The latest medical research on General Surgery
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about general surgery gathered by our medical AI research bot.
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Association of Severe Trauma With Work and Earnings in a National Cohort in Canada.JAMA Surgery
- design, setting, and participants
- main outcomes and measures
- conclusions and relevance
Traumatic injury disproportionately affects adults of working age. The ability to work and earn income is a key patient-centered outcome. The association of severe injury with work and earnings appears to be unknown.
To evaluate the association of severe traumatic injury with subsequent employment and earnings in long-term survivors.
This is a retrospective, matched, national, population-based cohort study of adults who had employment and were hospitalized with severe traumatic injury in Canada between January 2008 and December 2010. All acute care hospitalizations for severe injury were included if they involved adults aged 30 to 61 years who were hospitalized with severe traumatic injury, working in the 2 years prior to injury, and alive through the third calendar year after their injury. Patients were matched with unexposed control participants based on age, sex, marital status, province of residence, rurality, baseline health characteristics, baseline earnings, self-employment status, union membership, and year of the index event. Data analysis occurred from March 2019 to December 2019.
Changes in employment status and annual earnings, compared with unexposed control participants, were evaluated in the third calendar year after injury. Weighted multivariable probit regression was used to compare proportions of individuals working between those who survived trauma and control participants. The association of injury with mean yearly earnings was quantified using matched difference-in-difference, ordinary least-squares regression.
A total of 5167 adults (25.6% female; mean [SD] age, 47.3 [8.8] years) with severe injuries were matched with control participants who were unexposed (25.6% female; mean [SD] age, 47.3 [8.8] years). Three years after trauma, 79.3% of those who survived trauma were working, compared with 91.7% of control participants, a difference of -12.4 (95% CI, -13.5 to -11.4) percentage points. Three years after injury, patients with injuries experienced a mean loss of $9745 (95% CI, -$10 739 to -$8752) in earnings compared with control participants, representing a 19.0% difference in annual earnings. Those who remained employed 3 years after injury experienced a 10.8% loss of earnings compared with control participants (-$6043 [95% CI, -$7101 to -$4986]). Loss of work was proportionately higher in those with lower preinjury income (lowest tercile, -18.5% [95% CI, -20.8% to -16.2%]; middle tercile, -11.5% [95% CI, -13.2% to -9.9%]; highest tercile, -6.0% (95% CI, -7.8% to -4.3%]).
In this study, severe traumatic injury had a significant association with employment and earnings of adults of working age. Those with lower preinjury earnings experienced the greatest relative loss of employment and earnings.
Development and Validation of a Comprehensive Model to Estimate Early Allograft Failure Among Patients Requiring Early Liver Retransplant.JAMA Surgery
- design, setting, and participants
- main outcomes and measures
- conclusions and relevance
Expansion of donor acceptance criteria for liver transplant increased the risk for early allograft failure (EAF), and although EAF prediction is pivotal to optimize transplant outcomes, there is no consensus on specific EAF indicators or timing to evaluate EAF. Recently, the Liver Graft Assessment Following Transplantation (L-GrAFT) algorithm, based on aspartate transaminase, bilirubin, platelet, and international normalized ratio kinetics, was developed from a single-center database gathered from 2002 to 2015.
To develop and validate a simplified comprehensive model estimating at day 10 after liver transplant the EAF risk at day 90 (the Early Allograft Failure Simplified Estimation [EASE] score) and, secondarily, to identify early those patients with unsustainable EAF risk who are suitable for retransplant.
This multicenter cohort study was designed to develop a score capturing a continuum from normal graft function to nonfunction after transplant. Both parenchymal and vascular factors, which provide an indication to list for retransplant, were included among the EAF determinants. The L-GrAFT kinetic approach was adopted and modified with fewer data entries and novel variables. The population included 1609 patients in Italy for the derivation set and 538 patients in the UK for the validation set; all were patients who underwent transplant in 2016 and 2017.
Early allograft failure was defined as graft failure (codified by retransplant or death) for any reason within 90 days after transplant.
