To Örebro University

This study aimed to compare the outcomes of renal salvage (no nephrectomy) to nephrectomy patients with a penetrating American Association for the Surgery of Trauma-Organ Injury Scale grade III or IV kidney injury. The 2013-2021 Trauma Quality Improvement Program dataset was queried for patients with a penetrating grade III or IV kidney injury who underwent laparotomy within 24 h of admission. The association between nephrectomy and binary outcomes was investigated using Poisson regression models, with results presented as a prevalence ratio (PR) and corresponding 95% confidence interval (CI). A total of 2,214 grade III and 2,669 grade IV kidney injuries were identified. 89% of grade III injuries and 54% of grade IV injuries were managed without nephrectomy. After adjustment for confounding, nephrectomy in patients with a grade III penetrating kidney injury was associated with an increased risk of mortality [adjusted PR (95% CI): 1.53 (1.06-2.20), p = 0.023], complications [adjusted PR (95% CI): 1.25 (1.05-1.48), p = 0.010], post-complication mortality [adjusted PR (95% CI): 1.80 (1.09-2.96), p = 0.022], and ICU admission [adjusted PR (95% CI): 1.05 (1.00-1.11), p = 0.046], compared to renal salvage. In patients with a grade IV penetrating kidney injury, nephrectomy was only associated with an increased risk of ICU admission [adjusted PR (95% CI): 1.06 (1.02-1.09), p = 0.001], compared to renal salvage. Consequently, in patients with a grade III penetrating kidney injury, nephrectomy was associated with an increased risk of adverse outcomes. Among patients with a grade IV injury, nephrectomy was associated only with an increased risk of ICU admission. However, given the potential for residual confounding, these findings should be interpreted with caution.

Introduction: The Bologna guideline outlines three small bowel obstruction (SBO) management pathways. It remains unclear how pathway selection influences post-operative infections.

Methods: A multi-national, prospective, observational, audit of SBO management (November 1, 2023-May 31, 2024) captured demographics, care, and outcomes. Patients were grouped by pathway (successful non-operative management [NOM], NOM followed by surgery [NOM-T], direct to surgery [DTS]). Intergroup comparisons by chi-square or Fisher exact test, significance for p < 0.05.

Results: A total of 1,737 patients were assessed across 21 countries (850 NOM, 379 NOM-T, 508 DTS). Operative cohorts demonstrated similar age (NOM-T 65.2 ± 17.3 vs. DTS 65.5 ± 18.4 y; p = 0.834) and gender (NOM-T 53.6% vs. DTS, 52% female; p = 0.688). Comorbidities were more frequent in patients undergoing NOM-T (77.8%) versus DTS (69.7%; p < 0.001). DTS demonstrated more intestinal ischemia (NOM-T 22.8% vs. DTS 33%; p = 0.002). Time to OR was longer in NOM-T (43.8 ± 30.6 vs. DTS 12.4 ± 15.2 h; p < 0.001). Hospital length of stay (LOS) (NOM-T 12.4 ± 15.2 vs. DTS 7.7 ± 8.0 d; p < 0.001) and LOS (NOM-T 10.1 ± 10.4 vs. DTS 6.6 ± 9.1 d; p < 0.001) were longer in NOM-T. Superficial wound dehiscence (3.9%) and fascial dehiscence (2.6%) were uncommon. Overall surgical site infection (SSI) incidence was similar (NOM-T 8.7% vs. DTS 7.7%; p = 0.578). Deep SSI overall frequency was low (3.9%) but increased in NOM-T (5.5%) versus DTS (2.8%, p = 0.035).

Conclusions: An NOM trial before operation for adhesive SBO seems to increase deep SSI risk and likely reflects time to OR as well as hospital and surgeon factors-elements that merit specific evaluation.

BACKGROUND: The American College of Surgeons Committee on Trauma level verification system directs severely injured patients to specialized centers, a strategy that has been associated with improved outcomes. The correlation between outcome of pediatric trauma patients requiring surgical procedures and verification status of the treating institution is not well established. This study aims to examine the association between outcomes following isolated severe traumatic brain injury (iSTBI) and pediatric trauma center (PTC) verification status.

