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Tian BW. The rise of ACS and its importance. World J Emerg Surg 2024; 19:9. [PMID: 38459488 PMCID: PMC10921708 DOI: 10.1186/s13017-024-00538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Affiliation(s)
- Brian Wca Tian
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore, S169608, Singapore.
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2
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Fernandez CA. Damage Control Surgery and Transfer in Emergency General Surgery. Surg Clin North Am 2023; 103:1269-1281. [PMID: 37838467 DOI: 10.1016/j.suc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.
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Affiliation(s)
- Carlos A Fernandez
- Department of Surgery, Creighton University Medical Center, 7710 Mercy Road, Suite 2000, Omaha, NE 68124, USA.
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3
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Blank J, Shiroff AM, Kaplan LJ. Surgical Emergencies in Patients with Significant Comorbid Diseases. Surg Clin North Am 2023; 103:1231-1251. [PMID: 37838465 DOI: 10.1016/j.suc.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.
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Affiliation(s)
- Jacqueline Blank
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA
| | - Adam M Shiroff
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
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4
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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5
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Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre. Antibiotics (Basel) 2022; 11:antibiotics11111498. [PMID: 36358153 PMCID: PMC9686976 DOI: 10.3390/antibiotics11111498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (<0.001), Mannheim Peritonitis Index > 30 (p = 0.001) and APACHE II score (p < 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08−4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.
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Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:1075-1085. [PMID: 34882591 DOI: 10.1097/ta.0000000000003488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND After the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies. METHODS Systematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores. RESULTS A total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, -0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, -0.18; 95% confidence interval, -0.29 to -0.06). CONCLUSION This meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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7
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Factors Associated with Inability to Perform Delayed Primary Fascial Closure of Open Abdomen in Trauma Patients: a Retrospective Observational Study. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03184-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kwon E, Krause C, Luo-Owen X, McArthur K, Cochran-Yu M, Swentek L, Burruss S, Turay D, Krasnoff C, Grigorian A, Nahmias J, Butt A, Gutierrez A, LaRiccia A, Kincaid M, Fiorentino M, Glass N, Toscano S, Ley EJ, Lombardo S, Guillamondegui O, Bardes JM, DeLa'O C, Wydo S, Leneweaver K, Duletzke N, Nunez J, Moradian S, Posluszny J, Naar L, Kaafarani H, Kemmer H, Lieser M, Hanson I, Chang G, Bilaniuk JW, Nemeth Z, Mukherjee K. Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry). Eur J Trauma Emerg Surg 2021; 48:2107-2116. [PMID: 34845499 DOI: 10.1007/s00068-021-01814-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE 2B.
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Affiliation(s)
- Eugenia Kwon
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Cassandra Krause
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Xian Luo-Owen
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | | | - Meghan Cochran-Yu
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Lourdes Swentek
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Sigrid Burruss
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - David Turay
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Chloe Krasnoff
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Jeffrey Nahmias
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Ahsan Butt
- USC-Keck School of Medicine, Los Angeles, CA, USA
| | - Adam Gutierrez
- General Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Aimee LaRiccia
- General Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Michelle Kincaid
- General Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Michele Fiorentino
- Trauma and Surgical Critical Care, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Nina Glass
- Trauma and Surgical Critical Care, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Samantha Toscano
- General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric Jude Ley
- General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sarah Lombardo
- Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oscar Guillamondegui
- Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James Migliaccio Bardes
- Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Connie DeLa'O
- Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Salina Wydo
- Trauma, Cooper University Health System, Camden, NJ, USA
| | | | - Nicholas Duletzke
- General Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Jade Nunez
- General Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Simon Moradian
- Trauma and Critical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Joseph Posluszny
- Trauma and Critical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Leon Naar
- Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham Kaafarani
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Kemmer
- Surgery, Research Medical Center-Kansas City Hospital, Kansas City, MO, USA
| | - Mark Lieser
- Surgery, Research Medical Center-Kansas City Hospital, Kansas City, MO, USA
| | - Isaac Hanson
- Trauma and Critical Care Surgery, Mount Sinai Hospital-Chicago, Chicago, IL, USA
| | - Grace Chang
- Trauma and Critical Care Surgery, Mount Sinai Hospital-Chicago, Chicago, IL, USA
| | | | - Zoltan Nemeth
- Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA.
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Iacono SA, Krumrei NJ, Niroomand A, Walls DO, Lissauer M, To J, Butts CA. Age Is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery. J Surg Res 2021; 267:452-457. [PMID: 34237630 DOI: 10.1016/j.jss.2021.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/24/2021] [Accepted: 05/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.
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Affiliation(s)
- Stephen A Iacono
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nicole J Krumrei
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anna Niroomand
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David O Walls
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Matthew Lissauer
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jennifer To
- St. Luke's University Health Network, Bethlehem, Pennsylvania
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McArthur K, Krause C, Kwon E, Luo-Owen X, Cochran-Yu M, Swentek L, Burruss S, Turay D, Krasnoff C, Grigorian A, Nahmias J, Butt A, Gutierrez A, LaRiccia A, Kincaid M, Fiorentino MN, Glass N, Toscano S, Ley E, Lombardo SR, Guillamondegui OD, Bardes JM, DeLa'O C, Wydo SM, Leneweaver K, Duletzke NT, Nunez J, Moradian S, Posluszny J, Naar L, Kaafarani H, Kemmer H, Lieser MJ, Dorricott A, Chang G, Nemeth Z, Mukherjee K. Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial). J Trauma Acute Care Surg 2021; 91:100-107. [PMID: 34144559 PMCID: PMC8331055 DOI: 10.1097/ta.0000000000003210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population. METHODS We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head. RESULTS Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001). CONCLUSION Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Kaitlin McArthur
