Use of Temporary Abdominal Closure in Non-Trauma Surgery: A Cohort Study.

BACKGROUND: Damage control surgery in trauma is widely used but the evidence for the use of laparostomy in non-trauma abdominal emergencies is limited. This study aimed to characterise outcomes in emergency abdominal surgery by comparing laparostomy to one-stage laparotomy for patients of similar illness severity. METHODS: A retrospective study of adult patients requiring emergency abdominal surgery and post-operative intensive care stay was performed between 2016 and 2020 at a major Australian metropolitan hospital. Case selection was from a prospectively maintained database, and case notes were reviewed. Patients having delayed abdominal closure were compared with those having one-stage abdominal closure. The primary outcome was odds of in-hospital mortality. The secondary outcomes included intensive care unit length of stay (LOS), overall hospital LOS, definitive stoma rate and discharge destination. Multivariable logistic regression analysis was performed to adjust for potentially confounding variables. RESULTS: Two hundred and eighteen patients met inclusion criteria (80 laparostomy and 138 non-laparostomy). The most common indications for laparostomy were bowel ischaemia (41.3%), sepsis (26.3%) and physiological instability (22.5%). There was no evidence of difference in odds of in-hospital mortality between groups (adjusted OR = 1.67, CI: 0.85-3.28; p = 0.138). Patients requiring laparostomy had a slightly longer median ICU LOS (4 vs. 3 days; p < 0.001), similar median hospital LOS (19 vs. 14 days, p = 0.245) and similar discharge destination. There was no difference in stoma rate (35.0% vs. 35.5%). CONCLUSION: Compared with standard one-stage laparotomy, laparostomy resulted in similar odds of in-hospital mortality in emergency abdominal surgery patients requiring intensive care.

Emergency Management of Gallbladder Disease: Are Acute Surgical Units the New Gold Standard?

INTRODUCTION: Since 2011, all acute general surgical admissions have been managed by the consultant-led emergency general surgery service (EGS) at our institution. We aim to compare EGS management of acute biliary disease to its preceding model. MATERIALS AND METHODS: Retrospective review of prospectively collated databases was performed to capture consecutive emergency admissions with biliary disease from 1st February 2009 to 31st January 2013. Patient demographics, surgical intervention, use of diagnostic radiology, histological diagnosis, complications and hospital length of stay (LOS) were retrieved. RESULTS: A total of 566 patients were included (pre-EGS 254 vs. EGS 312). In the EGS period, the number of patients having surgery on index admission increased from 43.7 to 58.7 % (p < 0.001) as did use of intra-operative cholangiography from 75.7 to 89.6 % (p = 0.003). The conversion to open cholecystectomy rate also was reduced from 14.4 to 3.3 % (p < 0.001). Overall, a 14 % reduction in use of multiple (>1) imaging modalities for diagnosis was noted (p = 0.003). There was a positive trend in reduction of bile leaks but no significant difference in the overall morbidity and mortality. Time to theatre was reduced by 1 day [pre-EGS 2.7 (IQR 1.5-5.0) vs. EGS 1.7 (IQR 1.2-2.6) p < 0.001]. The overall hospital LOS was reduced by 1.5 days [pre-EGS 5.0 (IQR 3-7) vs. EGS 3.5 (IQR 2-5) p < 0.001]. CONCLUSION: Since the advent of EGS, more judicious use of diagnostic radiology, reduced complications, reduced LOS, reduced time to theatre and an increased rate of definitive management during the index admission were demonstrated.

'No zone' approach in the management of penetrating neck injuries - an Australian Tertiary Trauma Centre experience.