METHODS: This study analyzed data from the American College of Surgeons Trauma Quality Improvement Program for pediatric patients (<18 years) from 2013 to 2021 with iSTBI, defined as a head Abbreviated Injury Scale score ≥3 for intracranial pathology and Abbreviated Injury Scale score ≤1 in all other regions, resulting from blunt trauma and requiring neurosurgical intervention. Patients treated at Level I or Level II adult trauma centers without pediatric verification (ATCs) were compared with those treated at PTCs. Demographics, injury characteristics, and outcomes were collected. Inverse probability weighting was applied to adjust for baseline differences.

RESULTS: A total of 1,894 pediatric patients with surgically managed iSTBI, of whom 53% (n = 1,007) receiving treatment at a PTC, were included for further analysis. Following inverse probability weighting, treatment at a PTC correlated with a 30% lower risk of in-hospital mortality (relative risk, 0.70; 95% confidence interval, 0.55-0.90; p = 0.005) and a 63% decrease in the probability of failure-to-rescue (relative risk, 0.37; 95% confidence interval, 0.22-0.65; p < 0.001], in comparison to treatment at an ATC.

CONCLUSION: Pediatric patients with iSTBI requiring neurosurgical intervention experience significantly reduced mortality and failure-to-rescue rates when treated at the American College of Surgeons Committee on Trauma-verified PTCs compared with ATCs.

LEVEL OF EVIDENCE: Therapeutic; Level III.

Background: Severe lower extremity injuries in pediatric patients present significant challenges for surgeons deciding between repair and amputation. A novel scoring system, the MangLE score, has been developed to identify adult patients who are unlikely to require amputation after severe lower extremity injury. This study sought to evaluate the predictive ability of the MangLE score in pediatric patients.

Methods: A retrospective analysis was conducted using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Pediatric patients (≤17 years) with mangled lower extremities were included. Patients were stratified into age groups (0-3, 4-9, 10-13, and 14-17 years), and the predictive ability of the MangLE score for lower extremity amputation was assessed based on the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.

Results: A total of 7959 patients met the inclusion criteria. The MangLE score demonstrated an excellent predictive capability in patients aged 10-13 (AUC (95% CI): 0.87 (0.79-0.94)) and 14-17 (AUC (95% CI): 0.83 (0.79-0.86)). At the cutoff of ≥8, this resulted in an NPV of 99.7% for 10-13-year-olds and 99.4% for 14-17-year-olds. However, the MangLE score was ineffective in discriminating between those who did and did not require a lower extremity amputation in patients between 0 and 9 years old.

Discussion: The MangLE score maintains an excellent predictive ability for identifying those unlikely to require lower extremity amputation in pediatric mangled extremity patients aged 10-17; however, it fails to accurately predict this outcome in younger patients. Level of Evidence Level IV.

Background: Scapulothoracic dissociation is a rare, limb-, and potentially life-threatening injury in which the scapula and shoulder girdle are violently detached from the thoracic cage. However, the published data on the condition is mainly composed of case reports and single institution samples, which limits the overall generalizability. The aim of the current investigation was consequently to use a multi-institutional data set to characterize the injuries observed in patients with scapulothoracic dissociation along with the treatment strategies selected.

Methods: The 2016-2021 Trauma Quality Improvement Project (TQIP) database was used to identify cases of scapulothoracic dissociation. Patients were grouped based on the presence of neurovascular injury. The statistical significance of differences between the cohorts was determined using the Mann-Whitney U-test, chi-squared test, or Fisher's exact test, as appropriate.

Results: After applying the inclusion criteria, 74 cases of scapulothoracic dissociation were detected in the TQIP database; of these, 20% (N = 15) also suffered a neurovascular injury. The majority of patients with scapulothoracic dissociation without neurovascular injury could be managed non-operatively, while this was only the case for a minority with neurovascular injury (71.2% vs 26.7%, P = 0.004). Among patients who were ≥60 years old without neurovascular injury (N = 13), 92.3% (N = 12) could be managed non-operatively. Of those with neurovascular injury, 46.7% required internal fixation, 40% underwent vascular surgery, and 20% necessitated upper arm or forequarter amputation.

