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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Van Wijck SFM, Prins JTH, Verhofstad MHJ, Wijffels MME, Van Lieshout EMM. Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02421-7. [PMID: 38206442 DOI: 10.1007/s00068-023-02421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/04/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR. DESIGN Systematic review and meta-analysis. DATA SOURCES Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. REVIEW METHODS The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized. RESULTS Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures. CONCLUSION Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon. LEVEL OF EVIDENCE Level III, systematic review and meta-analysis.
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Affiliation(s)
- Suzanne F M Van Wijck
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jonne T H Prins
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Zavalis EA, Rameau A, Saraswathula A, Vist J, Schuit E, Ioannidis JP. Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses. BMJ Open 2024; 14:e076675. [PMID: 38195174 PMCID: PMC10810041 DOI: 10.1136/bmjopen-2023-076675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVES This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured. DESIGN Systematic review of systematic reviews (umbrella review). DATA SOURCES Cochrane Database of Systematic Reviews. ELIGIBILITY CRITERIA Systematic reviews attempt to compare surgical to drug interventions. DATA EXTRACTION We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review. SYNTHESIS The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed. RESULTS Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance. CONCLUSIONS Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.
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Affiliation(s)
- Emmanuel A Zavalis
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joachim Vist
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Denmark, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John P Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
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Zhang D, Wang L, Xi S, Li R, Jiao C, Zhang Q. A clinical study on the surgical treatment of simple multiple rib fractures in older adult patients. J Thorac Dis 2023; 15:4324-4336. [PMID: 37691685 PMCID: PMC10482652 DOI: 10.21037/jtd-22-1829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/19/2023] [Indexed: 09/12/2023]
Abstract
Background The treatment of simple rib fractures in older adults can be divided into surgical treatment and nonsurgical treatment, with indications for surgery presently being unclear. This study was conducted to determine whether older adult individuals with simple multiple rib fractures can benefit from surgical treatment. Methods A single-center, retrospective study was conducted. All 880 registry-identified patients aged ≥60 years who were admitted to Beijing Jishuitan Hospital with blunt rib fractures between 2013 to 2020 were included. They were divided into 2 groups according to whether internal fixation was performed. After screening of inclusion and exclusion criteria and propensity score matching, there were 226 patients, 113 of whom were placed in the operation group and 113 in the nonoperation group. The demographic characteristics, underlying diseases, number of rib fractures, hospital stay, intensive care unit (ICU) hospital stay, mechanical ventilation duration, fracture comorbidities on admission, pain index, and fracture healing condition were analyzed using chi-squared test and independent samples t test. Results The pain score and fracture healing time were significantly improved in the operation group (P<0.05), while the duration of painkiller use was significantly shorter in the operation group (P=0.009). However, there was no significant differences in mortality, the incidence of bone nonunion, length of stay in the ICU, or duration of mechanical ventilation between the 2 groups. Conclusions For patients in the clinical study, internal fixation surgery could reduce fracture healing time and minimize the use of painkillers. Surgical treatment was determined to be safe, as it did not increase the mortality of the older adult patients. For older patients with simple rib fractures who have no contraindications to surgery, internal fixation surgery is recommended.
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Affiliation(s)
- Dong Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Langran Wang
- The Fourth Clinical Medical College, Health Science Center of Peking University, Beijing, China
| | - Siqi Xi
- The Fourth Clinical Medical College, Health Science Center of Peking University, Beijing, China
| | - Run Li
- The Fourth Clinical Medical College, Health Science Center of Peking University, Beijing, China
| | - Chenbo Jiao
- The Fourth Clinical Medical College, Health Science Center of Peking University, Beijing, China
| | - Qiang Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
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Wang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. J Cardiothorac Surg 2023; 18:118. [PMID: 37038166 PMCID: PMC10084648 DOI: 10.1186/s13019-023-02203-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/31/2023] [Indexed: 04/12/2023] Open
Abstract
INTRODUCTION Multiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear. MATERIALS AND METHODS The present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality. RESULTS A total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p < 0.001), ventilation days (3.67 days vs. 4.55 days, p < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection. CONCLUSION The findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.
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Affiliation(s)
- Zhengwei Wang
- Department of Thoracic Surgery, The 904th Hospital of PLA Joint Logistic Support Force, Xing Yuan North Road 101, Wuxi, 214044, China
| | - Yifei Jia
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214044, China
| | - Mi Li
- Department of Thoracic Surgery, The 904th Hospital of PLA Joint Logistic Support Force, Xing Yuan North Road 101, Wuxi, 214044, China.