At day 90 after transplant, the incidence of EAF was 110 of 1609 patients (6.8%) in the derivation set and 41 of 538 patients (7.6%) in the external validation set. Median (interquartile range) ages were 57 (51-62) years in the derivation data set and 56 (49-62) years in the validation data set. The EASE score was developed through 17 entries derived from 8 variables, including the Model for End-stage Liver Disease score, blood transfusion, early thrombosis of hepatic vessels, and kinetic parameters of transaminases, platelet count, and bilirubin. Donor parameters (age, donation after cardiac death, and machine perfusion) were not associated with EAF risk. Results were adjusted for transplant center volume. In receiver operating characteristic curve analyses, the EASE score outperformed L-GrAFT, Model for Early Allograft Function, Early Allograft Dysfunction, Eurotransplant Donor Risk Index, donor age × Model for End-stage Liver Disease, and Donor Risk Index scores, estimating day 90 EAF in 87% (95% CI, 83%-91%) of cases in both the derivation data set and the internal validation data set. Patients could be stratified in 5 classes, with those in the highest class exhibiting unsustainable EAF risk.
This study found that the developed EASE score reliably estimated EAF risk. Knowledge of contributing factors may help clinicians to mitigate risk factors and guide them through the challenging clinical decision to allocate patients to early liver retransplant. The EASE score may be used in translational research across transplant centers.
Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre.Eur J Trauma Emerg Surg
Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre.
We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging.
We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first.
Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.
Minimally invasive posterior locked compression plate osteosynthesis shows excellent results in elderly patients with fragility fractures of the pelvis.Eur J Trauma Emerg Surg
Fragility fractures of the pelvis (FFP) are common in older patients. We evaluated the clinical outcome of using a minimally invasive posterior locked compression plate (MIPLCP) as therapeutic alternative.
53 Patients with insufficiency fractures of the posterior pelvic ring were treated with MIPLCP when suffering from persistent pain and immobility under conservative treatment. After initial X-ray, CT-scans of the pelvis were performed. In some cases an MRI was also performed to detect occult fractures. Postoperatively patients underwent conventional X-ray controls. Data were retrospectively analyzed for surgical and radiation time, complication rate, clinical outcome and compared to the literature.
Patients (average age 79.1 years) underwent surgery with operation time of 52.3 min (SD 13.9), intra-operative X-ray time of 9.42 s (SD 9.6), mean dose length product of 70.1 mGycm (SD 57.9) and a mean hospital stay of 21.2 days (SD 7.7). 13% patients (n = 7) showed surgery-related complications, such as wound infection, prolonged wound secretion, irritation of the sacral root or clinically inapparent screw malpositioning. 17% (n = 9) showed postoperative complications (one patient died due to pneumonia 24 days after surgery, eight patients developed urinal tract infections). 42 patients managed to return to previous living situation. 34 were followed-up after a mean period of 31.5 (6-90) months and pain level at post-hospital examination of 2.4 (VAS) with an IOWA Pelvic Score of 85.6 (55-99).
We showed that MIPLCP osteosynthesis is a safe surgical alternative in patients with FFP 3 and FFP 4. This treatment is another way of maintaining a high level of stability in the osteoporotic pelvic ring with a relatively low complication rate, low radiation and moderate operation time and a good functional outcome.
Early Dynamic Orchestration of Immunologic Mediators Identifies Multiply Injured Patients who are Tolerant or Sensitive to Hemorrhage.J Trauma Acute Care
Multiply injured patients are at risk of complications including infections, acute and prolonged organ dysfunction. The immunologic response to injury has been shown to affect outcomes. Recent advances in computational capabilities have shown that early dynamic coordination of the immunologic response is associated with improved outcomes after trauma. We hypothesized that patients who were sensitive or tolerant of hemorrhage would demonstrate differences in dynamic immunologic orchestration within hours of injury.
We identified two groups of multiply injured patients that demonstrated distinct clinical tolerance to hemorrhage (n = 10) or distinct clinical sensitivity to hemorrhage (n = 9) from a consecutive cohort of 100 multiply injured patients. Hemorrhage was quantified by integrating elevated shock index values for 24 hours after injury (Shock Volume). Clinical outcomes were quantified by average Marshall Organ Dysfunction Scores (MODS) from days two to five (aMODSD2-D5) after injury. Shock Sensitive (SS) patients had high cumulative organ dysfunction after lower magnitude hemorrhage. Shock Tolerant (ST) patients had low cumulative organ dysfunction after higher magnitude hemorrhage. Computational methods were used to analyze a panel of twenty immunologic mediators collected serially over the initial 72 hours after injury.