- From the Division of Acute Care Surgery (K. McArthur), Loma Linda University School of Medicine, Loma Linda, California; Division of Acute Care Surgery (C.K., E.K., X.L.-O., M.C.-Y., S.B., D.T., K. Mukherjee), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma, Burns, Critical Care, and Acute Care Surgery (L.S., C.K., A.G., J. Nahmias), UC Irvine Medical Center, Irvine, California; Division of Trauma and Critical Care (A.B., A.G.), LAC+USC Medical Center, Los Angeles, California; Grant Medical Center Trauma Services (A.L., M.K.), Ohio Health Grant Medical Center, Columbus, Ohio; Division of Trauma/Surgical Critical Care (M.N.F., N.G.), Rutgers-New Jersey Medical School, Newark, New Jersey; Division of Trauma (S.T., E.L.), Cedars-Sinai Medical Center, Los Angeles, California; Division of Trauma and Surgical Critical Care (S.R.L., O.D.G.), Vanderbilt University Medical Center, Nashville, Tennessey; Division of Trauma/Acute Care Surgery/Critical Care (J.M.B., C.D.), West Virginia University, Morgantown, West Virginia; Division of Trauma (S.M.W., K.L.), Cooper University Health System, Camden, New Jersey; Section of Acute Care Surgery (N.T.D., J. Nunez), University of Utah Medical Center, Salt Lake City, Utah; Division of Trauma and Critical Care Surgery (S.M., J.P.), Northwestern Memorial Hospital, Chicago, Illinois; Division of Trauma, Emergency Surgery and Surgical Critical Care (L.N., H. Kaafarani), Massachusetts General Hospital, Boston, Massachusetts; Trauma Center (H. Kemmer, M.J.L.), Research Medical Center-Kansas City Hospital, Kansas City, Missouri; Mount Sinai Hospital-Chicago (A.D., G.C.), Chicago, Illinois; and Trauma and Acute Care Center (Z.N.), Morristown Medical Center, Morristown, New Jersey
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11
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Current opinion on emergency general surgery transfer and triage criteria. J Trauma Acute Care Surg 2021; 89:e71-e77. [PMID: 32467469 DOI: 10.1097/ta.0000000000002806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Rodríguez-Holguín F, Serna JJ, Salcedo A, García A, Orlas C, Pino LF, Del Valle AM, Mejia D, Salamea-Molina JC, Brenner M, Hörer T. REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4064506. [PMID: 33795901 PMCID: PMC7968426 DOI: 10.25100/cm.v51i4.4422.4506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Claudia Orlas
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, USA.,Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, USA
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | | | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellin, Colombia.,Universidad de Antioquia, Department of Surgery, Medellin, Colombia
| | - Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery. Cuenca, Ecuador.,Universidad del Azuay, Escuela de Medicina. Cuenca, Ecuador
| | - Megan Brenner
- University of California, Department of Surgery Riverside University Health Systems. Riverside, CA, USA
| | - Tal Hörer
- 15 Örebro University Hospital, Faculty of Medicine, Department of Cardiothoracic and Vascular Surgery, Örebro, Sweden
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13
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Okada I, Hifumi T, Kiriu N, Yoneyama H, Inoue K, Seki S, Hasegawa E, Kato H, Masuno T, Yokobori S. Preoperative physical functional status affects the long-term outcomes of elderly patients with open abdomen. Acute Med Surg 2020; 7:e602. [PMID: 33282315 PMCID: PMC7700104 DOI: 10.1002/ams2.602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/08/2020] [Accepted: 10/16/2020] [Indexed: 11/08/2022] Open
Abstract
Aim The mortality rates among elderly patients with open abdomen (OA) are high, and pre-existing comorbidities could affect the outcomes. However, long-term prognosis remains uncertain. We examined long-term outcomes in elderly patients with OA, focusing on physical functional status. Methods We undertook a retrospective cohort study between 2007 and 2017 at a single institution. Patients with OA who were aged ≥65 years were categorized into two groups: "good preoperative functional status" group (GFG) and "poor preoperative functional status" group (PFG). The GFG was defined as Eastern Cooperative Oncology Group/World Health Organization performance status (PS) 0-1, whereas PFG was defined as PS 2-4. The primary outcomes were survival and PS 2 years following the initial surgery. Results Of the 53 participants, 38 and 15 were assigned to the GFG and PFG, respectively. The PFG (median age, 81 years) was older than the GFG (median age, 75.5 years; P = 0.040). The 2-year survival rate was 39.5% in GFG and 6.7% in PFG, and Kaplan-Meier analysis showed significant difference (P = 0.022). Among all patients, the PS at 2 years was worse than that at discharge (P = 0.007). Preoperative PS was correlated with 2-year survival (P = 0.003), whereas age and pre-existing comorbidities were not. Conclusion The long-term outcomes of elderly patients with OA are affected by the preoperative physical functional status. Functional status deteriorates in a time-dependent manner. Therefore, surgery requiring OA must be carefully considered for elderly patients with PS 2 or higher.
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Affiliation(s)
- Ichiro Okada
- Department of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Toru Hifumi
- Department of Emergency Medicine St. Luke's International Hospital Tokyo Japan
| | - Nobuaki Kiriu
- Department of Traumatology and Critical Care Medicine National Defense Medical College Tokorozawa Japan
| | - Hisashi Yoneyama
- Department of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Kazushige Inoue
- Department of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Satoshi Seki
- Department of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Eiju Hasegawa
- Department of Critical Care Medicine and Trauma National Hospital Organization Disaster Medical Center Tokyo Japan
| | - Hiroshi Kato
- Department of Emergency Medicine Minamitama Hospital Tokyo Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine Nippon Medical School Hospital Tokyo Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Nippon Medical School Hospital Tokyo Japan
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14
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Lee RK, Gallagher JJ, Ejike JC, Hunt L. Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society. Crit Care Nurse 2020; 40:13-26. [PMID: 32006038 DOI: 10.4037/ccn2020772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.
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Affiliation(s)
- Rosemary K Lee
- Rosemary K. Lee is an acute care nurse practitioner and clinical nurse specialist at Baptist Health South Florida, Coral Gables, Florida
| | - John J Gallagher
- John J. Gallagher is a clinical nurse specialist and trauma program coordinator, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Janeth Chiaka Ejike
- Janeth Chiaka Ejike is an associate professor of pediatrics, pediatric critical care medicine practitioner, and Program Director of the Pediatric Critical Care Medicine Fellowship at Loma Linda University Children's Hospital, Loma Linda, California
| | - Leanne Hunt
- Leanne Hunt is a senior lecturer at Western Sydney University and a registered nurse at Liverpool Hospital, Sydney, Australia
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15
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Ordoñez CA, Parra M, García A, Rodríguez F, Caicedo Y, Serna JJ, Salcedo A, Franco J, Toro LE, Ordoñez J, Pino LF, Guzmán M, Orlas C, Herrera JP, Aristizábal G, Pata F, Di Saverio S. Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management: Proposal of a New Decision-Making Algorithm. World J Surg 2020; 45:1043-1052. [PMID: 33151371 DOI: 10.1007/s00268-020-05854-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Damage control surgery (DCS) has emerged as a new option in the management of non-traumatic peritonitis patients to increase survival in critically ill patients. The purpose of this study was to compare DCS with conventional strategy (anastomosis/ostomies in the index laparotomy) for severe non-traumatic peritonitis regarding postoperative complications, ostomy rate, and mortality and to propose a useful algorithm in the clinical practice. METHODS Patients who underwent an urgent laparotomy for non-trauma peritonitis at a single level I trauma center in Colombia between January 2003 and December 2018, were retrospectively included. We compared patients who had DCS management versus definitive initial surgical management (DISM) group. We evaluated clinical outcomes and morbidities among groups. RESULTS 290 patients were included; 81 patients were treated with DCS and 209 patients underwent DISM. Patients treated with DCS had a worse critical status before surgery with higher SOFA score [median, DCS group: 5 (IQR: 3-8) vs. DISM group: 3 (IQR: 1-6), p < 0.001]. The length of hospital stay and overall mortality rate of DCS group were not significant statistical differences with DISM group. Complications rate related to primary anastomosis or primary ostomy was similar. There is not difference in ostomy rate among groups. At multivariate analysis, SOFA > 6 points and APACHE-II > 20 points correlated with a higher probability of DCS. CONCLUSION DCS in severe non-trauma peritonitis patients is feasible and safe as surgical strategy management without increasing mortality, length hospital of stay, or complications. DCS principles might be applied in the non-trauma scenarios without increase the stoma rate.
