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The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention.The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences.Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same.American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG.Prognostic and Epidemiolgic, Level III.

Major abdominal vascular injuries are noted in 5-10% of patients undergoing laparotomy for blunt trauma. In contrast, injuries to named abdominal vessels are present in 20-25% of patients undergoing laparotomy after gunshot wounds and in 10% after stab wounds. Hence, all surgeons performing laparotomies after abdominal trauma must be familiar with techniques for exposure and management of these injuries.

Background Reoperative abdominal surgery is one of the most challenging endeavors that general surgeons face. The aim of this narrative review is to offer a detailed and nuanced discussion of preoperative patient and surgeon preparation and intraoperative surgical technique. Study Design The topics discussed in this review are based on both the current literature and the experiences of the authors with complex reoperations in general, trauma, acute care, and hepatopancreatobiliary surgery. Results Ten essential steps for reoperative abdominal surgery include the following: 1. Review all previous operative notes and discharge summaries; 2. Review all prior outside and current in-house imaging; 3. Assess the patient's overall health status, reverse nutritional deficits, and explain risks of reoperation to the patient and family; 4. Refer the patient to a plastic surgeon when future skin coverage of a prosthesis in the abdominal wall may be needed; 5. Do a bowel preparation preoperatively; 6. Use selected Enhanced Recovery After Surgery protocols; 7. Operative technique matters; 8. Restoring gastrointestinal continuity simultaneously with abdominal wall reconstruction is not recommended; 9. Technical tips for complex reoperations; and 10. Plan well for the day of the operation. Conclusions Successful reoperative abdominal surgery in the most complex patients after previous trauma or acute care laparotomies demands adequate preoperative patient preparation, a clear-cut plan for operation, superb intraoperative technique, and solid decision-making; ie an unwavering commitment to making the patient whole again.

Introduction Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed. Methods A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution. Results The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome—including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair. Conclusions While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons’ opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.

A 59-year-old man presented to the trauma center with multiple stab wounds to his face, neck, chest, abdomen, bilateral arms, and bilateral hands. He did not complain of pain in any specific area of injury. The patient was able to state his name. His systolic blood pressure was 98 mm Hg, heart rate was 107 beats/min, and respiratory rate was 34 breaths/min with audible breath sounds bilaterally. There was a main 1.5 cm stab wound to his left neck posterior to the sternocleidomastoid muscle at the level of the thyroid cartilage. No air was bubbling out of this nor any of his other cervical wounds. In addition, there was no associated bleeding, hematoma, palpable thrill, or audible bruit. His neurologic examination revealed that his Glasgow Coma Scale score was 15, and he did not have any lateralizing signs or focal deficits. His cranial nerve examination was intact. On abdominal examination, he did have tenderness in all four quadrants, but did not have peritonitis. His pulse examination was normal in all four extremities. Which clinical finding would NOT warrant immediate exploration in the operating room? 1. Positive focused abdominal sonogram for trauma (FAST) with hypotension 2. Pulsatile bleeding from the neck wound 3. Peritonitis on abdominal examination 4. Crepitus on chest palpation After blood was drawn for type and cross-match, two large bore intravenous catheters were inserted. A chest X-ray and an extended focused abdominal sonogram for trauma (eFAST) examination were performed. The chest X-ray did not show any abnormalities, and the eFAST was negative. The patient’s repeat systolic blood pressure was 113 mm Hg. Because he had a normal blood pressure, did not have hard signs of a vascular or aerodigestive injury in his neck, and did not have a positive FAST nor peritonitis on abdominal examination, he underwent a CT scan of his abdomen and pelvis with …

Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors’ clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.

This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed30 days from operation, patency of venous repairs when assessed30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed.Review article, levels IV and V.

A 35-year-old man presented to the trauma center with two gunshot wounds to the left thigh that were reportedly from a handgun. Prehospital transport time was about 15 minutes and he received 1 L of intravenous crystalloid fluid for hypotension. It was reported that the patient fell after he was shot and that he hit his head and lost consciousness. The patient was pale and diaphoretic on arrival at the trauma center. His blood pressure was 83/53, heart rate was 82 beats per minute, respiratory rate was 18 breaths per minute, and oxygen saturation was 98% on room air. There was a missile wound in the proximal lateral left thigh and another in the distal posterior thigh. He had hard signs of an arterial injury in the left thigh, including arterial bleeding from the distal gunshot wound, an expanding hematoma, and a pulseless left foot, as well as decreased motor function and sensation in the left foot. A massive transfusion protocol was initiated as X-rays of the left lower extremity were completed (no fracture). After pressure dressing was applied to the site of hemorrhage in the left thigh (distal gunshot wound), the patient was taken to the CT scanner to evaluate for a traumatic brain injury and then to the operating room emergently for exploration of the left thigh. Skin preparation was applied from the umbilicus to the toes bilaterally and was circumferential on the lower extremities. An incision was made along the left medial thigh to expose the superficial femoral artery (SFA). Nearly circumferential injuries to the distal SFA and popliteal vein at the adductor hiatus (Hunter’s canal) were identified. Proximal and distal control with the application of vascular clamps to both vessels was obtained, and systemic heparin (7000 units, or approximately 100 U/kg) was administered …

An 18-year-old man presented to the trauma center with four gunshot wounds to the following areas: left lower flank, left lower quadrant of the abdomen, left supraclavicular region and left scapula. The patient was awake but alternated between periods of agitation and lethargy. He had a heart rate of 140 beats/min, a blood pressure of 100/60 mmHg, a respiratory rate of 12 breaths/min, and appeared pale with cool and clammy skin. Breath sounds were clear bilaterally. His left supraclavicular wound did not exhibit any signs of overt bleeding, nor was there an expanding hematoma, and he had a palpable left radial pulse. His abdominal examination was significant for the gunshot wounds as described earlier and tenderness over the left flank. Large bore intravenous access was obtained, and transfusion with whole blood was initiated. A Focused Assessment for the Sonographic Evaluation of the Trauma Patient (FAST) documented a fluid stripe in the right hepatorenal fossa. A foreign body X-ray series was then performed (figure 1). The patient was taken to the operating room where an emergency exploratory laparotomy was performed. A moderate amount of hemoperitoneum and bile staining was noted in the lesser sac. Figure 1 Foreign body series demonstrating retained bullets in the right upper quadrant. The following injuries were noted: (1) anterior and posterior perforations of the stomach, (2) a through-and-through central injury to the left lobe of the liver, (3) a perforation of the right hemidiaphragm and (4) an injury to the edge of the inferior pole of the spleen. The right upper quadrant of the abdomen was packed with laparotomy pads, and this appeared to control the bleeding. The tip of the spleen was inspected again and found to be hemostatic. The gastric injuries were then oversewn with a 3–0 polydioxanone (PDS) suture. Because of a concern about the …

