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Dodwad SJM, Isbell KD, Mueck KM, Klugh JM, Meyer DE, Wade CE, Kao LS, Harvin JA. Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial. J Surg Res 2024; 293:57-63. [PMID: 37716101 PMCID: PMC10841256 DOI: 10.1016/j.jss.2023.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/21/2023] [Accepted: 06/13/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL). METHODS The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference. RESULTS Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively. CONCLUSIONS Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.
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Affiliation(s)
- Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas.
| | - Kayla D Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Krislynn M Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - James M Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - David E Meyer
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Charles E Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - John A Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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Uchino H, Nguyen-Powanda P, Tokuno J, Kouyoumdjian A, Fiore JF, Grushka J. Enhanced recovery protocols in trauma and emergency abdominal surgery: a scoping review. Eur J Trauma Emerg Surg 2023; 49:2401-2412. [PMID: 37505285 DOI: 10.1007/s00068-023-02337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Enhanced recovery protocols (ERP) have been shown to improve patient outcomes and is now regarded as standard of care in elective surgical setting. However, the literature addressing the use of ERP in trauma and emergency abdominal surgery (EAS) is limited and heterogenous. A scoping review was conducted to comprehensively assess the literature on ERP in trauma laparotomy and EAS. METHODS Three bibliographic databases were searched for studies addressing ERP in trauma laparotomy and EAS. We extracted the study characteristics including study design, country, year, surgical procedures, ERP components used, and outcomes. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. RESULTS After screening of 1631 articles for eligibility, 39 studies were included in the review. There has been an increase in the number of articles in the field, with 44% of the identified studies published between 2020 and 2022. Fourteen different protocols were identified, with varying components for each operative phase (preoperative; 29, intraoperative; 20, postoperative; 27). The majority of the studies addressed the effectiveness of ERP on clinical outcomes (31/39: 79%). Only two studies (5%) included purely trauma populations. CONCLUSIONS Studies on ERP implementations in the EAS populations were published across a range of countries, with improved outcomes. However, a clear gap in ERP research on trauma laparotomy was identified. This scoping review indicates that standardization of care through ERP implementation has potential to improve the quality of care in both EAS and trauma laparotomy.
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Affiliation(s)
- Hayaki Uchino
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada.
| | - Philip Nguyen-Powanda
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Junko Tokuno
- Steinberg Centre for Simulation and Interactive Learning, McGill University, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Grushka
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
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Nieß H, Werner J. [Treatment of pancreatic injuries after blunt abdominal trauma]. Chirurgie (Heidelb) 2023:10.1007/s00104-023-01898-7. [PMID: 37369739 DOI: 10.1007/s00104-023-01898-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/29/2023]
Abstract
Pancreatic injuries resulting from blunt abdominal trauma are uncommon but carry a high risk of morbidity and mortality for patients. Prompt diagnosis and management are critical to optimize patient outcomes. This review article provides an overview of the different types of pancreatic injuries and the various management strategies available, based on the severity of the injury. In unstable patients with a positive focused assessment with sonography for trauma (FAST), immediate trauma laparotomy is required. Stable patients should be assessed with contrast-enhanced computed tomography (CT) imaging. Low-grade injuries can be managed with irrigation and drainage. In cases of left-sided ductal injury below the level of the portal vein, left-sided pancreatic resection is often necessary. Higher grade injuries to the pancreatic head need to be evaluated in the context of other accompanying injuries, where damage control may be required. Pancreaticoduodenectomy is a rare intervention and is usually only required in the later course in these cases.
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Affiliation(s)
- H Nieß
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, LMU Klinikum, LMU München, München, Deutschland.
| | - J Werner
- Klinik für Allgemein‑, Viszeral-, und Transplantationschirurgie, LMU Klinikum, LMU München, München, Deutschland
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Harmston C, Ward JBM, Patel A. Clinical outcomes and effect of delayed intervention in patients with hollow viscus injury due to blunt abdominal trauma: a systematic review. Eur J Trauma Emerg Surg 2018; 44:369-376. [PMID: 29302699 DOI: 10.1007/s00068-018-0902-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/01/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hollow viscus injury (HVI) due to blunt abdominal trauma remains a diagnostic challenge, often presenting late and results in delayed intervention. Despite several treatment algorithms, there is currently no consensus on how to manage patients with HVI. The aim of this review was to define clinical outcomes and the effect of delayed intervention in patients with HVI due to blunt abdominal trauma. The primary outcome of interest was difference in mortality between groups. METHODS Based on the preferred reporting items for systematic reviews and meta-analyses statement, a literature search was performed. Studies comparing clinical outcomes in adult patients with hollow viscus injury due to blunt abdominal trauma undergoing early or delayed laparotomy were included. Two independent reviewers screened the abstracts. RESULTS In all, 2288 articles were retrieved. After screening, 11 studies were included. Outcomes in 3812 patients were reported. Overall mortality was 17%. Ten studies reported no difference in mortality between groups. A statistical increase in morbidity was described in five studies, and a trend to increased morbidity was seen in a further two studies. Two studies reported increased mortality in delayed intervention in isolated bowel injury. CONCLUSIONS This systematic review summarises the results of studies considering outcomes in patients with HVI due to blunt abdominal trauma who have early vs delayed intervention. Overall mortality was significant at 17%. If all patients with hollow viscus injury are considered, the majority of studies do not show an increase in mortality. As patients with isolated bowel injuries have higher mortality in the studies reviewed, to improve outcomes in this subset further investigation is warranted.