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Affiliation(s)
- Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia. .,Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cali, Colombia.
| | - Michael Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Alberto García
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia.,Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cali, Colombia
| | - Fernando Rodríguez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia
| | - Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia
| | - José Julián Serna
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia.,Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cali, Colombia
| | - Alexander Salcedo
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia.,Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cali, Colombia
| | - Josefa Franco
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia
| | - Luis Eduardo Toro
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia
| | - Juliana Ordoñez
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cali, Colombia
| | - Luis Fernando Pino
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cali, Colombia
| | - Mónica Guzmán
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia
| | - Claudia Orlas
- Center for Surgery and Public Health, Department of Surgery, Harvard Medical School & Harvard T.H. Chan School of Public Health, Brigham & Women's Hospital, Boston, MA, USA
| | - Juan Pablo Herrera
- Center for Surgery and Public Health, Department of Surgery, Harvard Medical School & Harvard T.H. Chan School of Public Health, Brigham & Women's Hospital, Boston, MA, USA
| | - Gonzalo Aristizábal
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, Cali, 760032, Colombia
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy.,La Sapienza University, Rome, Italy
| | - Salomone Di Saverio
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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16
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Santry HP, Strassels SA, Ingraham AM, Oslock WM, Ricci KB, Paredes AZ, Heh VK, Baselice HE, Rushing AP, Diaz A, Daniel VT, Ayturk MD, Kiefe CI. Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach. BMC Med Res Methodol 2020; 20:247. [PMID: 33008294 PMCID: PMC7532630 DOI: 10.1186/s12874-020-01096-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. METHODS We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. RESULTS Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. DISCUSSION Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. CONCLUSIONS Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).
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Affiliation(s)
- Heena P. Santry
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 614, Columbus, OH 43210 USA
| | - Scott A. Strassels
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Angela M. Ingraham
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI USA
| | - Wendelyn M. Oslock
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Kevin B. Ricci
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Anghela Z. Paredes
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Victor K. Heh
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Holly E. Baselice
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Amy P. Rushing
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Adrian Diaz
- Department of Surgery, Ohio State University Wexner Medical Center, 410 W 10th Avenue, Columbus, OH USA
- Center for Surgical Health Assessment, Research, and Policy, The Ohio State University, 395 W 12th Avenue, Columbus, OH USA
| | - Vijaya T. Daniel
- Department of Surgery, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - M. Didem Ayturk
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
| | - Catarina I. Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA USA
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17
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Meléndez JJ, Orlas Bolaños CP, Herrera-Escobar JP, Guzmán M, Alcázar K, Martínez JJ, Martínez Meneses MF, Villegas JP, Serna Arbelaez JJ, Salcedo AS, Leal LL, Angamarca E, Ordóñez J, García AF, Parra MW, Ordóñez Delgado CA. La laparotomía de control de daños en pacientes sin trauma reduce el número de ostomías. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El objetivo de este estudio fue evaluar si la laparotomía de control de daños con ligadura y reconstrucción intestinal diferida, en pacientes con peritonitis secundaria a compromiso de víscera hueca, reduce el número de ostomías.
Métodos. Se incluyeron todos los pacientes menores de 18 años de edad que ingresaron a la clínica con sospecha de peritonitis de origen no traumático y que se sometieron a laparotomía entre enero del 2003 y diciembre del 2018. Se evaluaron las características sociodemográficas, comorbilidades, escalas de gravedad fisiológica, técnicas de reconstrucción intestinal y resultados clínicos.
Resultados. Se incluyeron 306 pacientes, distribuidos en tres grupos: 1) 120 (39,2 %) sometidos a resección y anastomosis, 2) 87 (28,4 %) sometidos a ostomía, y 3) 99 (32,3 %) sometidos inicialmente a ligadura intestinal. Los pacientes sometidos a ligadura intestinal presentaron mayor compromiso fisiológico al ingreso a la unidad de cuidado intensivo, con puntuación APACHE II: 14 (rango intercuartílico, RIC=10-18) en el grupo 1, 13 (RIC=11-18) en el grupo 2, y 18 (RIC=14-24) en el grupo 3 (p<0,01). Sin embargo, más de la mitad se reconstruyeron en la siguiente laparotomía: anastomosis mecánica (16/99; 16,1 %), anastomosis manual (49/99; 49,5 %), ostomía (34/99; 34,3 %). Además, estos pacientes sometidos a ligadura intestinal tuvieron un número significativamente mayor de nuevas laparotomías, y de días de asistencia respiratoria mecánica, de estancia en la unidad de cuidado intensivo y de estancia hospitalaria. No hubo diferencias estadísticamente significativas en la mortalidad entre los subgrupos: (grupo 1=19 (15,8 %), grupo 2=16 (18,4 %), grupo 3=19 (19,2 %) (p=0,79).
Conclusión. En este estudio, se logró evitar la ostomía como técnica de reconstrucción definitiva en más de la mitad de los pacientes con peritonitis que se sometieron a laparotomía de control de daños con ligadura intestinal.
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18
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Evans NA, Hardie RJ, Walker J, Bach J. Temporary abdominal packing for management of persistent hemorrhage after liver lobectomy in three dogs with hepatic neoplasia. J Vet Emerg Crit Care (San Antonio) 2019; 29:535-541. [PMID: 31423720 DOI: 10.1111/vec.12873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 09/10/2017] [Accepted: 09/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the technique and outcome of temporary abdominal packing for control of persistent hemorrhage from liver lobectomy sites in 3 dogs with hepatic neoplasia. SERIES SUMMARY Three dogs were treated with massive transfusion for hemoperitoneum secondary to bleeding hepatic tumors. Surgical resection of the affected liver lobe(s) was performed but hemostasis could not be achieved through conventional methods. All 3 dogs demonstrated acidosis, hypothermia, and coagulopathy. Temporary abdominal packing of liver lobectomy sites was performed and hemostasis was achieved in all dogs. One dog died prior to removal of the packing. The other 2 dogs had the packing removed with no evidence of rebleeding. One dog was euthanized after removal of the packing due to acute kidney injury and the remaining dog survived to discharge. NEW OR UNIQUE INFORMATION PROVIDED Temporary abdominal packing combined with medical management was successful in achieving hemostasis in all 3 dogs, however, 2 dogs died of complications related to multiple organ dysfunction syndrome. Temporary abdominal packing may be considered when definitive surgical hemostasis cannot be achieved or in unstable patients not able to tolerate prolonged surgical times. Further research is needed to better define efficacy, optimal patient selection, packing technique, timing of removal, and complications associated with temporary abdominal packing.
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Affiliation(s)
- Natashia A Evans
- Department of Medical Sciences (Evans, Walker, Bach) and Department of Surgical Sciences (Hardie), School of Veterinary Medicine, University of Wisconsin, Madison, WI
| | - Robert J Hardie
- Department of Medical Sciences (Evans, Walker, Bach) and Department of Surgical Sciences (Hardie), School of Veterinary Medicine, University of Wisconsin, Madison, WI
| | - Julie Walker
- Department of Medical Sciences (Evans, Walker, Bach) and Department of Surgical Sciences (Hardie), School of Veterinary Medicine, University of Wisconsin, Madison, WI
| | - Jonathan Bach
- Department of Medical Sciences (Evans, Walker, Bach) and Department of Surgical Sciences (Hardie), School of Veterinary Medicine, University of Wisconsin, Madison, WI
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19
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Doig CJ, Page SA, McKee JL, Moore EE, Abu-Zidan FM, Carroll R, Marshall JC, Faris PD, Tolonen M, Catena F, Cocolini F, Sartelli M, Ansaloni L, Minor SF, Peirera BM, Diaz JJ, Kirkpatrick AW. Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis. World J Emerg Surg 2019; 14:39. [PMID: 31404221 PMCID: PMC6683332 DOI: 10.1186/s13017-019-0259-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study (https://clinicaltrials.gov/ct2/show/NCT03163095) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS. Main body Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity. Conclusions A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.