A 24-year-old man presented to the trauma center with obvious distress and a gunshot wound above the left nipple. The patient was speaking but was confused and diaphoretic with a systolic blood pressure of 80 mm Hg, heart rate of 110 beats per minute and a respiratory rate of 20 breaths per minute. He had a single gunshot wound 5 cm superior to the left nipple and decreased breath sounds over the left hemithorax. After blood was drawn for type and cross-match, two #14 gauge intravenous catheters were inserted into the antecubital veins and lactated Ringer’s infusions were started. A surgeon-performed extended ultrasound focused assessment for the sonographic evaluation of the trauma patient (FAST) examination documented the absence of pleural sliding and of a comet tail artifact in the left hemithorax. Also, there was no pericardial fluid noted. A 36-Fr thoracostomy tube was inserted through the left fifth intercostal space, and a rush of air from the left hemithorax was noted. A stat chest X-ray was performed (figure 1). Figure 1 Gunshot wound to superior mediastinum injured posterior left common carotid artery at its origin on the transverse arch, left innominate vein and distal innominate artery. Patient had a contained hematoma and was transported to the operating room. From Feliciano.14 The patient’s systolic blood pressure remained at 80 mm Hg. In addition to intubation and transfusion of blood, your choice for the next step in management would be: 1. emergent left anterolateral thoracotomy. 2. contact the endovascular specialist. 3. CT aortogram with contrast. 4. median sternotomy in the operating room. The surgical team felt that the contained hematoma in the superior mediastinum reflected an injury to a great vessel. A median sternotomy was performed, and three separate vascular injuries were noted as follows

A 25-year-old man presented to the trauma center with gunshot wounds to the left shoulder and left lower quadrant. The patient was combative and diaphoretic with a systolic blood pressure of 100 mm Hg and a heart rate of 132 beats per minute. He had a single gunshot wound to the soft tissue of the superior aspect of the left shoulder, with normal pulses at the left wrist and a normal neurological examination in the left upper extremity. His abdominal examination was significant for a gunshot entrance wound in the left lower quadrant and diffuse peritonitis. The right femoral pulse was not palpable. After blood was drawn for type and cross-match, a surgeon-performed ultrasound was ‘negative’ for a hemopericardium and a left hemopneumothorax. A massive transfusion protocol was initiated, and a cephalosporin antibiotic was administered. On the first set of arterial blood gases, the pH was 7.11 with a base deficit of −17.5. After transport to the operating room, the patient was intubated, a midline exploratory laparotomy was performed and 2 L of hemoperitoneum were evacuated. There were multiple enterotomies in the small bowel, transection of the right external and internal iliac arteries and near transection of the right spermatic cord. Intestinal clamps were rapidly placed at the sites of enterotomies. Progressive hypotension mandated manual compression of the supraceliac abdominal aorta. A vascular clamp was then applied to the right common iliac artery, and the distal end of the right internal iliac artery was clamped and ligated. As the distal end of the right external iliac artery had retracted under the inguinal ligament, the midline abdominal incision was extended obliquely across the inguinal ligament into the right groin. A vascular clamp was then applied to the distal end of the right external iliac artery. The right spermatic cord was ligated. …

The story of trauma resuscitation is similar to that of many other advances in medicine: described, forgotten, reinvented, ridiculed, and finally accepted. Even after acceptance, the concepts go through periods of neglect and indifference before they are tried and enhanced, till the next advance. Damage control, a strategy for management of critically injured or ill patients, is a prime example of this phenomenon. It reminds us of the famous words of Oliver Goldsmith in 1761: “for he who fights and runs away, will live to fight another day, but he who is in battle slain, will never rise and fight again”. Damage control was based on the recognition of the lethal triad of hypothermia, acidosis, and a coagulopathy resulting from massive blood loss, large-volume resuscitation and ischemia-reperfusion. It was an approach that J. Hogarth Pringle from Glasgow, Scotland, suggested in 1908 with his principles of compression and hepatic packing for control of venous hemorrhage from the injured liver: temporary, expeditious and effective. Packing, however, was rarely utilized during World War II and the Vietnam War because of the presumed risk of rebleeding with removal of the packs. The ever-difficult challenge of “non-surgical bleeding” from a coagulopathy due to massive hepatic injuries did, eventually, lead to a resurrection of the concept of perihepatic packing in the 1980s in civilian centers and became one of the initial steps in damage control for patients with severe and/or multiple intra-abdominal injuries.

Isolated injuries to the pancreas and duodenum from either blunt or penetrating trauma are infrequent, and early mortality is usually due to associated vascular injuries in the upper abdomen. Delays in diagnosis after blunt trauma are less common in the modern era due to the availability of multidetector CT. Pancreatic injuries without involvement of the main duct are managed nonoperatively, while ductal injuries are treated with resection of the body and tail or head and a rare Roux-en-Y reconstruction in most circumstances. The most common complication after resection continues to be a pancreatic fistula. Duodenal perforations are treated with transverse or oblique closure, Roux-en-Y duodenojejunostomy, or resection. Pyloric exclusion with gastrojejunostomy is still used for selected combined pancreatoduodenal or complex duodenal injuries.

A 22-year-old man presented to the trauma center with a single gunshot wound to the right upper quadrant. The patient’s systolic blood pressure was reported to be 80 mm Hg in the field. The patient was alert and responsive on arrival. His initial vital signs were a heart rate of 120 beats per minute, a systolic blood pressure of 138 mm Hg, and a respiratory rate of 20/min. His abdominal examination was significant for a gunshot wound approximately 10 cm inferior to the right costal margin and 6 cm lateral to the midline. In addition, his abdomen was distended and diffusely tender to palpation. After blood was drawn for type and cross-match, the patient was moved to the operating room. A massive transfusion protocol was initiated, and a cephalosporin antibiotic was administered. After intubation, a midline exploratory laparotomy was performed. A significant hemoperitoneum was evacuated. At this point, the anesthesiologist stated that the patient’s systolic blood pressure had dropped to 80 mm Hg. On rapid inspection of the abdominal cavity, through-and-through wounds to the prepyloric gastric antrum, through-and-through wounds to the head of the pancreas, and a large midline supramesocolic hematoma were noted. Division of the gastrocolic omentum allowed for exposure and suture repair of the anterior and posterior holes in the prepyloric antrum. A few peripancreatic bleeders were ligated as the head of the pancreas was inspected. The location of the through-and-through wounds in the head of the pancreas suggested that neither the common bile duct nor the main pancreatic duct of Wirsung was injured. The most appropriate next step at operation is: 1. Left anterolateral thoracotomy/cross-clamp descending thoracic aorta 2. Add median sternotomy to midline laparotomy incision 3. Left medial mobilization maneuver 4. Cattell-Braasch maneuver At this point, the midline supramesocolic hematoma was larger than when first observed. It was approached by a left medial mobilization maneuver …

