral y los admitidos fuera del mismo y durante los fines de semana y festivos. Nuestra hipótesis era que la angiografía y AE serían más frecuentes en el horario laboral, y el tiempo hasta las mismas sería superior fuera del horario laboral habitual, con una mortalidad mayor en este grupo para una gravedad global similar. Un objetivo secundario ha sido valorar la correlación entre EC en la TC y la angiografía. Métodos: Análisis retrospectivo de 2 cohortes de pacientes con HRP por fractura de pelvis. Se estudia la realización de angiografía dividiendo a los pacientes según su hora de llegada a lo largo de un periodo de 24 años (grupo A: horario laboral, y grupo B: fuera del mismo). La indicación de angiografía y AE fue realizada por la guardia de cirugía general, en consenso con el radiólogo intervencionista. Se han analizado variables demográficas, mecanismo lesivo, lesiones asociadas, gravedad fisiológica y anatómica, EC en la TC y la angiografía, necesidad de AE, estancia en unidad de cuidados intensivos (UCI) y mortalidad. Resultados: Se admitió a 104 pacientes con diagnóstico de HRP por fractura pélvica. Se realizó angiografía, con AE en 63 casos (61%). Los grupos eran comparables en las variables analizadas. En el 70% de los pacientes del grupo A se realizó angiografía, frente al 57% del grupo B, sin diferencias en tiempo hasta la AE. Se demostró EC en la TC en 53 de los 96 pacientes en los que se hizo, lo que se confirmó mediante angiografía en el 85%. No hubo diferencias estadísticamente significativas de mortalidad entre ambos grupos. Conclusiones: Se demuestra un tiempo corto entre la admisión en Urgencias y la AE, sin relación con el momento del ingreso durante el día, y una buena correlación entre la EC en la TC y la angiografía

Introduction: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. Methods: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. Results: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. Conclusions: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography

Pelvic fractures with associated retroperitoneal hematoma: time until angioembolization and results. / Fracturas de pelvis con hematoma retroperitoneal asociado: tiempo hasta la angioembolización y resultados.

INTRODUCTION: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. METHODS: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. RESULTS: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. CONCLUSIONS: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography.

Enfisema gástrico como presentación de síndrome de Boerhaave / Boerhaave syndrome presenting as gastric emphysema

No disponible

El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España / The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain

El modelo Acute Care Surgery agrupa bajo una misma disciplina el trauma, la cirugía de urgencias y los cuidados intensivos posquirúrgicos. Concebido y extendido durante las 2 últimas décadas por territorio norteamericano, la magnitud e idiosincrasia clínica de la urgencia quirúrgica han hecho que este modelo se haya asumido en muchos otros puntos de la geografía mundial. En nuestro país, el reflejo ha sido la creación e implantación de las denominadas unidades de trauma y cirugía de urgencias, cuyos objetivos son comunes a las publicadas para el modelo original: evitar la nocturnidad en las urgencias quirúrgicas, liberar a los profesionales vinculados a la cirugía electiva en horario laboral y convertirse en el eslabón y referente perfectos de la continuidad asistencial. En el presente artículo se resumen el nacimiento y la expansión del modelo original, la evidencia aportada en cuanto a resultados y la situación actual en nuestro país

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. / El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Hemodynamic consequences of extremity injuries following a terrorist bombing attack: retrospective cohort study.

BACKGROUND: Extremities are commonly injured following bomb explosions. The main objective of this study was to evaluate the prevalence of hemorrhagic shock (HS) in victims of explosion suffering from extremity injuries. METHODS: Retrospective study based on a cohort of patient records maintained in one hospital's mass casualty registry. RESULTS: Sixty-six victims of explosion who were hospitalized with extremity injuries were identified and evaluated. Sixteen (24.2%) of these were hemodynamically unstable during the first 24 h of treatment. HS could be attributed to associated injuries in seven of the patients. In the other nine patients, extremity injury was the only injury that could explain HS in seven patients and the extremity injury was a major contributor to HS together with another associated injury in two patients. In those 9 patients, in whom the extremity injury was the sole or major contributor to HS, a median of 10 (range 2-22) pRBC was transfused during the first 24 h of treatment. Six of the nine patients were in need of massive transfusion. Fractures in both upper and lower extremities, Gustilo IIIb-c open fractures and AIS 3-4 were found to be risk factors for HS. CONCLUSIONS: Ample consideration should be given to patients with extremity injuries due to explosions, as these may be immediately life threatening. Tourniquet use should be encouraged in the pre-hospital setting. Before undertaking surgery, emergent HS should be considered in these patients and prevented by appropriate resuscitation.

Teaching courses in the management of visceral trauma. / Docencia en el manejo del traumatismo visceral.

Several changes introduced in the management of trauma during the last two decades have considerably decreased the practical exposure to bleeding trauma patients by residents and young surgeons. Hemorrhage still represents the second cause of death from trauma worldwide, and the surgical maneuvers required for its control must be learned and practised in specific courses. These courses address the "second hour" of trauma, beyond ATLS©, and also emphasize the decision-making process, communication among team members, and discussion of clinical scenarios. The significant progress made in simulation technologies and virtual reality systems have yet to replace living tissue models to train surgeons in the rapid control of active bleeding, although that replacement is probably not far away.