Conclusion: While scapulothoracic dissociation can be a serious, debilitating injury, most cases don't result in neurovascular injury and can often be managed non-operatively, particularly among the elderly.

Background: Most studies demonstrating efficacy of surgical stabilization of rib fractures (SSRF) are in patients with isolated severe chest wall injury. Recent evidence suggests SSRF may reduce mortality in polytrauma patients. The present study examines SSRF outcomes in severe polytrauma patients.

Methods: The 2013-2021 Trauma Quality Improvement Project database was used to identify severe polytrauma patients, defined as Injury Severity Score (ISS) ≥15 and abbreviated injury scale (AIS) ≥2 in 2 or more regions, with rib fractures. Exclusion criteria included AIS 6 in any region, death ≤72 hours, or SSRF >72 hours after admission. Outcomes of interest were in-hospital mortality, pneumonia, acute respiratory distress syndrome (ARDS), and length of mechanical ventilation. Adjustment for confounding was achieved using inverse probability of treatment weighting, Poisson regression models and quantile regression models.

Results: A total of 388 091 patients met inclusion criteria, of which 1.3% (N = 5020) underwent SSRF. SSRF was associated with a 57% decreased risk of mortality (P < 0.001) and 53% lower risk of ARDS (P < 0.001). Patients who underwent SSRF also required approximately 1 day less of mechanical ventilation (P < 0.001). Patients with ISS 15-19 exhibited an association between SSRF and a 55% (P = 0.023) lower rate of pneumonia.

Conclusion: SSRF within 72 hours of admission in severe polytrauma patients is associated with a lower rate of mortality and acute respiratory distress syndrome, along with shorter duration of mechanical ventilation. A reduction in the rate of pneumonia was only observed among patients with ISS 15-19.

Background: Surgical stabilization of rib fractures (SSRF) remains controversial as studies search for the patient population who would benefit most from SSRF. This study aimed to identify the predictive risk factors in patients with chest wall injuries who underwent SSRF and sustained in-hospital complications.

Methods: This study is a retrospective review of the 2016-2019 Trauma Quality Improvement Program database. Data included age, sex, comorbidities, Abbreviated Injury Score (AIS), injury pattern, interventions, and complications. All adult patients who suffered ≥1 rib fracture following an isolated thoracic injury (AIS ≥2 but < 6 and AIS ≤ 1 in all other regions) and underwent SSRF were eligible for inclusion.

Results: A total of 1823 patients were included in this study of whom 4.8% (N = 87) of patients suffered an in-hospital complication. Patients who suffered a complication were generally older, male, had a higher cardiac risk, were more severely injured, and tended to have a longer time to SSRF (3.8 vs 2.5 days, P < 0.001). The top 5 predictors of in-hospital complications were RCRI, thorax AIS, time to SSRF, age, and sex. These variables were sufficient for achieving an acceptable discriminative ability for complications (AUC (95% CI): 0.78 (0.73-0.83)).

Discussion: Cardiovascular risk, thoracic injury severity, and delayed SSRF were correlated with elevated risk of complications. As time to surgery constitutes the sole changeable factor, prompt intervention may substantially diminish postoperative morbidity. These findings can enhance risk classification and assist therapeutic decision making for SSRF.

Acute appendicitis is a leading cause of emergency abdominal surgery, with laparoscopic appendectomy (LA) established as the gold standard treatment. Notwithstanding its extensive utilization, there is no agreement on the most effective method for closing the appendiceal stump and dividing the mesoappendix. This review sought to assess existing treatments in terms of surgical duration, hospital length of stay (LOS), complications, and cost-effectiveness. A comprehensive review of 53 studies was performed. Eligible studies included adult patients undergoing appendectomy and examined various procedures for appendiceal stump closure and mesoappendix division. The primary outcomes were surgical duration and LOS; the secondary objectives were postoperative complications and cost-effectiveness. For appendiceal stump closure, clips and staples were frequently linked to decreased surgical duration in comparison to ligatures or sutures, although outcomes varied. Clips were also associated with a reduced length of hospital stay. Cost-effectiveness analyses consistently found clips to be the most economical option for stump closure, with staples the most expensive. Complication rates were largely comparable, though loop ligatures were linked to more organ/space infections, and clips showed higher rates of surgical site infections in some studies. For mesoappendix division, electrocautery and energy devices generally shortened operative time compared with mechanical methods. Electrocautery was the least costly for mesoappendix division, while energy devices tended to increase costs. Division of the mesoappendix and appendiceal stump closure can be achieved with a wide range of techniques and tools. The optimal treatment strategy varies significantly based on the outcome investigated.