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Despite advances in trauma care, a subset of patients surviving damage control cannot achieve fascial closure and require split-thickness skin grafting (STSG) of their open abdomen. Controversy exists as to whether reconstruction of the gastrointestine (GI) should be staged or performed at the time of abdominal wall reconstruction (AWR). Many surgeons do not believe that operations through the STSG can be completed safely or without loss of graft. This series reviews the outcomes of operations for GI reconstruction performed through the elevated healed STSG. Concurrent series on all patients undergoing abdominal operation through the STSG. The technique involves elevating the STSG, lysing adhesions only as needed, avoid detaching underlying omentum or viscera to avoid devascularization, and then reattaching the elevated STSG to the abdominal wall with simple sutures. From 1995 to 2017, 27 patients underwent 40 distinct procedures during 36 separate abdominal reoperations (89% GI) through the elevated STSG approach at three Level I trauma centers at a mean interval of 11 months from application of the STSG. One STSG was lost (patient closed with skin flaps), one patient had 30 per cent loss of the STSG (regrafted), and one patient had 10 per cent loss of the STSG (allowed to granulate). One patient required a small bowel resection for intraoperative enterotomy during a difficult operative dissection. There were no GI complications, intraabdominal infections, or deaths, and all patients were deemed fit to undergo AWR after three months. Major intraabdominal reoperations can be readily and safely accomplished through the elevated STSG approach with a

A minimally invasive (MI) approach using small incisions and vessel loops for drainage of simple perianal abscesses has been described in the pediatric population with decreased postoperative pain and comparable results to the traditional incision and drainage (I&D). The hypothesis was MI I&D will yield similar outcomes in adults. Patients who underwent I&D of perianal abscesses at an urban hospital from January 2008 to December 2015 were identified by Current Procedural Terminology code. Patients below 18 years of age, with inflammatory bowel diseases, or fistulae were excluded. Recurrences, readmissions, operative time, length of stay, complications, and costs were compared. There were 47 traditional and 96 MI I&D with no significant differences in demographics, average body mass index, and abscess size. No significant differences were noted in recurrences, readmissions, length of stay, operative time, or costs (P > 0.05). Postoperative complications occurred more frequently in the traditional group (P < 0.01) with a lower rate of follow-up (P < 0.05). MI I&D for simple anal abscesses in adults is associated with better compliance and fewer complications than the traditional approach. Although further studies are needed to determine if MI I&D confers superiority, this approach should be considered as first-line treatment for uncomplicated perirectal abscesses in adults.

A 24-year-old man presented to the trauma center with gunshot wounds to the neck, chest and back. The patient was awake but lethargic with a heart rate of 120 beats per minute, a systolic blood pressure of 80 mm Hg and absent breath sounds on the right. He was noted to have an expanding hematoma of the left neck under a gunshot wound, a gunshot wound to the left chest at the level of the nipple, a gunshot wound overlying the left scapula, and a fourth gunshot wound penetrating the left deltoid muscle. The most appropriate first step in management of this patient in addition to resuscitation is: 1. Foreign body X-ray series. 2. Left anterolateral thoracotomy. 3. Orotracheal intubation/right thoracostomy tube. 4. Pressure dressing to left neck. The patient underwent orotracheal intubation, insertion of a right thoracostomy tube, and transfusion of blood through large bore intravenous catheters. A foreign body series demonstrated a deep sulcus sign on the left with a pulmonary contusion, a retained bullet in the region of the right shoulder and several bullet fragments in the left shoulder (figure 1). Subsequently, a left-sided thoracostomy tube was inserted with drainage of a hemothorax. After transfusion of 3 units of packed red blood cells and 3 units of plasma, the patient’s systolic blood pressure increased to 120 mm Hg and his heart rate decreased to 80 beats per minute. As the patient’s cervical hematoma was stable, a CT scan of the neck and chest was performed with a single load of intravenous contrast. The CT scan demonstrated an intimal defect in the left common carotid artery and a trajectory highly concerning for esophageal perforation (figure 2). Figure 1 Paper clips mark gunshot wounds. Red arrows are anterior and blue arrows are posterior. Figure 2 CT scan demonstrating carotid (red arrow) and esophageal (blue arrow) injuries. The most …

Blunt carotid artery injury (BCI) is present in approximately 1.0% to 2.7% of all blunt trauma admissions and can result in significant morbidity and mortality. Management ranges from antithrombotic therapy alone to surgery, where potential indications include pseudoaneurysm, failed or contraindication to medical therapy, and progression of neurologic symptoms. Still, optimal management, including approach and timing, continues to be an active area for debate. The goal of this study was to assess the epidemiologic characteristics of BCI, and, after controlling for presenting features intrinsic to the data, compare outcomes based on management, operative approach, and timing of intervention.A retrospective review was conducted of adult BCI patients identified within the National Trauma Data Bank from 2002 to 2016. The National Trauma Data Bank is the largest trauma database in the United States, collating data from each trauma admission for more than 900 trauma centers. Independent variables of interest included nonoperative versus operative management (OM); endovascular versus open intervention, and early (within 24 hours) versus delayed (after 24 hours) intervention. For each independent variable, groups were compared after propensity score matching to control for presenting factors and patterns of injury.There were 9190 patients who met the inclusion criteria, 812 of whom underwent operative intervention (open, n = 288; endovascular, n = 481, both: n = 43). During the review, there was no difference in proportion of OM over time, although there was a statistically significant decrease in the proportion of open intervention (0.48% per year; P .05). For outcomes, operative versus nonoperative management (nOM) resulted in no difference in mortality, but the operative group demonstrated an increased risk of stroke (11.8% vs 6.5%), longer hospital and intensive care length of stay, and more days on mechanical ventilation (P .001 for each). With regard to timing: mortality was increased for early intervention (early, 16% vs delayed, 6.3%; P .001), which was predominantly driven by the endovascular cohort (early, 19.2% vs delayed, 2.5%; P .001).In this study, there was no significant trend in the overall volume of operative or nOM; however, when considering approach to OM, there was a significant decrease in open procedures. Consistent with previous literature, injury to the neck, head, and chest was significant associated with BCI. Also outcomes demonstrated an increased prevalence of stroke after operative relative to nOM. Importantly, after critically assessing the timing to intervention, results strongly suggested that, if possible, intervention should be delayed for at least 24 hours.