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Bauer F, Haag S, Najafi K, Miller B, Kepros J. Surgical stabilization of rib fracture patients versus nonoperative controls treated by a multidisciplinary team in a single institution. Heliyon 2023; 9:e15205. [PMID: 37123889 PMCID: PMC10130754 DOI: 10.1016/j.heliyon.2023.e15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Despite promising evidence, surgical stabilization of rib fractures (SSRF) is not ubiquitously offered in all trauma centers. Some centers struggle with patient selection while some struggle due to surgeon comfort with the technique. To address this issue, our trauma center developed a multidisciplinary SSRF approach between orthopedic and trauma surgery. Methods This retrospective study compared 43 patients who underwent SSRF at a level 1 trauma center with 43 nonoperatively managed controls. Our study Indications were flail chest with >3 segments; non-flail with severe, bi-cortical displacement of >3 contiguous segments. Main outcome measures included mortality, ICU duration, hospital stay LOS, rates of ventilator-associated pneumonia (VAP) and ventilator days. Results Results of SSRF included decreases in mortality (2% vs 16.3%; p = 0.03) and in ICU duration. Patients with SSRF had a significantly shorter duration in the ICU than the nonoperative group (8.72 vs 14 days; p = 0.013) but a similar hospital duration (LOS mean, 12.81 vs 15.2; p = 0.29). Less patients in the SSRF group developed VAP but the difference was not significant (2% vs 14%, p = 0.055). Discussion SSRF patient outcomes supported prior evidence. The tandem approach had benefits as surgeons were able to leverage skills and expertise, increase collaboration between services, and complete more difficult reconstructions. Our experience may serve as a model for trauma centers interested in starting a new program or enhancing current service offerings.
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Zavalis EA, Rameau A, Saraswathula A, Vist J, Schuit E, Ioannidis JPA. Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.30.23285207. [PMID: 36778340 PMCID: PMC9915830 DOI: 10.1101/2023.01.30.23285207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored. Design Systematic review of systematic reviews (umbrella review). Data sources Cochrane Database of Systematic Reviews (CDSR). Eligibility criteria and synthesis of results Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses. Results Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs. Conclusions Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed. Protocol registration https://osf.io/p9x3j.
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Affiliation(s)
- Emmanuel A Zavalis
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joachim Vist
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ewoud Schuit
- Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherland, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Zhang D, Jiao C, Xi S, Wang L, Li R, Zhang Q. Evaluation of surgical outcomes in elderly patients with rib fractures: A single-centre propensity score matching study. Front Surg 2023; 10:1174365. [PMID: 37143770 PMCID: PMC10151702 DOI: 10.3389/fsurg.2023.1174365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Background Rib fractures are the most common injuries in chest trauma. Compared with younger patients, elderly patients with rib fracture have a higher incidence of complications and mortality. A retrospective study was conducted to investigate the effect of internal fixation compared with conservative treatment on the outcome of rib fracture in elderly patients. Material and methods We used a 1:1 propensity score matching method to perform a retrospective analysis of 703 elderly patients with rib fractures treated in the Thoracic Surgery Department of Beijing Jishuitan Hospital between 2013 and 2020. After matching, the length of hospital stay, death, symptom relief and rib fracture healing were compared between the surgery and the control group. Results The study included 121 patients receiving SSRF in the surgery group and 121 patients receiving conservative treatment in the control group. The length of hospital stay in the surgery group was significantly longer than that in the conservative group (11.39d vs. 9.48d, p = 0.000). After 9 months of follow-up, the fracture healing rate in the surgery group was significantly higher than that in the control group (96.67% vs. 88.89%, p = 0.020). The fracture healing time (p = 0.000), improvement in pain score (p = 0.000) and duration of pain medication use (p = 0.000) were also significantly better in the surgery group than in the control group. Conclusion Compared with conservative treatment, surgical treatment can prolong hospital stay to some extent. However, it has the advantages of more rapid healing and lessened pain. For rib fractures in elderly individuals, surgical treatment is a safe and effective option under strict surgical indications and is recommended.
