Is it possible to predict mortality in patients with high-grade blunt liver injury? A single trauma center study

BACKGROUND

Blunt abdominal trauma constitutes a significant portion of trauma cases and is often associated with liver injury. Given that high-grade liver injuries remain life-threatening, identifying patients who will likely require more vigilant attention and care is crucial. This study aims to determine the parameters that increase mortality in patients with high-grade liver trauma.

METHODS

This study enrolled 38 patients with Grade III or higher liver injuries, treated by the general surgery department between 2008 and 2023. Eleven patients who died were categorized into Group 1, and 27 survivors were placed in Group 2. We evaluated their respective mechanisms of injury, imaging results, Glasgow Coma Scale scores, Base Excess, Lactate levels, pH, and Injury Severity Score findings. Receiver Operating Characteristics (ROC) analysis was performed for parameters with significant differences, and certain cutoff values were determined.

RESULTS

The grade of liver injury and additional abdominal organ injuries were significantly higher in Group 1 (p<0.05). The difference in extra-abdominal injury sites was statistically insignificant between the groups (p>0.05). Erythrocyte suspension requirements were significantly higher in Group 1 (p<0.05). Average lactate and base deficit values were also significantly higher in Group 1 (p<0.05), while leukocyte counts were significantly lower in Group 1 (p<0.05).

CONCLUSION

Base deficit, hemoglobin (Hb), lactate levels, injury severity, liver injury grade, accompanying abdominal injuries at admission, and erythrocyte suspension demands were found to be associated with increased mortality rates. Certain cutoff values for the aforementioned parameters could be established. However, further data are required to confirm these findings.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Management of Spontaneous Major Rectus Sheath Hematoma in a COVID-19 Patient: A Case Report and Literature Review

A rectus sheath hematoma, which is mostly encountered due to abdominal traumas or anticoagulant use, can be challenging, and a delayed diagnosis may lead to hypovolemic shock and even death. In this study, we aimed to present the management of a case of rectus sheath hematoma that developed in a patient who was hospitalized and under coronavirus disease 2019 (COVID-19) treatment. A 70-year-old female patient was admitted to the intensive care unit (ICU) due to respiratory failure and developed a sudden onset of tachycardia and hypotension. The patient was then diagnosed with a rectus sheath hematoma and after ensuring hemodynamic stability she was treated with angiographic embolization. Following the treatment, the patient remained hemodynamically stable and a control computed tomography (CT) revealed regression in the hematoma. Rectus sheath hematomas especially accompanied by additional comorbidities or aggressive surgical interventions may result in high mortality rates in the early period. It should also be kept in mind that during the COVID-19 pandemic, which has affected the world in the last two years, rectus sheath hematomas may be the underlying cause of sudden hypotension and abdominal distension, and it should not be forgotten that angiographic embolization performed by experienced interventional radiologists is the mainstay of treatment in cases where hemodynamic stability can’t be achieved.