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 (

Background Because of its uncommon nature and a lack of comprehensive literature, abdominal wall hernias caused by blunt trauma continue to present a management dilemma. This study was performed to identify the incidence of associated injuries, the need for urgent operative intervention, and recurrence rates after hernia repair. Methods A retrospective review of patients diagnosed with a traumatic abdominal wall hernia from January 2002 to December 2014 was performed. Data were collected from the trauma registry and included patient demographics, location and type of hernia, associated injuries, operative interventions, complications, and length of stay. Results Eighty patients (64% male; median age, 36 years; mean Injury Severity Score [ISS], 22) were identified during the study period. A motor vehicle collision was the most frequent mechanism of injury (n = 58). Overall, 35 patients (44%) underwent urgent laparotomy or laparoscopy, and 10 of these (29%) were nontherapeutic excluding hernia repair. Of interest, 17 patients (49%) required bowel resection. Notably, the need for operative intervention and nontherapeutic rate differed depending on hernia location. Hernia repair was performed in 23 patients, the majority of whom (78.3%) underwent repair within 5 days of injury. There were six recurrences, four of which were repaired acutely (within 1 week of injury), with an overall first-time hernia recurrence rate of 26%. Conclusion In the largest series to date, traumatic abdominal wall hernias were found to be associated with a high percentage of intra-abdominal injuries requiring urgent laparotomy or laparoscopy. Rates of therapeutic interventions varied by hernia location, with anterior abdominal hernias associated with the highest need for a therapeutic operation. Acute repair was associated with the majority of the recurrences. Level of evidence Epidemiologic study, level III; therapeutic study, level IV.

Physiologic changes in the elderly lead to higher morbidity and mortality after injury. Increasing level of trauma activation has been proposed to improve geriatric outcomes, but the increased cost to the patient and stress to the hospital system are significant downsides. The purpose of this study was to identify the age at which an increase in activation status is beneficial.A retrospective review of trauma patients 70 years or older from October 1, 2011, to October 1, 2016, was performed. On October 1, 2013, a policy change increased the activation criteria to the highest level for patients 70 years or older with a significant mechanism of injury. Patients who presented prior to (PRE) were compared with those after the change (POST). Data collected included age, Injury Severity Score (ISS), length of stay (LOS), complications, and mortality. Primary outcome was mortality, and secondary outcome was LOS. Multivariable regressions controlled for age, ISS, injury mechanism, and number of complications.A total of 4,341 patients met the inclusion criteria, 1,919 in PRE and 2,422 in POST. Mean age was 80.4 and 81 years in PRE and POST groups, respectively (p = 0.0155). Mean ISS values were 11.6 and 12.4 (p0.0001) for the PRE and POST groups. POST had more Level 1 activations (696 vs. 220, p0.0001). After controlling for age, ISS, mechanism of injury, and number of complications, mortality was significantly reduced in the POST group 77 years or older (odds ratio, 0.53; 95% confidence interval, 0.3-0.87) (Fig. 1). Hospital LOS was significantly reduced in the POST group age 78 years or older (regression coefficient, -0.55; 95% confidence interval, -1.09 to -0.01) (Fig. 2).This study suggests geriatric trauma patients 77 years or older benefit from the highest level of trauma activation with shorter LOS and lower mortality. A focused approach to increasing activation level for elderly patients may decrease patient cost.Therapeutic/Care Management, level IV.

Abdominal pain is the common reason patients seek treatment in emergency departments (ED), and computed tomography (CT) is frequently used for diagnosis; however, length of stay (LOS) in the ED and risks of radiation remain a concern. The hypothesis of this study was the Alvarado score (AS) could be used to reduce CT scans and decrease ED LOS for patients with suspected acute appendicitis (AA).A retrospective review of patients who underwent CT to rule out AA from January 1, 2015, to December 31, 2015, was performed. Patient demographics, medical history, ED documentation, operative interventions, complications, and LOS were all collected. Alvarado score was calculated from the medical record. Time to CT completion was calculated from times the patient was seen by ED staff, CT order, and CT report.Four hundred ninety-two patients (68.1% female; median age, 33 years) met the inclusion criteria. Most CT scans (70%) did not have findings consistent with AA. Median AS for AA on CT scan was 7, compared with 3 for negative CT (p0.001). One hundred percent of female patients with AS of 10 and males with AS of 9 or greater had AA confirmed by surgical pathology. Conversely, 5% or less of female patients with AS of 2 or less and 0% of male patients with AS of 1 or less were diagnosed with AA. One hundred six (21.5%) patients had an AS within these ranges and collectively spent 10,239 minutes in the ED from the time of the CT order until the radiologist's report.Males with an AS of 9 or greater and females with AS of 10 should be considered for treatment of AA without imaging. Males with AS of 1 or less and females with AS of 2 or less can be safely discharged with follow-up. Using AS, a significant proportion of patients can avoid the radiation risk, the increased cost, and increased ED LOS associated with CT.Diagnostic IV, therapeutic IV.

The open abdomen is used when the abdominal incision cannot be closed, when an early reoperation is necessary, to prevent an abdominal compartment syndrome, for the treatment of secondary or tertiary peritonitis, for the treatment of omphaloceles in neonates, and for the treatment of missing portions of the abdominal wall. The unique contribution of Oswaldo A. Borraez Gaona, MD, of Bogota, Colombia, was the application of a plastic bag over the open abdomen in injured patients. The bag allows for rapid access for a relaparotomy and covers and protects the viscera until edema and/or infection resolves.

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with esophageal injuries.

Injuries to major abdominal vessels are among the most lethal in all of trauma surgery. Patients are hemodynamically unstable upon arrival, the vessels are large, many named arteries and veins are adjacent to one another, moderate to extensive dissection is required to expose some, there are always associated intra-abdominal injuries, and there are sequelae when arterial repairs are delayed and/or when venous ligation is performed.