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Affiliation(s)
- Christopher J Doig
- 1Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.,2Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Stacey A Page
- 2Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jessica L McKee
- 3Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | | | - Fikri M Abu-Zidan
- 7Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, UAE
| | - Rosemary Carroll
- 8Surgical Services John Hunter Hospital, Newcastle, NSW Australia
| | - John C Marshall
- 6Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Peter D Faris
- 5Research Facilitation Analytics (DIMR), University of Calgary, Calgary, Alberta Canada
| | - Matti Tolonen
- 9Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Fausto Catena
- 10Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Cocolini
- 11General, Emergency and Trauma Surgery dept, Bufalini Hospital, Cesena, Italy
| | | | - Luca Ansaloni
- 13Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesena, Italy
| | - Sam F Minor
- 14Department of Critical Care and Department of Surgery, NSHA- Queen Elizabeth II Health Sciences Centre, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
| | - Bruno M Peirera
- 15Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Jose J Diaz
- 16Department of Surgery, Acute Care Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
| | - Andrew W Kirkpatrick
- 17Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,18Department of Surgery, University of Calgary, Calgary, Alberta Canada.,19EG23 Foothills Medical Centre, Calgary, Alberta T2N 2 T9 Canada
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Richman A, Burlew CC. Lessons from Trauma Care: Abdominal Compartment Syndrome and Damage Control Laparotomy in the Patient with Gastrointestinal Disease. J Gastrointest Surg 2019; 23:417-424. [PMID: 30276590 DOI: 10.1007/s11605-018-3988-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Aaron Richman
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA
| | - Clay Cothren Burlew
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA.
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22
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Girard E, Abba J, Boussat B, Trilling B, Mancini A, Bouzat P, Létoublon C, Chirica M, Arvieux C. Damage Control Surgery for Non-traumatic Abdominal Emergencies. World J Surg 2018; 42:965-973. [PMID: 28948335 DOI: 10.1007/s00268-017-4262-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Damage control surgery (DCS) was a major paradigm change in the management of critically ill trauma patients and has gradually expanded in the general surgery arena, but data in this setting are still scarce. The study aim was to evaluate outcomes of DCS in patients with general surgery emergencies. METHODS Between 2005 and 2015, 164 patients (104 men, age 66) underwent DCS for non-traumatic abdominal emergencies. The decision to perform DCS was triggered by the presence of at least one trauma DCS criterion: hypotension (<70 mmHg), hypothermia (<35 °C), acidosis (pH < 7.25), coagulopathy (INR ≥ 1.7) and massive (>5 RBC) transfusion. Statistical tests were performed to identify risk factors for operative mortality. Observed outcomes were compared to those predicted by commonly employed scores (APACHE II, POSSUM, P-POSSUM, SAPS II). RESULTS DCS was performed for acute mesenteric ischemia (n = 68), peritonitis (n = 44), pancreatitis (n = 28), bleeding (n = 14) and other (n = 10). Abdominal compartment syndrome was associated in 52 patients (32%). Seventy-four (45%) patients died and 150 patients (91%) experienced complications. On multivariate analysis, age (p = 0.018) and INR ≥ 1.7 (p = 0.001) were independent predictors of mortality. Mortality was 24% (13/55), 48% (22/46) and 62% (39/63) in patients with one, two and ≥3 DCS criteria, respectively. Comparison of observed and score-predicted mortality suggested DCS use resulted in significant survival benefit of the whole cohort and of patients with pancreatitis and postoperative peritonitis. CONCLUSIONS DCS can be lifesaving in critically ill patients with general surgery emergencies. Patients with peritonitis and acute pancreatitis are those who benefit most of the DCS approach.
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Affiliation(s)
- Edouard Girard
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France.
- TIMC Research Unit, CNRS, Grenoble-Alpes University, Grenoble, France.
- Service de Chirurgie Digestive et Générale, Hôpital Michallon, Centre Hospitalier Universitaire Grenoble-Alpes, Boulevard de la Chantourne, 38700, Grenoble, La Tronche, France.
| | - Julio Abba
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Bastien Boussat
- TIMC Research Unit, CNRS, Grenoble-Alpes University, Grenoble, France
- Quality of Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Bertrand Trilling
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France
- TIMC Research Unit, CNRS, Grenoble-Alpes University, Grenoble, France
| | - Adrian Mancini
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre Bouzat
- Anesthesiology and Intensive Care Medicine, Grenoble-Alpes University Hospital, Grenoble, France
| | - Christian Létoublon
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Mircea Chirica
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Catherine Arvieux
- Digestive and Emergency Surgery Department, Grenoble-Alpes University Hospital, Grenoble, France
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23
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Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, Agresta F, Allievi N, Bellanova G, Coccolini F, Coy C, Fugazzola P, Martinez CA, Montori G, Paolillo C, Penachim TJ, Pereira B, Reis T, Restivo A, Rezende-Neto J, Sartelli M, Valentino M, Abu-Zidan FM, Ashkenazi I, Bala M, Chiara O, De' Angelis N, Deidda S, De Simone B, Di Saverio S, Finotti E, Kenji I, Moore E, Wexner S, Biffl W, Coimbra R, Guttadauro A, Leppäniemi A, Maier R, Magnone S, Mefire AC, Peitzmann A, Sakakushev B, Sugrue M, Viale P, Weber D, Kashuk J, Fraga GP, Kluger I, Catena F, Ansaloni L. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018; 13:36. [PMID: 30123315 PMCID: PMC6090779 DOI: 10.1186/s13017-018-0192-3] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023] Open
Abstract
ᅟ Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC). Methods The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017. Results CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value. Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required. Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation. Conclusions The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.