BACKGROUND: Whole blood transfusion (WBT) is associated with improved hemostasis and possibly mortality in patients with hemorrhagic shock after injury but there are no studies in patients with isolated severe traumatic brain injury (TBI). The objective of this investigation was to compare outcomes of balanced component therapy (BCT) versus WBT in patients with an isolated severe TBI.

METHODS: Adult patients (≥18 years) registered in the Trauma Quality Improvement Program (2016-2019) who suffered a blunt isolated severe TBI (head Abbreviated Injury Score ≥3 in the head and ≤1 in the remaining body regions) and who received a BCT (1-2:1 packed red blood cell (PRBC):fresh frozen plasma and 1-2:1 PRBC:platelets) or WBT were eligible for inclusion. Patients were matched, based on the transfusion received, using propensity score matching. The primary outcome of interest was in-hospital mortality.

RESULTS: A total of 217 patients received either WBT (n=82) or BCT (n=135). After propensity score matching, 50 matched pairs were analyzed. The rate of in-hospital mortality was significantly lower in the WBT compared with BCT group (43.1% vs 66.7%, p=0.025) corresponding to a relative risk (RR) reduction of 35% in in-hospital mortality (RR (CI 95%): 0.65 (0.43 to 0.97)). However, in subgroup analyses comparing those who were managed surgically and conservatively, this association only remained significant among patients who underwent neurosurgical intervention.

CONCLUSIONS: WBT in patients with severe isolated TBI is associated with better survival compared with BCT in patients who require neurosurgical intervention. Further investigation into this finding using an appropriately powered, prospective study design is warranted.

LEVEL OF EVIDENCE: Level III, therapeutic.

BACKGROUND: Atlantoaxial rotatory subluxation (AARS) is an important differential diagnosis in pediatric patients presenting with torticollis, which is caused by the subluxation of the C1 vertebra relative to the C2 vertebra. Because of the uncommon nature of this condition, there is a paucity in sufficiently sized studies describing AARS. The aim of the current investigation was therefore to characterize current clinical characteristics and management of AARS.

METHODS: The American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2021 was queried for pediatric (17 years old or younger) patients who were diagnosed with AARS following blunt trauma. Patients were grouped by age in order to describe and compare demographics, clinical characteristics, and in-hospital outcomes. A subgroup analysis was also performed on patients with isolated AARS, defined as AARS without the presence of a cervical fracture and an Abbreviated Injury Scale score of ≤1 in all regions besides the spine.

RESULTS: A total of 469 cases of AARS were identified, 211 (45.0%) were isolated AARS. Of these patients, 56.3% of AARS patients and 64.5% of isolated AARS patients were 8 years old or younger. Atlantoaxial rotatory subluxation in adolescents was due to a motor vehicle collision in 60.0% of cases, while 52.5% of infants/toddlers were injured in falls. Of all patients with AARS, 87.4% were managed conservatively, with or without a brace/other immobilizing device, while surgery was only indicated in 9.3% of patients. In cases of isolated AARS, conservative treatment was even more prevalent, with 92.4% of patients managed conservatively and only 4.7% requiring surgical intervention.

CONCLUSION: Atlantoaxial rotatory subluxation is most common in children 8 years old and younger, with the majority of cases resulting from falls or motor vehicle accidents. In the Trauma Quality Improvement Program database, most cases were able to be managed conservatively without the need for surgical intervention.

LEVEL OF EVIDENCE: Care Management; Level III.