Over the past 65+ years, most civilian peripheral vascular injuries have been managed by trauma surgeons with training or experience in vascular repair or ligation. This is appropriate as the in-hospital trauma team is immediately available, and there are often other injuries present in the victim. The pitfall to avoid during evaluation of the patient in the emergency center is a missed diagnosis. In the patient without 'hard' signs of a peripheral vascular injury, a careful history (bleeding), physical examination including measurement of ankle-brachial (ABI) or brachial-brachial index and liberal use of CT arteriography depending on an ABI

A 29-yearold man presented to the trauma center with a single gunshot wound to the right costal margin. The patient was alert and responsive on arrival, but became increasingly lethargic throughout the assessment. His initial vital signs were a heart rate of 100 beats per minute, a systolic blood pressure of 80 by palpation and a respiratory rate of 20/min. His abdominal exam was significant for a single gunshot wound to the right costal margin at the midclavicular line, and his abdomen was distended and tense to palpation. The most appropriate first step in management of this patient in addition to resuscitation is: 1. Massive transfusion and abdominal CT scan. 2. Surgeon-performed FAST (focused assessment for the sonographic evaluation of trauma) examination. 3. Transfer to operating room. 4. Emergent hepatic arteriogram. A massive transfusion protocol was initiated, packed red blood cells were administered, and the patient was taken directly to the operating room where he underwent endotracheal intubation. After the administration of a cephalosporin antibiotic, a midline exploratory laparotomy was performed. A significant hemoperitoneum was evacuated. After evisceration of the small bowel to the right, the infrarenal abdominal aorta was cross-clamped because of profound hypotension. A large right retroperitoneal hematoma was exposed by a right-sided medial mobilization maneuver. After visualizing a 5 cm longitudinal anterior split in the infrarenal inferior vena cava (IVC) with a corresponding 2 cm posterior perforation just above the confluence of the common iliac veins, vascular cross-clamps were applied to both common iliac veins and the infrarenal IVC. There was still significant back-bleeding from the lumbar veins. After an attempt to repair the significant anterior laceration in the IVC, it became obvious that the IVC would be significantly narrowed. In addition, the patient remained profoundly hypotensive. At this point, both common iliac veins, the infrarenal IVC just above the perforations, and several …

Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS.A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease.Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases.This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Concern over lack of resident interest caused by the nonoperative nature and compromised lifestyle associated with a career as a "trauma surgeon" has led to the emergence of a new acute care surgery (ACS) specialty. This study examined the opinions of current general surgical residents about training and careers in this new field.A 36-item online anonymous survey regarding ACS was sent to the program directors of 55 randomly selected general surgery (GS) training programs for distribution to their categorical residents. The national sample consisted of 1,515 PGY 1 to 5 trainees.Response rate was 45%. More than 90% of residents had an appropriate understanding of the components of ACS as generally described (trauma, surgical critical care, and emergency GS). Nearly half (46%) of all respondents have considered ACS as a career. Overall, ACS ranked as the second most appealing career ahead of surgical critical care and trauma but behind GS. Most residents believed that ACS offers better or equivalent case complexity (88%), scope of practice (84%), case volume (75%), and level of reimbursement (69%) compared with GS alone. Respondents who answered ACS had a better scope of practice (61% vs. 36%), lifestyle as an attending surgeon (77% vs. 34%), or level of reimbursement (83% vs. 38%) compared with GS were twice as likely (p0.0001) to have considered ACS as a career. Overall, 40% of the residents believed that ACS offers a worse lifestyle in comparison with GS.These results suggest that there is notable interest in the emerging specialty of ACS. The level of resident interest in ACS as a fellowship and career may be increased by marketing those aspects of practice, which are viewed positively and addressing negative perceptions related to lifestyle. It may be appealing to add an elective GS component to certain ACS practice options.

Background Despite the lethality of injuries to the heart, optimizing factors that impact mortality for victims that do survive to reach the hospital is critical. Methods From 2003 to 2012, prehospital data, injury characteristics, and clinical patient factors were analyzed for victims with penetrating cardiac injuries (PCIs) at an urban, level I trauma center. Results Over the 10-year study, 80 PCI patients survived to reach the hospital. Of the 21 factors analyzed, prehospital cardiopulmonary resuscitation (odds ratio [OR] = 30), scene time greater than 10 minutes (OR = 58), resuscitative thoracotomy (OR = 19), and massive left hemothorax (OR = 15) had the greatest impact on mortality. Cardiac tamponade physiology demonstrated a “protective” effect for survivors to the hospital (OR = .08). Conclusions Trauma surgeons can improve mortality after PCI by minimizing time to the operating room for early control of hemorrhage. In PCI patients, tamponade may provide a physiologic advantage (lower mortality) compared to exsanguination.

Because of the unique physiology and comorbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an American College of Surgeons Level I trauma center.As of October 1, 2013, all injured patients 70 years or older were mandated to have the highest-level trauma activation upon emergency department (ED) arrival regardless of physiology or mechanism of injury. Patients admitted before that date were designated as PRE; those admitted after were designated as POST. The study period was from October 1, 2011, through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), ED length of stay (LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p0.05 was considered significant). χ or Fisher's exact test was used as appropriate for bivariate analyses of categorical variables; patients' ages were compared using the Wilcoxon rank-sum test.A total of 2,269 patients (mean, 80.63 years; mean ISS, 12.2; PRE, 1,271; POST, 933) were included in the study. On multivariable analysis, increasing age, higher ISS, and hypotension were associated with higher mortality. POST patients were more likely to have an ED LOS of 2 hours or shorter (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) after controlling for hypotension, ISS, and comorbidities. POST mortality significantly decreased (odds ratio, 0.689; 95% confidence interval, 0.484-0.979).Based on age alone, the focused intervention of a higher level of trauma activation decreased ED LOS and mortality in injured geriatric patients.Therapeutic/care management study, level IV.

Patients with trauma to the heart, great vessels, or lungs often die in the prehospital setting. As such, patients with one or more of these injuries who arrive at the emergency department (ED) have a chance of survival if rapid diagnosis and treatment are rendered. Resuscitative thoracotomy is occasionally indicated in patients with penetrating thoracic injury, including those in extremis or those with recent cardiac arrest. Penetrating cardiac injury with tamponade is diagnosed with ultrasound while intrapleural bleeding is evident on chest x-ray or on placement of a tube thoracostomy. A sternotomy or an anterolateral thoracotomy is used for cardiac and great vessel injury exposure, and a variety of techniques are available to control hemorrhage until suture repair can be accomplished. Blunt cardiac trauma is uncommon, is diagnosed with electrocardiogram, and mandates admission with monitored intensive care. Great vessel repair follows standard principles; and, in the case of occlusion or contained disruption (i.e., pseudoaneurysm), a contrast-enhanced computed tomography (CT) scan may be afforded to confirm extent and location of injury. Patients who are hemodynamically normal may also be candidates for conventional arteriography with or without endovascular stent graft repair. Fewer than 10% of patients with lung injury require thoracotomy for hemorrhage control because most are successfully managed with tube drainage. When thoracotomy is necessary, most injuries are successfully treated with suture pneumonorrhaphy, stapled wedge resection, or pulmonotomy (i.e., pulmonary tractotomy). Lobectomy or pneumonectomy are rare and are reserved for hilar injuries or extensive parenchymal injuries involving more than 75% of a lobe.