PURPOSE: Penetrating neck injuries (PNIs), defined as deep to the platysma, can result in significant morbidity and mortality. Management has evolved from a zone-based approach to a 'no zone' algorithm, resulting in reduced non-therapeutic neck exploration rates. The aim of this study was to examine PNIs and its management trends in an Australian tertiary trauma centre, to determine if a 'no zone' approach could be safely implemented in this population, as has been demonstrated internationally. METHODOLOGY: This was a retrospective observational study at a level 1 adult Australian tertiary trauma centre using prospectively collated data from January 2008 to December 2018. Observed data included age, gender, mechanism of injury, computed tomography angiography (CT-A) use and operative intervention. Patients were examined based on zone of injury and presenting signs - 'hard', 'soft' or 'asymptomatic'. Major outcomes were CT-A usage, positive CT-A correlation with therapeutic neck explorations and negative neck exploration rates. RESULTS: This study identified 238 PNI patients, with 204 selected for review. Most injuries occurred in zone 2 (71.6%), with soft signs accounting for 53.4% of cases. Over 10 years, CT-A utilization increased from 55% to 94.1%, with positive CT-As being more likely to yield therapeutic neck explorations. There was a general decreased trend in operative intervention but without a clear reduction in non-therapeutic neck explorations. CONCLUSION: Our data suggests similarities with results from around the world, demonstrating that the 'no zone' approach should be considered when managing PNIs, but with clinician discretion in individual cases.

Paradigms in trauma laparoscopy for anterior abdominal stab wounds: A scoping review.

INTRODUCTION: Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW. METHODOLOGY: Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure. RESULTS: Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury. CONCLUSION: This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/hospital experience, patient factors, and resource availability.

Defining futile and potentially avoidable interhospital trauma transfers.

PURPOSE: Interhospital transfer of critically injured patients to a major trauma service reduces preventable death in major trauma. Yet some of those transferred die without intervention. These 'futile' interhospital trauma transfers (IHTs), and other potentially avoidable IHTs place enormous stress on families of trauma victims, can delay care, and incur great cost to public health resources. This study sought to characterise these IHTs using current state guidelines for interhospital transfer. METHODS: A retrospective cohort study was conducted using our institution's trauma registry from January 2016-December 2020. All adult patients transferred to our major trauma service were analysed. Futile IHTs were defined as death or transfer to hospice care without surgical, endoscopic, or radiological intervention, and without ICU admission, within 72 h of admission. Potentially avoidable IHTs were defined as all patients discharged alive without intervention or ICU care, and secondary over-triage patients are a subset of these patients who were discharged within 72 h of admission. Patient demographics, injuries, and treatments were categorised from electronic records and analysed. RESULTS: Of 2,837 IHTs, seven (0.2 %) met criteria for futility. The majority were female, median age of 80 (IQR 85-75) and had a median Injury Severity Score (ISS) of 16 (IQR 25.5-11.5). By contrast, 1391 patients (49 %) were classified as potentially avoidable and 513 (18 %) were considered secondary over-triage. The majority were male, median age of 43 (IQR 62-28), and had a median ISS of 9 (IQR 13-4). Of these potentially avoidable IHTs, 984 (70.7 %) were discharged directly home. CONCLUSION: Futile IHTs were infrequent, however over half of all trauma patients transferred from other hospitals were discharged without tertiary-level intervention. Trauma services should consider developing systems such as telehealth to support regional general and orthopaedic surgeons to co-manage lower risk trauma, particularly minor head and minor spinal trauma patients. This could be an integral part of safely reducing potentially avoidable IHTs and their associated costs while maintaining a low rate of preventable mortality in trauma.

An algorithm for the management of traumatic abdominal wall hernia based on a 9-year review.

BACKGROUND: Traumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma, usually in the setting of multitrauma, with little consensus or guidelines for management. We present a case series of patients with traumatic herniae over a 9-year period and a suggested management algorithm. METHOD: Retrospective review of all patients with TAWH from 1st January 2011 to 31st December 2019 at a Level 1 adult Major Trauma Centre. Clinical presentation, surgical intervention and complications and recurrence were analysed. RESULTS: Forty-seven patients were found to have TAWH, 0.5% of all major trauma admissions. Thirty (63.8%) were repaired, 12 acutely, 11 semi-acute and 7 delayed. All but 1 (fall>3 m) were transport associated, with a median Injury Severity Score (ISS) of 29. Follow-up data for operative cases were available for all but one (97%). Seven (23.3%) cases had a recurrence, more common in the acute repair group (33.3%) compared to semi-acute (18.2%), and elective group (14.3%). CONCLUSION: TAWH is a rare but potentially serious consequence of blunt abdominal trauma. This series has favoured earlier repair for anterior TAWH, or all those undergoing a laparotomy for other reasons, and elective repair for lumbar or lateral TAWH that do not require a laparotomy for other conditions. We present our preferred algorithm for management, accepting that there are many available strategies in this heterogeneous group of injuries. Loss of follow up and recurrence are a concern, and clinicians are encouraged to develop processes to ensure that TAWH are not a 'forgotten hernia'.