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Affiliation(s)
- Michele Pisano
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Luigi Zorcolo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Cecilia Merli
- Unit of Emergency Medicine Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | | | - Elia Poiasina
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Marco Ceresoli
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | | | - Niccolò Allievi
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | - Federico Coccolini
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | - Claudio Coy
- 9Colorectal Unit, Campinas State University, Campinas, SP Brazil
| | - Paola Fugazzola
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | | | - Ciro Paolillo
- Emergency Department Udine Healthcare and University Integrated Trust, Udine, Italy
| | | | - Bruno Pereira
- 14Department of Surgery, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Oncology Surgery and Intensive Care, Oswaldo Cruz Hospital, Recife, Brazil
| | - Angelo Restivo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Joao Rezende-Neto
- 16Department of Surgery Division of General Surgery, University of Toronto, Toronto, Canada
| | | | - Massimo Valentino
- 18Radiology Unit Emergency Department, S. Antonio Abate Hospital, Tolmezzo, UD Italy
| | - Fikri M Abu-Zidan
- 19Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Miklosh Bala
- 21Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | | | - Nicola De' Angelis
- 22Unit of Digestive Surgery, HPB Surgery and Liver Transplant Henri Mondor Hospital, Créteil, France
| | - Simona Deidda
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Belinda De Simone
- Department of General and Emergency Surgery Cannes' Hospital Cannes, Cedex, Cannes, France
| | | | - Elena Finotti
- Department of General Surgery ULSS5 del Veneto, Adria, (RO) Italy
| | - Inaba Kenji
- 25Division of Trauma & Critical Care University of Southern California, Los Angeles, USA
| | - Ernest Moore
- 26Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Steven Wexner
- Digestive Disease Center, Department of Colorectal Surgery Cleveland Clinic Florida, Tallahassee, USA
| | - Walter Biffl
- 28Acute Care Surgery The Queen's Medical Center, Honolulu, HI USA
| | - Raul Coimbra
- 29Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Sciences, San Diego, USA
| | - Angelo Guttadauro
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | - Ari Leppäniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Stefano Magnone
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Alain Chicom Mefire
- 32Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Andrew Peitzmann
- 33Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- 34General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Dieter Weber
- 37Trauma and General Surgeon, Royal Perth Hospital, Perth, Australia
| | - Jeffry Kashuk
- 38Surgery and Critical Care Assuta Medical Centers, Tel Aviv, Israel
| | - Gustavo P Fraga
- 39Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ioran Kluger
- 40Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
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24
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Abstract
PURPOSE OF REVIEW This article reviews the key principles of abdominal compartment syndrome and the open abdomen, exploring some of the unresolved issues. It reviews new concepts in care. RECENT FINDINGS Recent use of peritoneal resuscitation, and benefits of mesh-mediated traction are discussed. Abdominal compartment syndrome remains a result of complex interaction between general haemorrhage, sepsis and fluid resuscitation. Improved resuscitation and sepsis control has decreased but not abolished the need for the open abdomen and progression for abdominal compartment syndrome. Fourth-generation abdominal wall dressings need to be combined with a dynamic closure system; currently, negative pressure wound therapy at the index open abdomen coupled with mesh-mediated tractions offers the best outcome. SUMMARY The key to optimizing outcome is early abdominal closure within 7 days because failure to do so will increase morbidity, mortality and fistulae formation. Novel techniques complementing existing de-resuscitation techniques are discussed.
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25
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Tolonen M, Coccolini F, Ansaloni L, Sartelli M, Roberts DJ, McKee JL, Leppaniemi A, Doig CJ, Catena F, Fabian T, Jenne CN, Chiara O, Kubes P, Kluger Y, Fraga GP, Pereira BM, Diaz JJ, Sugrue M, Moore EE, Ren J, Ball CG, Coimbra R, Dixon E, Biffl W, MacLean A, McBeth PB, Posadas-Calleja JG, Di Saverio S, Xiao J, Kirkpatrick AW. Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria. World J Emerg Surg 2018; 13:17. [PMID: 29636790 PMCID: PMC5889572 DOI: 10.1186/s13017-018-0177-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.
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Affiliation(s)
- Matti Tolonen
- 1Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Federico Coccolini
- 2Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesna, Italy
| | | | - Derek J Roberts
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Jessica L McKee
- 6Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | - Ari Leppaniemi
- 1Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Christopher J Doig
- 7Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Fausto Catena
- 8Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Timothy Fabian
- 9University of Tennessee Health Sciences Center, Memphis, TN USA
| | - Craig N Jenne
- 10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Osvaldo Chiara
- General Surgery and Trauma Team Niguarda Hospital Milano, Milan, Italy
| | - Paul Kubes
- 12Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada.,13Departments of Physiology and Pharmacology Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Gustavo P Fraga
- 15Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Bruno M Pereira
- 16Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Jose J Diaz
- 17Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
| | - Michael Sugrue
- 18Letterkenny University Hospital, Donegal Clinical Research Academy, Donegal, Ireland
| | - Ernest E Moore
- 19Trauma and Critical Care Research, University of Colorado, Denver, CO USA
| | - Jianan Ren
- 20Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chad G Ball
- 21Acute Care, and Hepatobiliary Surgery, and Regional Trauma Services, University of Calgary, Calgary, Alberta Canada
| | - Raul Coimbra
- 22Riverside University Health System Medical Center, Moreno Valley, USA.,23Loma Linda University School of Medicine, Loma Linda, CA USA
| | - Elijah Dixon
- 24Surgery, Oncology, and Community Health Sciences, City Wide Section of General Surgery, University of Calgary, Calgary, Alberta Canada
| | - Walter Biffl
- 25Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California USA
| | - Anthony MacLean
- 26Division of General Surgery Foothills Medical Centre, Department of Surgery, University of Calgary, Calgary, Canada
| | - Paul B McBeth
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada.,10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,27The Trauma Program, University of Calgary, Calgary, Alberta Canada
| | | | - Salomone Di Saverio
- 28Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jimmy Xiao
- 6Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | - Andrew W Kirkpatrick
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada.,10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,27The Trauma Program, University of Calgary, Calgary, Alberta Canada.,29EG23 Foothills Medical Centre, Calgary, Alberta T2N 2T9 Canada
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26
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Khubchandani JA, Ingraham AM, Daniel VT, Ayturk D, Kiefe CI, Santry HP. Geographic Diffusion and Implementation of Acute Care Surgery: An Uneven Solution to the National Emergency General Surgery Crisis. JAMA Surg 2018; 153:150-159. [PMID: 28979986 PMCID: PMC5838713 DOI: 10.1001/jamasurg.2017.3799] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/25/2017] [Indexed: 01/14/2023]
Abstract
Importance Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood. Objective To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging. Design, Setting, and Participants A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached. Interventions Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS. Main Outcomes and Measures We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access). Results Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities. Conclusions and Relevance Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.
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Affiliation(s)
| | | | - Vijaya T. Daniel
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Didem Ayturk
- University of Massachusetts Medical School, Department of Surgery, Worcester
| | - Catarina I. Kiefe
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
| | - Heena P. Santry
- University of Massachusetts Medical School, Department of Surgery, Worcester
- University of Massachusetts Medical School, Department of Quantitative Health Sciences, Worcester
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27
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Abstract
Damage control surgery (DCS) began as an adjunct approach to hemorrhage control, seeking to facilitate the body's innate clotting ability when direct repair or ligation was impossible, but it has since become a valuable instrument for a broader collection of critically ill surgical patients in whom metabolic dysfunction is the more immediate threat to life than imminent exsanguination. Modern damage control is a strategy that combines the principles of DCS with those of damage control resuscitation. When used correctly, damage control may improve survival in previously unsalvageable patients; when used incorrectly, it can subject patients to imprudent risk and contribute to morbidity. This review discusses the evolution of damage control in both concept and practice, summarizing available literature and experience to guide patient selection, medical decision-making, and strategy implementation throughout the preoperative, intraoperative, and early postoperative periods.
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Affiliation(s)
- Brian C Beldowicz
- Division of Military, Department of Emergency Medicine, Uniformed Services University of the Health Sciences, Sacramento, California
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28
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Vogler J, Bagwell L, Hart L, Holmes S, Sciarretta JD, Davis JM. Rapid Source-Control Laparotomy: Is There a Mortality Benefit? Surg Infect (Larchmt) 2017; 18:787-792. [PMID: 28846501 DOI: 10.1089/sur.2017.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine the influence rapid source-control laparotomy (RSCL) has on the mortality rate in non-trauma patients with intra-abdominal infection. The hypothesis was that RSCL reduces deaths and hospital lengths of stay (LOS) in patients compared with definitive repair and primary fascial closure (PFC). METHODS The International Classification of Diseases-10 codes for sepsis, gastric and duodenal ulcer perforation or hemorrhage, incisional or ventral hernia with obstruction, intestinal volvulus, ileus with obstruction, diverticulitis with perforation or abscess, vascular disorder of intestine, non-traumatic intestinal perforation, peritoneal abscess, and unspecified peritonitis were used to query the 2015 National Surgical Quality Improvement Project (NSQIP) database for all patients treated with either RSCL or PFC. The two groups of patients were compared on the basis of LOS and deaths. Collected data included age, gender, body mass index (BMI), site classification, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and pre-operative septic state. RESULTS After adjusting for the aforementioned variables, propensity score-matched cohorts (n = 210 in each cohort) were used to evaluate the influence of incision closure type on LOS and mortality rate. The odds of death (31.4% vs. 21.4%) with RSCL was 1.78 (95% confidence interval 1.08-2.95; p = 0.02) times that of PFC. Closure type was not significantly associated with an increased LOS (median 14 vs. 11 days; p = 0.35). CONCLUSIONS This retrospective cohort analysis demonstrated that RSCL is associated with higher odds of death in general surgical patients with intra-abdominal infection. There is a need for further studies to delineate what, if any, physiologic parameters indicate a need for RSCL.