Dynamic Network Analysis demonstrated the ST patients had increased orchestration of cytokines that are reparative and protective including interleukins 9, 17E/25, 21, 22, 23 and 33 during the initial 0-8hr and 8-24hr intervals after injury. SS patients had delayed immunologic orchestration of a network of largely pro- and anti-inflammatory mediators. Elastic Net Linear Regression demonstrated that a group of five mediators could discriminate between SS and ST patients.
Preliminary evidence from this study suggest that early immunologic orchestration discriminates between patients who are notably tolerant or sensitive to hemorrhage. Early orchestration of a group of reparative/protective mediators was amplified in Shock Tolerant patients.Original Article Prospective Clinical Outcomes Study LEVEL OF EVIDENCE: III.
Sexual Dysfunction Following Traumatic Pelvic Fracture.J Trauma Acute Care
While sexual dysfunction in men following traumatic pelvic fracture is common, little is known of how men experience changes in their sexual health after injury. The aim of the present study was to explore the personal and interpersonal impacts of sexual dysfunction in men after pelvic injury and to understood how interactions with the healthcare system can be optimized to improve patient-centered trauma survivorship care.
Median age of interviewees was 46 years (IQR 44, 54), with a median time since injury of 41 months (IQR 22, 55). Five primary themes were identified from the analysis: (1) effects on self-image and romantic relationships; (2) unknown care pathways and lack of communication; (3) inconsistencies with healthcare provider priorities; (4) provision of sexual health information and resources; and (5) the importance of setting expectations. Interviewees suggested that improved communication, provision of information related to possible side-effects of their injuries, and expectation setting would improve post-trauma experiences.
Men's experiences with sexual dysfunction after pelvic trauma can be heavily influenced by their interactions with healthcare providers and the value that is placed on sexual health as a component of survivorship. Incorporating these findings into a patient-centered trauma survivorship program may improve patient experiences.
ANTITHROMBIN-III AMELIORATES POST-TBI CEREBRAL LEUKOCYTE MOBILIZATION ENHANCING RECOVERY OF BLOOD BRAIN BARRIER INTEGRITY.J Trauma Acute Care
Acute traumatic coagulopathy often accompanies traumatic brain injury (TBI) and may impair cognitive recovery. Antithrombin III (AT-III) reduces the hypercoagulability of TBI. AT-III and heparinoids such as enoxaparin (ENX) demonstrate potent anti-inflammatory activity, reducing organ injury and modulating leukocyte (LEU) activation, independent of their anticoagulant effect. It is unknown what impact AT-III exerts on cerebral LEU activation and BBB permeability after TBI. We hypothesized that AT-III reduces live microcirculatory LEU-endothelial (EC) interactions and leakage at the BBB following TBI.
Level II Evidence (Therapeutic / care management).
Both AT-III and ENX similarly reduced in vivo penumbral LEU rolling and adhesion (p<0.05). AT-III also reduced live BBB leakage (p<0.05). AT-III animals demonstrated the least 48-hour bw loss (8.4 ±1%) vs CCI +VEH (11.4 ± 0.5%, p<0.01). GNT scores were similar among groups.
AT-III reduces post-TBI penumbral EC-LEU interactions in the BBB leading to reduced neuro-microvascular permeability. AT-III further reduced body weight loss compared to heparinoid or no therapy. Further study is needed to determine if these AT-III effects on neuroinflammation affect longer term neurocognitive recovery after TBI.
Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).J Trauma Acute Care
Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared to nonoperative management, is associated with favorable outcomes in patients with TBI.
Therapeutic, level IV.
The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. SSRF was performed at a median of 3 days and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (OR 0.59 (95% CI 0.38-0.98), p=0.043) and 30-day mortality (OR 0.32 (95% CI 0.11-0.91), p=0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (0.19 (95% CI 0.04-0.88), p=0.034).