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Affiliation(s)
| | | | - Abhilasha Patel
- University Hospitals of North Staffordshire, West Midlands, UK
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Ball CG, Campbell A, Grondin SC, Dixon E. The efficacy of a novel saline/bipolar radiofrequency energy instrument for arresting ongoing solid and non-solid organ hemorrhage in a swine model. Injury 2016; 47:2706-2708. [PMID: 27717541 DOI: 10.1016/j.injury.2016.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 07/19/2016] [Accepted: 09/29/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ongoing hemorrhage is often life threatening and can be challenging to stop in critically injured patients. Traditional techniques for addressing this issue include high voltage cautery (Bovie), topical hemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a novel energy device for arresting ongoing bleeding from both solid and non-solid organs within a swine model. METHODS A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a small hand piece was employed to arrest ongoing hemorrhage from an escalating series of injuries in large male swine. Liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall targets were evaluated and digitally recorded. Methodology was descriptive. RESULTS Four large male swine received escalating injuries to their liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall. Injury patterns included a variety of surface decapsulation, superficial lacerations, deep lacerations, "through and through" missiles and complete transections. Application of the bipolar/RF instrument to sites of ongoing hemorrhage was successful in 97% of all scenarios. Depth of tissue penetration via microscopic evaluation ranged from 1.1mm to 3.0mm depending on the target organ composition. No air leaks were observed following application to the bleeding lung. Surgeon reported 'ease of use' score was high (4.8/5). CONCLUSION This energy technology is successful in arresting ongoing hemorrhage from varying intensities of traumatic injuries to the liver, spleen, kidney, abdominal wall, lung and heart in the swine model. Additional testing is required before advocating its use on any thoracic organs.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
| | - Andre Campbell
- Department of Surgery, University of California, San Francisco, CA, United States.
| | - Sean C Grondin
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
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Ball CG, Campbell A, Grondin SC, Dixon E, DuBose J, McBeth PB, Lall R. Use of a novel saline/bipolar radiofrequency energy instrument as an adjunct for arresting ongoing solid organ surface and laceration bleeding in critically injured patients. Injury 2016; 47:1996-9. [PMID: 27015755 DOI: 10.1016/j.injury.2016.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 02/19/2016] [Accepted: 02/27/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Solid organ (liver, spleen and kidney) haemorrhage is often life threatening and can be difficult to stop in critically ill patients. Traditional techniques for arresting this ongoing bleeding include coagulation by high voltage cautery (Bovie), topical haemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a new energy device for arresting persistent solid organ haemorrhage. PATIENTS AND METHODS A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a simple hand piece was employed to arrest ongoing bleeding from solid organ injuries at 2 high volume, level 1 trauma centres. This instrument is extrapolated from experience within elective hepatic resections. Standard statistics were employed (p<0.05=significant). RESULTS From January 2013 to January 2015, 36 severely injured patients (mean injury severity score=31; blunt mechanisms=32/36 (89%)) underwent use of this new saline/RF energy instrument to arrest ongoing haemorrhage from the liver (29), spleen (5) and kidney (2). Of these patients, 25 received instrument use during an initial laparotomy, while 11 patients underwent use following removal of sponges during a return laparotomy after an initial damage control procedure. Success in arresting ongoing haemorrhage was 97% (35/36) in these highly selected cases. The surgeons reported an 'ease of use' score of 4.9 out of 5. No postoperative complications (including delayed haemorrhage) were noted as a direct result of the energy instrument. CONCLUSIONS This simple saline/RF energy instrument has the potential to arrest ongoing solid organ surface/capsular bleeding, as well as moderate haemorrhage associated with deep lacerations.
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Affiliation(s)
- Chad G Ball
- Departments of Surgery, University of Calgary, Calgary, AB, Canada.
| | - Andre Campbell
- Departments of Surgery, University of California, San Francisco, CA, USA.
| | - Sean C Grondin
- Departments of Surgery, University of Calgary, Calgary, AB, Canada.
| | - Elijah Dixon
- Departments of Surgery, University of Calgary, Calgary, AB, Canada.
| | - Joseph DuBose
- Departments of Surgery, University of Maryland, Baltimore, MD, USA.
| | - Paul B McBeth
- Departments of Surgery, University of Calgary, Calgary, AB, Canada.
| | - Rohan Lall
- Departments of Surgery, University of Calgary, Calgary, AB, Canada.
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Joseph B, Zangbar B, Pandit V, Kulvatunyou N, Haider A, O'Keeffe T, Khalil M, Tang A, Vercruysse G, Gries L, Friese RS, Rhee P. Mortality after trauma laparotomy in geriatric patients. J Surg Res 2014; 190:662-6. [PMID: 24582068 DOI: 10.1016/j.jss.2014.01.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/13/2014] [Accepted: 01/16/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. METHODS A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. RESULTS A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. CONCLUSIONS Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Bardiya Zangbar
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Ansab Haider
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Mazhar Khalil
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Gary Vercruysse
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S Friese
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
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