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Affiliation(s)
- James Vogler
- 1 Department of Surgery, Grand Strand Regional Medical Center , Myrtle Beach, South Carolina
| | - Laura Bagwell
- 2 Medical University of South Carolina , Charleston, South Carolina
| | - Leslie Hart
- 3 Department of Health and Human Performance, College of Charleston , Charleston, South Carolina
| | - Sharon Holmes
- 4 National Surgical Quality Improvement Program, Grand Strand Regional Medical Center , Myrtle Beach, South Carolina
| | - Jason D Sciarretta
- 1 Department of Surgery, Grand Strand Regional Medical Center , Myrtle Beach, South Carolina
| | - John Mihran Davis
- 1 Department of Surgery, Grand Strand Regional Medical Center , Myrtle Beach, South Carolina
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29
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Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience. J Trauma Acute Care Surg 2017; 82:1100-1105. [PMID: 28338592 DOI: 10.1097/ta.0000000000001452] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates. METHODS This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed. RESULTS Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups. CONCLUSIONS The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies. J Trauma Acute Care Surg 2017; 82:901-909. [PMID: 28431416 DOI: 10.1097/ta.0000000000001412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children. METHODS An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications. RESULTS Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury. CONCLUSION DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 331] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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Cristaudo A, Jennings S, Gunnarsson R, Decosta A. Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis. Am Surg 2017. [DOI: 10.1177/000313481708300220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.
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Affiliation(s)
- Adam Cristaudo
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Scott Jennings
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ronny Gunnarsson
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Alan Decosta
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- Department of Surgery, Cairns Hospital, Cairns, Queensland, Australia
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Abstract
Failed burn resuscitation can occur at various points. Early failed resuscitation will be largely caused by prehospital factors. During resuscitation, failure will present as a patient's nonresponse to adjunctive therapy. Late failure will occur in the setting of multiple organ dysfunction syndrome. Burn care providers must be vigilant during the resuscitation to identify a threatened resuscitation so that adjunctive therapies or rescue maneuvers can be used to convert to a successful resuscitation. However, when a patient's resuscitative course becomes unsalvageable, transition to comfort care should be taken to avoid prolongation of suffering.
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Affiliation(s)
- Elisha G Brownson
- Department of Surgery, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA
| | - Tam N Pham
- Department of Surgery, Harborview Medical Center, 325 Ninth Avenue, Box 359796, Seattle, WA 98104, USA.
| | - Kevin K Chung
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Abstract
BACKGROUND Damage-control surgery with open abdomen (OA) is described for trauma, but little exists regarding use in the emergency general surgery. This study aimed to better define the following: demographics, indications for surgery and OA, fascial and surgical site complications, and in-hospital/long-term mortality. We hypothesize that older patients will have increased mortality, patients will have protracted stays, they will require specialized postdischarge care, and the indications for OA will be varied. METHODS A prospective observational study of emergency general surgery OA patients from June 2013 to June 2014 was performed. Demographics, clinical/operative variables, comorbidities, indications for procedure and OA, wound/fascial complications, and disposition were collected. Patients were stratified into age groups (≤ 60, 61-79, and ≥ 80 years). Six-month and 1-year mortality was determined by query of the Social Security Death Index. RESULTS A total of 338 laparotomies were performed, of which 96 (28%) were managed with an OA. Median age was 61 years (interquartile range [IQR], 0-68 years), and 51% were male. The median Charlson Comorbidity Index was 2 (IQR, 1.5-5.1), and the median hospital stay was 25 days (IQR, 15-50 days). The most common indications for operation were perforated viscus/free air (20%), mesenteric ischemia (17%), peritonitis (16%), and gastrointestinal hemorrhage (12%). The most common indication for OA was damage control (37%). In the 63 patients with fascial closure, there were 9 (14%) wound infections and 6 (10%) fascial dehiscences. A total of 30% of the patients died in the hospital, and an additional six patients died 6 months after discharge. Patients in the oldest age stratum were more likely to die at 6 months than those in the lower strata. CONCLUSION Older patients were more likely to die by 6 months, the median hospital stay was 3 weeks, and there were multiple indications for OA management. With a 6-month mortality of 36% and 70% of survivors requiring postdischarge care, this population represents a critically ill population meriting additional study. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Holihan JL, Alawadi ZM, Harris JW, Harvin J, Shah SK, Goodenough CJ, Kao LS, Liang MK, Roth JS, Walker PA, Ko TC. Ventral hernia: Patient selection, treatment, and management. Curr Probl Surg 2016; 53:307-54. [DOI: 10.1067/j.cpsurg.2016.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/14/2016] [Indexed: 12/14/2022]
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Peck GL, Blitzer DN, Bulauitan CS, Huntress LA, Truche P, Feliciano DV, Dente CJ. Outcomes after Distal Pancreatectomy for Trauma in the Modern Era. Am Surg 2016. [DOI: 10.1177/000313481608200614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple stump closure techniques after distal pancreatectomy (DP) for trauma have been described, and all are associated with a significant fistula rate. With increasing emphasis on abbreviated laparotomy, stapled pancreatectomy has become more common. This study describes the outcomes of patients with different closure techniques of the pancreatic stump after resection following pancreatic trauma. Retrospective analysis of 50 trauma patients, who sustained grade III pancreatic injuries with subsequent DP and stapled stump closure, were conducted from 1995 to 2011. Demographic, operative, and outcome data were analyzed to characterize patients, and to directly compare closure techniques. After 12 patients were excluded because of early death (<72 hours), final analyses included 38 patients: 19 (50%) had stapled closure alone and 19 (50%) had stapling with adjunct, including additional closure with sutures, fibrin sealants, or a combination of sutures with fibrin sealants/omental coverage. Twenty-four patients (63%) had postoperative complications, most commonly pancreatic fistula (n = 11, 29%). There were no significant differences with regard to pancreatic fistula or other abdominal complications between closure groups, or were any factors associated with increased likelihood of complications. DP remains a morbid operation after trauma regardless of closure technique. Stapled closure alone is perhaps the method of choice in this setting due to the time constraints directly related to outcomes.
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Affiliation(s)
- Gregory L. Peck
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | | | | | - Paul Truche
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey
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Smith JW, Nash N, Procter L, Benns M, Franklin GA, Miller K, Harbrecht BG, Bernard AC. Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma. Am Surg 2016. [DOI: 10.1177/000313481608200518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.