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Affiliation(s)
- Dong Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Chenbo Jiao
- Health Science Center, Peking University, Beijing, China
| | - Siqi Xi
- Health Science Center, Peking University, Beijing, China
| | - Langran Wang
- Health Science Center, Peking University, Beijing, China
| | - Run Li
- Health Science Center, Peking University, Beijing, China
| | - Qiang Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
- Correspondence: Qiang Zhang
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9
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van Gool MH, van Roozendaal LM, Vissers YLJ, van den Broek R, van Vugt R, Meesters B, Pijnenburg AM, Hulsewé KWE, de Loos ER. VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases. Gen Thorac Cardiovasc Surg 2022; 70:985-992. [PMID: 35657504 DOI: 10.1007/s11748-022-01830-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest. METHODS From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported. RESULTS VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury. CONCLUSIONS Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.
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Affiliation(s)
| | | | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Raoul van Vugt
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Berend Meesters
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Karel W E Hulsewé
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Erik R de Loos
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.
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10
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Craxford S, Marson BA, Nightingale J, Forward DP, Taylor A, Ollivere B. Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales. Bone Joint J 2022; 104-B:729-735. [PMID: 35638213 DOI: 10.1302/0301-620x.104b6.bjj-2021-1502.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries. METHODS A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy. RESULTS A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001). CONCLUSION SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.
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11
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Becker L, Schulz-Drost S, Spering C, Franke A, Dudda M, Kamp O, Lefering R, Matthes G, Bieler D. Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma—A Matched-Pairs Analysis of the German Trauma Registry. Front Surg 2022; 9:852097. [PMID: 35647014 PMCID: PMC9130625 DOI: 10.3389/fsurg.2022.852097] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeIn severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay.MethodsData from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS) ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3–10 days after trauma.ResultsAfter the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226).ConclusionsWe were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.
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Affiliation(s)
- L. Becker
- Department of Trauma Surgery, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
- Correspondence: L. Becker
| | - S. Schulz-Drost
- Department of Trauma Surgery, Helios Hospital Schwerin, Schwerin, Germany
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - C. Spering
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Hospital Göttingen Medical Center, Göttingen, Germany
| | - A. Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - M. Dudda
- Department of Trauma Surgery, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - O. Kamp
- Department of Trauma Surgery, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - R. Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - G. Matthes
- Department of Trauma Surgery and Reconstructive Surgery, Ernst von Bergmann Hospital, Potsdam, Germany
| | - D. Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
- Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Hospital, Düsseldorf, Germany
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12
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Prins JTH, Van Lieshout EMM, Ali-Osman F, Bauman ZM, Caragounis EC, Choi J, Christie DB, Cole PA, DeVoe WB, Doben AR, Eriksson EA, Forrester JD, Fraser DR, Gontarz B, Hardman C, Hyatt DG, Kaye AJ, Ko HJ, Leasia KN, Leon S, Marasco SF, McNickle AG, Nowack T, Ogunleye TD, Priya P, Richman AP, Schlanser V, Semon GR, Su YH, Verhofstad MHJ, Whitis J, Pieracci FM, Wijffels MME. Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury. Eur J Trauma Emerg Surg 2022; 48:3327-3338. [PMID: 35192003 PMCID: PMC9360098 DOI: 10.1007/s00068-022-01906-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/29/2022] [Indexed: 11/13/2022]
Abstract
Purpose Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. Methods A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. Results In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11–0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, − 2.96 days; 95% CI − 5.70 to − 0.23; p = 0.034). Conclusion In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.