Pelvic ring fractures often result in severely injured patients with multiple organ injuries. The most common associated injuries are intraabdominal or urogenital, and urogenital injuries are the most common associated injuries in those with severe pelvic fractures. Prompt and effective diagnosis and management of these injuries is essential to successful outcomes, but this is potentially complicated by poor communication and coordination among the many specialists involved. To address this, we present a multi-disciplinary review of pelvic fracture-associated bladder and urethral injuries that is specifically geared towards orthopaedic, urology, and trauma surgeons caring for these patients.

As part of the 2011 American Association for the Surgery of Trauma (AAST) meeting in Chicago, the Military Liaison Committee led an interactive, case-based debate of vascular trauma and hemorrhage control entitled Tourniquets, Vascular Shunts and Endovascular Technologies: Esoteric or Essential? During the panel session, use of a real-time audience response system resulted in a sensing session during- which opinions and practice patterns related to these topics were tabulated. The purpose of this report is to provide the results from the audience response system gathered during this session as well as select peer-reviewed publications cited during the presentation of each scenario. In addition, the objective of this summary is to provide a perspective as to whether these surgical adjuncts or techniques are esoteric or essential in contemporary trauma practice.

There are little data regarding the use of massive transfusion protocols (MTP) outside of the trauma setting. This study compares the use of an MTP between trauma and non-trauma (NT) patients. Data were collected for trauma and NT patients from the prospectively maintained MTP database at a Level I trauma center over a 4-year period. Massive transfusion was defined as $ 10 units packed red blood cells (PRBCs) in a 24-hour period. Of 439 MTP activations, 37 (8%) were NT patients (64% male; mean age = 51 years, initial base deficit = -10.8). Activations were for gastrointestinal bleeding (n = 18), bleeding during surgery (n = 13), obstetrical complications (n = 5), and ruptured aortic aneurysm (n = 1). Over-activation of MTP (< 10 units PRBCs/24 hours) was higher in NT than trauma patients (19/37, 51% vs 118/284, 29%, P < 0.01). For massive transfusion patients, 24-hour mortality was higher in NT compared with trauma patients (10/17, 59% vs 100/284, 35%, P = 0.05), but there was no difference in 30-day mortality (10/17, 59% vs 144/284, 51%, P = 0.51). With over-activation in 51% of NT patients, MTP usage outside of trauma is inefficient. Outcomes in NT patients were worse than trauma patients, which may be related to the underlying disease processes.

BACKGROUND Elevated base deficit (BD) and lactate levels at admission in patients with injury have been shown to be associated with increased mortality. This relationship is undefined in the Canadian experience. The goal of this study was to define the association between arterial blood gas (ABG) values at admission and mortality for Canadians with severe blunt injury. METHODS A retrospective review of 3,000 consecutive adult major trauma admissions (Injury Severity Score, ≥ 12) to a Canadian academic tertiary care referral center was performed. ABG values at the time of arrival were analyzed with respect to associated mortality and length of stay. RESULTS A total of 2,269 patients (76%) had complete data available for analysis. After exclusion of patients who sustained a penetrating injury or were admitted for minor falls (ground levels or low height), 445 had an ABG drawn within 2 hours of arrival. Patients who died displayed a higher median lactate (3.6 vs. 2.2, p < 0.0001), a worse median BD (-10 vs. -5, p < 0.0001), and a lower pH (7.23 vs. 7.31, p < 0.0001) at arrival compared with those of survivors. A statistically significant association was also observed between lactate and BD values at arrival and both mortality and length of stay (p < 0.0001). CONCLUSION Despite population differences, ABGs at admission in Canadian patients with blunt trauma accurately reflect mortality in a similar manner to the previously published literature. Survival curves with lactate and BD values at arrival should be available to all clinicians within their individual trauma centers for both acute care and quality assurance. LEVEL OF EVIDENCE Prognostic study, level III.

While a 20-year-old woman was being chased by an assailant, she tripped on railroad tracks, fell, and felt immediate pain in her left knee. As the pain led to loud screaming, the assailant fled. The emergency medical service brought the patient to a level 1 trauma center. The patient was awake and alert with normal vital signs. She was unable to move her left knee, which appeared to be dislocated. Although she had sensation in the left foot and limited movement of the left ankle and toes, there were no palpable distal pulses or Doppler signals. The most appropriate first step in the management of this patient is: 1. Left below-knee four-compartment fasciotomy. 2. CT arteriography. 3. Administration of unfractionated heparin. 4. Operative exploration. In consultation with the trauma attending surgeon, the trauma fellow administered intravenously 5000 units of unfractionated heparin in light of the probable complete occlusion of the popliteal artery and the lack of an open wound or other major associated injuries. Orthopedic surgery agreed that the patient had a posterior dislocation of the left knee with probable injury to the mid-left popliteal artery (figure 1). The dislocation was successfully reduced under intravenous sedation. No pulsations were noted in the left pedal arteries after the reduction. Figure 1 Posterior dislocation of the left knee joint. The most appropriate next step in the management of this patient is: 1. Left below-knee four-compartment fasciotomy. 2. CT arteriography. 3. Administration of aspirin (ASA) 181 mg. 4. Contact the endovascular surgeon. A one-shot left femoral arteriogram (patient cared for before availability of CT arteriography) documented a thrombosis in the left mid-popliteal artery (figure 2). Figure 2 Blunt thrombosis of the left popliteal artery behind the knee joint. The patient was typed and crossed for two units of packed red blood cells, received 1 g of cephalosporin antibiotic intravenously, and was moved to the …