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Affiliation(s)
- Jason W. Smith
- Hiram C. Polk Jr. Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Nick Nash
- Hiram C. Polk Jr. Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Levi Procter
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Matthew Benns
- Hiram C. Polk Jr. Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Glen A. Franklin
- Hiram C. Polk Jr. Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Keith Miller
- Hiram C. Polk Jr. Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Brian G. Harbrecht
- Hiram C. Polk Jr. Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Andrew C. Bernard
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Yagi T, Fujita M, Inoue T, Otsuji M, Koga Y, Nakahara T, Miyauchi T, Kaneda K, Oda Y, Tsuruta R. Cardiac arrest due to massive hemorrhage from uterine adenomyosis with leiomyoma successfully treated with damage control resuscitation. Acute Med Surg 2016; 3:388-391. [PMID: 29123819 DOI: 10.1002/ams2.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 01/30/2016] [Indexed: 11/11/2022] Open
Abstract
Case A 57-year-old woman was transferred to our emergency department by ambulance with cardiopulmonary arrest caused by massive genital bleeding. Cardiopulmonary resuscitation, including massive transfusion, was carried out and the return of spontaneous circulation was achieved. A giant uterine tumor was considered the source of the bleeding. Although hysterectomy was necessary to achieve definitive hemostasis, the patient was unable to tolerate the operation because of hemodynamic instability, acidosis, and coagulopathy. Therefore, we undertook vaginal gauze packing and uterine artery embolization to attain temporary hemostasis, which resulted in hemodynamic stabilization. Abdominal hysterectomy for definitive hemostasis was carried out 10 h after the embolization. Outcome The patient made a good post-surgical recovery without any complications. Conclusion In treating hemorrhagic shock due to uterine leiomyoma, damage-control resuscitation may be useful as a bridge prior to definitive hemostasis through hysterectomy.
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Affiliation(s)
- Takeshi Yagi
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Tomoaki Inoue
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Mari Otsuji
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Takashi Nakahara
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Takashi Miyauchi
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Yasutaka Oda
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
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Becher RD, Peitzman AB, Sperry JL, Gallaher JR, Neff LP, Sun Y, Miller PR, Chang MC. Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery. World J Emerg Surg 2016; 11:10. [PMID: 26913055 PMCID: PMC4765073 DOI: 10.1186/s13017-016-0067-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/15/2016] [Indexed: 01/20/2023] Open
Abstract
Background The staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients. Methods All EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined. Results 215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died. Conclusions The acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.
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Affiliation(s)
- Robert D Becher
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB 310, New Haven, CT 06510 USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC USA
| | - Lucas P Neff
- Department of Surgery, David Grant Medical Center, Travis Air Force Base, Fairfield, CA USA
| | - Yankai Sun
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Preston R Miller
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Michael C Chang
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC USA
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Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients. Am J Surg 2015; 210:1126-30; discussion 1130-1. [PMID: 26520871 DOI: 10.1016/j.amjsurg.2015.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/24/2015] [Accepted: 06/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Emergency general surgery patients are increasingly being managed with an open abdomen (OA). Factors associated with complications after primary fascial closure (PFC) are unknown. METHODS Demographic and operative variables for all emergency general surgery patients managed with OA at an academic medical center were prospectively examined from June to December 2013. Primary outcome was complication requiring reoperation. RESULTS Of 58 patients, 37 managed with OA achieved PFC. Of these, 14 needed re-exploration for dehiscence, compartment syndrome, infection, or other. Complications after PFC were not associated with age, type of operative intervention, time to closure, re-explorations, comorbidities, or mortality. Complications correlated with higher body mass index (P = .02), skin closure (P = .04), plasma infusion (P = .01), and less intraoperative bleeding (P = .05). Deep surgical site infection correlated with fascial dehiscence (P = .02). CONCLUSIONS Reoperation after PFC was more likely in obese and nonhemorrhagic patients. Recognition of these factors and strategies to reduce surgical site infection may improve outcomes.
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Focchi S, Carrara A, Avesani EC. Advances in management of patients with acute diverticulitis. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Collins CE, Pringle PL, Santry HP. Innovation or rebranding, acute care surgery diffusion will continue. J Surg Res 2015; 197:354-62. [PMID: 25891673 DOI: 10.1016/j.jss.2015.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/11/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patterns of adoption of acute care surgery (ACS) as a strategy for emergency general surgery (EGS) care are unknown. METHODS We conducted a qualitative study comprising face-to-face interviews with senior surgeons responsible for ACS at 18 teaching hospitals chosen to ensure diversity of opinions and practice environment (three practice types [community, public or charity, and university] in each of six geographic regions [Mid-Atlantic, Midwest, New England, Northeast, South, and West]). Interviews were recorded, transcribed, and analyzed using NVivo (QSR International, Melbourne, Australia). We applied the methods of investigator triangulation using an inductive approach to develop a final taxonomy of codes organized by themes related to respondents' views on the future of ACS as a strategy for EGS. We applied our findings to a conceptual model on diffusion of innovation. RESULTS We found a paradox between ACS viewed as a health care delivery innovation versus a rebranding of comprehensive general surgery. Optimism for the future of ACS because of increased desirability for trauma and critical care careers as well as improved EGS outcomes was tempered by fear over lack of continuity, poor institutional resources, and uncertainty regarding financial viability. Our analysis suggests that the implementation of ACS, whether a true health care delivery innovation or an innovative rebranding, fits into the Rogers' diffusion of innovation theory. CONCLUSIONS Despite concerns over resource allocation and the definition of the specialty, from the perspective of senior surgeons deeply entrenched in executing this care delivery model, ACS represents the new face of general surgery that will likely continue to diffuse from these early adopters.
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Affiliation(s)
- Courtney E Collins
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patricia L Pringle
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Heena P Santry
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
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De Siqueira J, Tawfiq O, Garner J. Managing the open abdomen in a district general hospital. Ann R Coll Surg Engl 2014; 96:194-8. [PMID: 24780782 DOI: 10.1308/003588414x13814021678556] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The need to manage an open abdomen is becoming more common in general surgical practice and a variety of methods of temporary abdominal closure (TAC) are available. The evidence for the efficacy of the various forms of TAC as well as the subsequent definitive fascial closure (DFC) rates and complications comes mainly from large trauma series in the US, which represent a different patient population to those in the UK in whom TAC is usually required. METHODS All cases of open abdomen management in our hospital over a five-year period were reviewed to ascertain the methods of TAC used, our success in achieving DFC and the applicability of managing such cases in a district hospital environment. RESULTS Nineteen patients underwent TAC, with two deaths (10.5%) and an overall DFC rate at hospital discharge of 12/17 (70.6%). The median lengths of critical care and hospital stays were 19.5 and 38.0 days respectively. Thirteen out of seventeen survivors had at least one significant complication. CONCLUSIONS The management of the open abdomen can be achieved safely in a district general hospital setting with acceptable outcomes for the non-trauma patients commonly seen in UK practice but it is a resource intensive and expensive undertaking.