In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI.
The swine as a vehicle for research in trauma induced coagulopathy: introducing Principal Component Analysis for viscoelastic coagulation tests.J Trauma Acute Care
Uncontrolled bleeding is the leading cause of potentially preventable deaths among trauma patients. Tissue injury and shock result in trauma-induced coagulopathy (TIC). There are still uncertainties regarding detection methods and best practice management for TIC, and a deeper understanding of the pathophysiology requires robust animal models. The applicability of swine in coagulation studies, particularly after trauma has not been sufficiently elucidated. We therefore evaluated the swine as a vehicle for TIC-research in a selection of trauma modalities.
basic science, does not require a level of evidence.
PT(INR), aPTT, thrombocytes and fibrinogen did not change after trauma. D-dimer increased (p<.0001), prothrombin decreased (p<.05) and aPC decreased (p<.01) after polytrauma. PAI-1 decreased after pulmonary contusion with hemorrhage (p<.05). Positive controls displayed changes in PT(INR), thrombocytes, fibrinogen, prothrombin, aPC (p<.05). Principal Component Analysis of ROTEM presented pathologic coagulation profiles in both polytrauma and positive control groups with vectors extending outside the 95% confidence interval, which were not detected in negative controls.
Coagulopathy was induced after severe porcine blast polytrauma, specifically detected in ROTEM. A novel method for Principal Component Analysis of viscoelastic tests was introduced which may increase the detection sensitivity and differentiation of TIC phenotypes and should be further investigated in trauma populations.
Tibial plateau fractures in Belgium: epidemiology, financial burden and costs curbing strategies.Eur J Trauma Emerg Surg
We describe the incidence of tibial plateau fractures and the evolution of its management and financial burden in Belgium, perform a similar audit at University Hospitals Leuven, and define strategies to curb the increasing cost.
Between 2006 and 2018, a total number of 35,226 tibial plateau fractures were diagnosed in Belgium and 861 at our center. The incidence increased 41% over time (mean 25/100,000 persons per year). The mean rate of surgery in Belgium was 37% and slightly decreased over time, due to a larger increase of non-operatively treated tibial plateau fractures. The rate of surgery at the UHL was 49%. Surprisingly, the average cost per patient was equal for operatively and non-operatively treated patients in Belgium, and driven by the length-of stay.
Since length-of-stay is the main driver of the total healthcare costs of tibial plateau fractures, guidelines on appropriate length-of-stay can help to decrease variability and curb the total healthcare costs, particularly of the non-operatively treated patients. Our performance was in line with this.
Nasogastric tube after small bowel obstruction surgery could be avoided: a retrospective cohort study.Eur J Trauma Emerg Surg
The safety and feasibility of early removal of nasogastric tube (NGT) after small bowel obstruction (SBO) surgery have not yet been assessed. Such a practice could allow to implement enhanced recovery after surgery (ERAS) protocols after acute SBO surgery. The aims of this study were to assess the safety of early NGT removal by comparing the short-term outcomes of patients with postoperative NGTs and those with no postoperative NGT.
All patients undergoing surgery for strangulation or adhesive SBO between January the 1st of 2014 and December the 31st of 2017 were retrospectively included.
Among the 123 included, NGT was removed immediately after the end of the procedure in 26 cases (21.1%) and 19 patients required NGT replacement (15.4%). In univariate analysis, early removal of NGT was significantly associated with a reduction of overall morbidity, severe morbidity and postoperative ileus occurrence. Multivariate analysis confirmed that NGT left in place was a risk factor for postoperative ileus [Odd Ratio (OR) 4.9, Confidence Interval (CI) 95% 1.3-19.2; p = 0.02], while it has no incidence on severe morbidity.
Early NGT removal after ASBO surgery seemed to be feasible, safe and efficient, at least in selected patients. This primary study represents the initial foundations for building the implementation of ERAS protocols after ASBO surgery.
An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures.Eur J Trauma Emerg Surg
The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18-64 years old) undergoing SSRF.
The Trauma Quality Improvement Program (2010-2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.
From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62-6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98-6.32, p < 0.001).
Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk-benefit ratio.