Timing and methods of frailty assessments in geriatric trauma patients: A systematic review.

INTRODUCTION: The trauma population is aging and better prognostic measures for geriatric trauma patients are required. Frailty rather than age appears to be associated with poor outcomes. This systematic review aimed to identify the optimum frailty assessment instrument and timing of assessment in patients aged over 65 years admitted to hospital after traumatic injury. The secondary aim was to evaluate outcomes associated with frailty in elderly trauma populations. METHODS: This systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018090620). A MEDLINE and EMBASE literature search was conducted from inception to June 2019 combining the concepts of injury, geriatric, frailty, assessment and prognosis. Included studies were in patients 65 years or older hospitalised after injury and exposed to an instrument meeting consensus definition for frailty assessment. Study quality was assessed using criteria for review of prognostic studies combined with a GRADE approach. RESULTS: Twenty-eight papers met inclusion criteria. Twenty-eight frailty or component instruments were reported, and assessments of pre-injury frailty were made up to 1-year post injury. Pre-injury frailty prevalence varied from 13% (13/100) to 94% (17/18), with in-hospital mortality rates from 2% (5/250) to 33% (6/18). Eleven studies found an association between frailty and mortality. Eleven studies reported an association between frailty and a composite outcome of mortality and adverse discharge destination. Generalisability and assessment of strength of associations was limited by single centre studies with inconsistent findings and overlapping cohorts. CONCLUSIONS: Associations between frailty and adverse outcomes including mortality in geriatric trauma patients were demonstrated despite a range of frailty instruments, administering clinicians, time of assessment and data sources. Although evidence gaps remain, incorporating frailty assessment into trauma systems is likely to identify geriatric patients at risk of adverse outcomes. Consistency in frailty instruments and long-term geriatric specific outcome measures will improve research relevance. LEVEL OF EVIDENCE: Level III prognostic.

Impact of introduction of an acute surgical unit on management and outcomes of small bowel obstruction.

BACKGROUND: The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes. METHODS: A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality. RESULTS: Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02). CONCLUSION: The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change.

Radiation fear: Impact on compliance with trauma imaging guidelines in the pregnant patient.

BACKGROUND: The Royal Melbourne Hospital is a Level 1 adult trauma center, and due to its colocation with The Royal Women's Hospital, it functions as the state's major obstetric trauma center. Obstetric trauma guidelines have been established to facilitate management of pregnant patients, yet adherence to these recommendations has not been evaluated. The aim of this study was to assess compliance with recommended imaging guidelines in obstetric trauma patients. METHODS: The prospectively collated trauma registry at Royal Melbourne Hospital was used to identify obstetric trauma presentations to the emergency department from January to December 2012. Demographics, mechanism of injury, clinical examination findings, and the use of diagnostic radiology were collected to determine adherence to recommended imaging guidelines. RESULTS: Of 74 obstetric trauma patients, the most common mechanisms of injury were motor vehicle collisions (81%), assaults (8%), and falls (7%). Despite the mechanism and severity of injury, 29 patients (39%) did not undergo imaging during their initial emergency department assessment. All of the remaining 45 patients (61%) were imaged as part of their assessment; however, plain x-rays were often used to avoid imaging with computed tomography.Of the 32 patients identified with a high-risk mechanism, chest x-ray was used in 84.4%, pelvic x-ray in 28.1%, and computed tomography-angiography in 34.4%. In the high-risk mechanism group, the compliance rate with guidelines was only 18.8% (6 patients had the recommended radiologic assessment). CONCLUSION: Concerns about fetal radiation have resulted in a low compliance rate with recommended trauma guidelines at our institution. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.