Objective: Hemothorax is a common sequela of chest trauma. Complications after chest trauma include retained hemothorax and empyema requiring multiple interventions. We studied the epidemiology of hemothorax and its complications at a level I trauma center. Methods: The trauma registry was reviewed from Jan 1995 to May 2005. All patients ‡ 16 years of age who were admitted with hemothorax, an AIS chest score of ‡ 3, and did not receive an immediate thoracotomy were entered in the study cohort. The patient demographics, details of the injury event, treatments, hospital length of stay (LOS), complications and outcome were analyzed. Results: The study cohort of 522 patients with a hemothorax were treated with 685 chest thoracostomy tubes. Overall, the median ISS was 18 and 62% were penetrating injuries. 109 patients (21%) had a retained hemothorax and required placement of ‡ 2 chest tubes with a median LOS of 15 days longer than patients with no retained hemothorax (p < 0.0001). The overall complication rate was 5% (26/522). Of these, 20 patients had empyema (3.8%), 8 patients required decortication, and 6 patients received streptokinase treatment. Conclusions: More than 1 out of every 5 patients undergoing intervention for trauma-induced hemothorax develops a complication. The development of retained hemothorax is associated with empyema in 15.6% of cases and a 2-week median increase in length of stay. Future research into interventions such as Video-assisted thoracoscopic surgery (VATS) on the day of admission to completely evacuate hemothorax is warranted to reduce complication rates, length of stay and cost.

Background A 10-year review of temporary intravascular shunts (TIVS) at a regional trauma center. Methods Retrospective chart review of all patients treated with temporary intravascular shunts from January 1, 1997 to January 1, 2007. Results Seven hundred eighty-six patients were treated for vascular injuries. Sixty-seven (9%) had a total of 101 (72 arterial, 29 venous) TIVS placed to facilitate damage control or to allow for reconstruction of Gustilo IIIc fractures or limb replantation. Seven patients who, on trauma day 0, died or had an extremity which was deemed unsalvageable were excluded. Of 60 patients who met inclusion criteria, seven died from TBI (3%), MOF (3%), sepsis (2%), deceleration of care (2%), and loss of airway (2%), which was deemed preventable. Conclusions TIVS have a shunt thrombosis rate of 5%, amputation rate of 18%, overall survival of 88%, and combination limb/patient survival rate of 73%. TIVS have an established role primarily in patients requiring either "damage control" for exsanguination or temporary vascular conduits during stabilization of Gustilo IIIc fractures. Truncal injuries are associated with the highest mortality likely due to accompanying multisystem trauma.

Pancreatic trauma is rare with an incidence between one and two percent in patients with abdominal trauma. Morbidity and mortality, however, are significant with rates approaching 40-45% in some reports. The majority of patients with injuries to the pancreas have associated trauma to other organs which are primarily responsible for the high mortality rate. The continuity of the main pancreatic duct is the most important determinant of outcome after injury to the pancreas. If there is no evidence of ductal injury on fine-cut CT or on ERCP, nonoperative management is chosen. The indications for operative management are as follows: (1) peritonitis on physical examination; (2) hypotension and a positive FAST; and (3) evidence of disruption of the pancreatic duct on fine-cut CT or on ERCP. After exposure and evaluation of the extent of injuries to the pancreas and duodenum, a decision must be made on the procedure. For pancreatic contusions, hematomas, or small lacerations, simple external drainage or pancreatorrhaphy with drainage can be performed. For ductal transection at the neck, body, or tail, the procedure of choice is a distal pancreatectomy or Roux-en-Y distal pancreatojejunostomy. If the patient has suffered a ductal transection at the head of the pancreas without injury to the duodenum, a Roux-en-Y distal pancreatojejunostomy or anterior Roux-en-Y pancreatojejunostomy is the operation of choice. For combined pancreatoduodenal injuries, the options are repair and drainage, diversion via a pyloric exclusion procedure, or pancreatoduodenectomy. Complications of pancreatic injuries include fistulas and intra-abdominal abscesses, and an occasional pancreatic pseudocyst. Key Words.

Options for a hemodynamically stable patient with a penetrating wound to the flank or back but no peritonitis, includes serial physical examinations versus a triple-contrast CT scan. There is, however, little consensus on the minimum time for serial examinations to exclude an injury that requires an operation. Therefore, a retrospective review of patients who sustained a penetrating wound to the flank or back and were admitted to a Level I trauma center was performed. Patients were identified through the trauma registry, patient charts, and morbidity/mortality records. From 1995 to 2003, 93 patients undergoing observation for a penetrating flank/back wound subsequently required a therapeutic laparotomy. The time from admission to operation was less than 3 hours for 84 per cent of the patients requiring therapeutic intervention. A further 10 per cent presented with symptoms between 4 to 6 hours, and 6 per cent between 7 to 18 hours. All the injuries caused symptoms within 18 hours of the injury event. The majority of patients (94%) who require a laparotomy after a period of observation for a penetrating flank/back wound will develop signs and symptoms within 6 hours of admission. A period of hospitalization longer than 18 hours did not detect further injuries in the asymptomatic patient.

Background The American Association for the Surgery of Trauma (AAST) has developed a new grading system for uniform description of anatomic severity of emergency general surgery (EGS) diseases, ranging from Grade I (mild) to Grade V (severe). The purpose of this study was to determine the relationship of AAST grades for acute colonic diverticulitis with patient outcomes. A secondary purpose was to propose an EGS quality improvement program using risk-adjusted center outcomes, similar to National Surgical Quality Improvement Program and Trauma Quality Improvement Program methodologies. Methods This was a retrospective study of 1,105 patients (one death) from 13 centers. At each center, two reviewers (blinded to each other's assignments) assigned AAST grades. Interrater reliability was measured using κ coefficient. Relationship between AAST grade and clinical events (complications, intensive care unit use, surgical intervention, and 30-day readmission) as well as length of stay was measured using regression analyses to control for age, comorbidities, and physiologic status at the time of admission. Final model was also used to calculate observed-to-expected (O-E) ratios for adverse outcomes (death, complications, readmissions) for each center. Results Median age was 54 years, 52% were males, 43% were minorities, and 22% required a surgical intervention. Almost two thirds had Grade I or II disease. There was a high level of agreement for grades between reviewers (κ = 0.81). Adverse events increased from 13% for Grade I, to 18% for Grade II, 28% for Grade III, 44% for Grade IV, and 50% for Grade V. Regression analysis showed that higher disease grades were independently associated with all clinical events and length of stay, after adjusting for age, comorbidities, and physiology. O-E ratios showed statistically insignificant variations in risk of death, complications, or readmissions. Conclusion AAST grades for acute colonic diverticulitis are independently associated with clinical outcomes and resource use. EGS quality improvement program methodology that incorporates AAST grade, age, comorbidities, and physiologic status may be used for measuring quality of EGS care. High-quality EGS registries are essential for developing meaningful quality metrics. Level of evidence Prognostic study, level V.