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Transcatheter thrombolysis centered stepwise management strategy for acute superior mesenteric venous thrombosis. Int J Surg 2014; 12:442-51. [DOI: 10.1016/j.ijsu.2014.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 03/23/2014] [Indexed: 02/07/2023]
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Edelmuth RCL, Buscariolli YDS, Ribeiro MAF. [Damage control surgery: an update]. Rev Col Bras Cir 2014; 40:142-51. [PMID: 23752642 DOI: 10.1590/s0100-69912013000200011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 08/15/2012] [Indexed: 11/22/2022] Open
Abstract
The damage control surgery is a widely accepted concept today among abdominal trauma specialists when it comes to the severely traumatized. In these patients, the death is due, in most cases, to the installation of the lethal triad (hypothermia, coagulopathy and acidosis) and not the inability to repair the serious initial damage. In this review, the authors address the lethal triad in its three phases and emphasize the measures taken to prevent them, as well as discussing the indication and employment of damage control surgery in its various stages. Restoring the physiological status of the patient in the ICU, so that he/she can be submitted to final operation and closure of the abdominal cavity, another challenge in severe trauma patients, is also discussed.
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Stawicki SP, Green JM, Martin ND, Green RH, Cipolla J, Seamon MJ, Eiferman DS, Evans DC, Hazelton JP, Cook CH, Steinberg SM. Results of a prospective, randomized, controlled study of the use of carboxymethylcellulose sodium hyaluronate adhesion barrier in trauma open abdomens. Surgery 2014; 156:419-30. [PMID: 24962185 DOI: 10.1016/j.surg.2014.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 03/09/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The open abdominal (OA) approach is a management strategy used in the most severely injured trauma patients. In addition to the morbidity and mortality, a major challenge is the gradual development of dense adhesions that make reoperations progressively more difficult. This randomized, prospective, proof-of-concept study was conducted to determine the effect of carboxymethylcellulose sodium hyaluronate adhesion barrier (CMHAB; Seprafilm, Genzyme Biosurgery, Bridgewater, NJ) on abdominal adhesions and wound characteristics in trauma open abdomens. METHODS A prospective, randomized, controlled study of wound and adhesion characteristics with or without CMHAB was conducted at 5 level I trauma centers. Consenting patients were randomized to either CMHAB or no adhesion barrier (NAB) groups. We evaluated patient demographics, injury characteristics/severity, reason for OA management, wound sizes (transverse/longitudinal), Zuhlke adhesion score, abdominal contamination score, hospital/intensive care durations of stay, morbidity, and mortality. RESULTS Thirty patients were enrolled (17 randomized to CMHAB; 13 randomized to NAB) with mean age of 40.3, Injury Severity Score of 30, Abbreviated Injury Score (AIS)-abdomen of 3.68, APACHE II score of 14.4, and 67% blunt trauma mechanism. The groups were well-matched with regard to age, sex, Injury Severity Score/abdominal AIS, penetrating/blunt injury rates, initial lactate/base deficit, mortality, OA indications, and contamination scores. There were no differences in nonabdominal or abdominal complications (ie, fistula, abscess, wound related) between the groups. Patients with CMHAB had shorter intensive care unit durations of stay (15 vs 22 days; P < .05). Intraoperative adhesion scores were not different during the first four operations but diverged significantly at the 5th operative intervention or after about 1 week of OA therapy. After the 5th operation, adhesion scores in the NAB group were 67% greater (approximately 1 Zuhlke point) than the CMHAB group. We did not note differences between wound sizes over time, closure types, or wound closure characteristics between CMHAB and NAB. CONCLUSION Although CMHAB did not eliminate adhesions in this proof-of-concept study, it limited their severity, particularly in abdomens left open >9 days or requiring ≥5 operations. There was no difference in wound sizes, overall or abdominal complications, or mortality between the groups. Further research is warranted to better delineate potential benefits of CMHAB, especially in the setting of reoperations in post-OA patients.
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Affiliation(s)
- Stanislaw P Stawicki
- Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH.
| | - John M Green
- Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Niels D Martin
- Thomas Jefferson University and the University of Pennsylvania, Philadelphia, PA
| | - Raymond H Green
- Department of Surgery, Cooper University Hospital, Camden, NJ
| | | | - Mark J Seamon
- Department of Surgery, Cooper University Hospital, Camden, NJ
| | - Daniel S Eiferman
- Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - David C Evans
- Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | | | - Charles H Cook
- Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Steven M Steinberg
- Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
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Pliakos I, Michalopoulos N, Papavramidis TS, Arampatzi S, Diza-Mataftsi E, Papavramidis S. The Effect of Vacuum-Assisted Closure in Bacterial Clearance of the Infected Abdomen. Surg Infect (Larchmt) 2014; 15:18-23. [DOI: 10.1089/sur.2012.156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ioannis Pliakos
- Third Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Nikolaos Michalopoulos
- Third Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodossis S. Papavramidis
- Third Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Stergiani Arampatzi
- Second Department of Microbiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Eudoxia Diza-Mataftsi
- Second Department of Microbiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Spiros Papavramidis
- Third Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Liao LM, Fu CY, Wang SY, Liao CH, Kang SC, Ouyang CH, Kuo IM, Yang SJ, Hsu YP, Yeh CN, Chen SW. Risk factors for late death of patients with abdominal trauma after damage control laparotomy for hemostasis. World J Emerg Surg 2014; 9:1. [PMID: 24387340 PMCID: PMC3892102 DOI: 10.1186/1749-7922-9-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 12/26/2013] [Indexed: 12/25/2022] Open
Abstract
Introduction In this study, we explored the possible causes of death and risk factors in patients who overcame the initial critical circumstance when undergoing a damage control laparotomy for abdominal trauma and succumbed later to their clinical course. Methods This was a retrospective study. We selected patients who fulfilled our study criteria from 2002 to 2012. The medical and surgical data of these patients were then reviewed. Fifty patients (survival vs. late death, 39 vs. 11) were enrolled for further analysis. Results In a univariable analysis, most of the significant factors were noted in the initial emergency department (ED) stage and early intensive care unit (ICU) stage, while an analysis of perioperative factors revealed a minimal impact on survival. Initial hypoperfusion (pH, BE, and GCS level) and initial poor physiological conditions (body temperature, RTS, and CPCR at ED) may contribute to the patient’s final outcome. An analysis and summary of the causes of death were also performed. Conclusions According to our study, the risk factors for late death in patients undergoing DCL may include both the initial trauma-related status and clinical conditions after DCL. In our series, the cause of death for patients with late mortality included the initial brain insult and later infectious complications.
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Affiliation(s)
| | | | - Shang-Yu Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Taoyuan, Kwei Shan Township, Taiwan.
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Moore FA, Catena F, Moore EE, Leppaniemi A, Peitzmann AB. Position paper: management of perforated sigmoid diverticulitis. World J Emerg Surg 2013; 8:55. [PMID: 24369826 PMCID: PMC3877957 DOI: 10.1186/1749-7922-8-55] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 12/16/2022] Open
Abstract
Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.
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Affiliation(s)
- Frederick A Moore
- Acute Care Surgery, University of Florida, 1600 Southwest Archer Road, PO Box 100108, Gainesville, FL 32610-0108, USA
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Via Cracvia 23, Bologna 40139, Italy
| | - Ernest E Moore
- University of Colorado Health Science Center, Denver Health Science Center, 777 Bannock Street, Denver, CO 80204-4507, USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University of Helsinki, Haartmaninkatu 4, PO Box 340, Meilahi Hospital, FIN-00029 HUS, Helsinki, HUS 00290, Finland
| | - Andrew B Peitzmann
- University of Pittsburgh, F-1281, UPMC-Presbyterian, Pittsburgh, PA 15213, USA
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Kwon E, Browder T, Fildes J. Surgical Management of Fulminant Diverticulitis. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0040-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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