Patients with penetrating wounds to the neck present with overt symptoms and/or signs or are asymptomatic or modestly/moderately symptomatic. With overt symptoms and/or signs, immediate resuscitation and an emergency operation are appropriate. Asymptomatic patients or those with modest or moderate symptoms and/or signs undergo observation or a diagnostic evaluation to avoid the 45% "negative" exploration rate documented in the past (denominator = all patients). Asymptomatic patients with penetration of the platysma muscle, but no signs of a visceral or vascular injury, should undergo serial physical examinations every 6-8 for 24-36 h before discharge. Noncontrast CT does not add to the accuracy of serial physical examinations. In stable patients with a variety of modest/moderate symptoms or signs possibly related to an injury to the carotid artery, CT-arteriography has become the diagnostic modality of choice. Patients with possible injuries to the cervical esophagus are often still evaluated with a Gastrografin swallow and, if needed, a "thin" barium swallow prior to fiberoptic esophagoscopy. CT-esophagograms are likely to replace these time-honored studies in the near future. Over 85% of patients with injuries to the trachea present with overt symptoms or signs, while the remainder have historically been evaluated with laryngoscopy and fiberoptic bronchoscopy. Again, cervical multislice CT is likely to replace these studies. Operative repair of the carotid artery with 6-0 polypropylene sutures requires heparinization and shunting on rare occasions. Both the trachea and esophagus are repaired with 3-0 absorbable sutures, and tracheostomy and esophageal diversion are used in only large and/or complex injuries. Sternal head or sternocleiodomastoid interposition flaps are used when combined visceral and vascular injuries are present.

Emergent right hemicolectomies have historically been associated with surprisingly high morbidity and mortality rates. A retrospective review of emergent right hemicolectomies over a 7-year period was performed to assess current morbidity and mortality. Emergent right hemicolectomy was defined as a procedure performed for an acute abdomen with no formal preoperative cleansing of the colon. Demographic data, diagnostic evaluation, length of stay and outcomes were evaluated. Over the study period, 122 emergent right hemicolectomies were performed on both general surgery and trauma patients. The average patient was 52.9 ± 18.5 years old, and the majority of patients (66.4%) were male. The indications for the procedures performed were bowel perforation (51), hemorrhage (25), cancer (16), benign obstruction (14), phlegmon (8), ischemia (6), or other (2). Resection with primary anastomosis was performed in 98 patients, 16 had an end ileostomy, and 8 underwent damage control procedures in which gastrointestinal continuity was not reestablished at the time of the original operation. Postoperative complications developed in 48 patients (39.3%). The majority of the complications (83.3%) were related to infection including intra-abdominal abscess (21 patients), sepsis (16), and wound infection (5). Other complications included anastomotic leak (5), wound dehiscence (3), stoma-related (3) and postoperative bowel obstruction (2). The patients who developed complications did not differ from those who had an uneventful postoperative course in terms of age, indication for procedure, or presence of intra-abdominal abscess or gross contamination at the time of the original procedure. The overall mortality rate was 13 per cent. Patients who died were older than those who lived (63 ± 19 vs 52 ± 18; P = 0.03) and were significantly more likely to have evidence of shock on presentation ( P = 0.0013). Emergent right hemicolectomies continue to be associated with high morbidity and mortality rates. The most common complications are related to infection. Age and manifestations of shock at the time of admission are strong predictors of mortality.

Background Rhabdomyolysis accounts for up to 28% of the causes of posttraumatic acute renal failure requiring dialysis. Clinically significant rhabdomyolysis is poorly characterized biochemically and difficult to diagnose. Methods A retrospective review of all surgical, trauma, burn, and pediatric surgical patients admitted to Grady Memorial Hospital in Atlanta, GA, from January 1995, through April 2002 was performed. Patients were screened for serum creatinine, base deficit, serum creatine kinase (CK) ≥1,000, presence of myoglobinuria, or if they had a clinical diagnosis of rhabdomyolysis by an attending surgeon. Results The sequential addition of admission laboratory values for serum creatinine ≥1.5 mg/dL (positive predictive value [PPV] = 33%), base deficit ≤−4 (PPV = 52%), serum CK level ≥5,000 U/L (PPV = 80%), and myoglobinuria increases the ability to predict which patients will develop dialysis-requiring acute renal failure after an episode of rhabdomyolysis. Patients with maximum CK ≥5,000 are also at increased risk for persistent renal insufficiency (Cr ≥2.0 mg/dL). Conclusions An algorithm for testing at-risk surgical patients was developed and may aid in the early diagnosis of clinically significant rhabdomyolysis.

Objective: The goal of this survey was to establish a benchmark for trauma surgeons' level of operational understanding of the command structure for a prehospital incident, a mass casualty incident (MCI), and weapons of mass destruction (WMD). The survey was distributed before the World Trade Center destruction on September 11, 2001. Methods: The survey was developed by the authors and reviewed by a statistician for clarity and performance. The survey was sent to the membership of the 2000 Eastern Association for the Surgery of Trauma spring mailing, with two subsequent mailings and a final sampling at the Eastern Association for the Surgery of Trauma 2001 meeting. Of 723 surveys mailed, 243 were returned and statistically analyzed (significance indicated by p < 0.05). Results: No statistical difference existed between level of designation of a trauma center (state or American College of Surgeons) and a facility's level of preparedness for MCIs or WMD. Physicians in communities with chemical plants, railways, and waterway traffic were statistically more likely to work at facilities with internal disaster plans addressing chemical and biological threats. Across all variables, physicians with military training were significantly better prepared for response to catastrophic events. With the exception of cyanide (50%), less than 30% of the membership was prepared to manage exposure to a nerve agent, less than 50% was prepared to manage illness from intentional biological exposure, and only 73% understood and were prepared to manage blast injury. Mobile medical response teams were present in 46% of the respondents' facilities, but only 30% of those teams deployed a trauma surgeon. Approximately 70% of the membership had been involved in an MCI, although only 60% understood the command structure for a prehospital incident. Only 33% of the membership had training regarding hazardous materials. Of interest, 76% and 65%, respectively, felt that education about MCIs and WMD should be included in residency training. Conclusion: A facility's level of preparedness for MCIs or WMD was not related to level of designation as a trauma center, but may be positively influenced by local physicians with prior military background. Benchmark information from this survey will provide the architecture for the development and implementation of further training in these areas for trauma surgeons.