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Affiliation(s)
- Jonne T H Prins
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Francis Ali-Osman
- Department of Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, 85020, USA
| | - Zachary M Bauman
- Division of Trauma, Emergency General Surgery, Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jeff Choi
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, 94305, USA
| | - D Benjamin Christie
- Department of Trauma Surgery/Critical Care, Mercer University School of Medicine, The Medical Center Navicent Health, Macon, GA, 31201, USA
| | - Peter A Cole
- HealthPartners Orthopedics and Sports Medicine, Bloomington, MN, 55420, USA.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.,Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, 55101, USA
| | - William B DeVoe
- Department of Surgery, Riverside Methodist Hospital, Columbus, 43214 OH, USA
| | - Andrew R Doben
- Department of Surgery, Saint Francis Hospital, Hartford, CT, 06105, USA
| | - Evert A Eriksson
- Division of Trauma and Critical Care, Department of Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Joseph D Forrester
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, 94305, USA
| | - Douglas R Fraser
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, 89102, USA
| | - Brendan Gontarz
- Department of Surgery, Saint Francis Hospital, Hartford, CT, 06105, USA
| | - Claire Hardman
- Division of Trauma, Department of Surgery, Wright State University/Miami Valley Hospital, Dayton, OH, 45409, USA
| | - Daniel G Hyatt
- Department of Surgery, Riverside Methodist Hospital, Columbus, 43214 OH, USA
| | - Adam J Kaye
- Department of Surgery, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Huan-Jang Ko
- Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, 30059, Taiwan
| | - Kiara N Leasia
- Department of Surgery, Denver Health Medical Center, Denver, CO, 80204, USA
| | - Stuart Leon
- Division of Trauma and Critical Care, Department of Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Silvana F Marasco
- CJOB Department of Cardiothoracic Surgery, The Alfred, Melbourne, Australia.,Department of Surgery, Monash University, Clayton, VIC, Australia
| | - Allison G McNickle
- Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, 89102, USA
| | - Timothy Nowack
- Department of Trauma Surgery/Critical Care, Mercer University School of Medicine, The Medical Center Navicent Health, Macon, GA, 31201, USA
| | - Temi D Ogunleye
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.,Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, 55101, USA
| | - Prakash Priya
- Department of Surgery, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA
| | - Aaron P Richman
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Victoria Schlanser
- Department of Trauma/Burn, John H Stroger Hospital of Cook County, Chicago, IL, 60612, USA
| | - Gregory R Semon
- Division of Trauma, Department of Surgery, Wright State University/Miami Valley Hospital, Dayton, OH, 45409, USA
| | - Ying-Hao Su
- Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, 30059, Taiwan
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Julie Whitis
- Department of Surgery, University of Texas Rio Grande Valley, Doctors Hospital at Renaissance, Edinburg, TX, 78539, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, 80204, USA
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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13
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Becker L, Schulz-Drost S, Spering C, Franke A, Dudda M, Lefering R, Matthes G, Bieler D. Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU ®. Eur J Trauma Emerg Surg 2022; 48:2773-2781. [PMID: 35118558 PMCID: PMC9360126 DOI: 10.1007/s00068-021-01864-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 12/26/2021] [Indexed: 11/29/2022]
Abstract
Purpose In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay. Methods Data from the TraumaRegister DGU® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability. Results In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h. Conclusions In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.
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Affiliation(s)
- Lars Becker
- Department of Trauma Surgery, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany.
| | - Stefan Schulz-Drost
- Department of Trauma Surgery, Helios Hospital Schwerin, Schwerin, Germany.,Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Christopher Spering
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Hospital Göttingen Medical Center, Göttingen, Germany
| | - Axel Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Marcel Dudda
- Department of Trauma Surgery, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Gerrit Matthes
- Department of Trauma Surgery and Reconstructive Surgery, Ernst Von Bergmann Hospital, Potsdam, Germany
| | - Dan Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany.,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Hospital, Düsseldorf, Düsseldorf, Germany
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14
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Chuang CH, Huang CK, Li CY, Hu MH, Lee PY, Wu PT. Surgical stabilization of the ipsilateral scapula and rib fractures using the mirror Judet approach: a preliminary result. BMC Musculoskelet Disord 2022; 23:105. [PMID: 35101018 PMCID: PMC8802444 DOI: 10.1186/s12891-021-04991-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We report our preliminary results using a single approach, the mirror Judet approach, for patients with both ipsilateral scapula and multiple rib fractures. METHODS Five consecutive patients [median age: 56 years (range: 44 ~ 60)] with ipsilateral scapula and multiple rib fractures that met the surgical indications were retrospectively reviewed. A single approach, the mirror Judet approach, was used for surgical stabilization of the scapula and targeted rib fractures. Thoracoscopic surgery was performed first for management of associated lung lesions and marking the targeted rib. All patients received the same rehabilitation protocol and a minimum 12-month follow-up. RESULTS All surgically-fixed fractures eventually united without malunion. No complaints of intercostal neuralgia, infection, or other complications were seen. The mean range of motion in the injured shoulder returned to at least 90% of the contralateral side range. The mean Disabilities of the Arm, Shoulder, and Hand score at the 12th month was 2.0 (range: 0-7). All patients were able to return to their previous work. CONCLUSION The mirror Judet approach allows for the surgical stabilization of the ipsilateral scapula and multiple rib fractures using the same approach and provides acceptable functional outcomes in well-selected patients. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Chang-Han Chuang
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, 524 Sec. 1 Chung-Shan Rd., Changhua, 500, Taiwan.,Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chin-Kai Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Ying Li
- Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Ming-Hsien Hu
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, 524 Sec. 1 Chung-Shan Rd., Changhua, 500, Taiwan.,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Yuan Lee
- Department of Orthopaedic Surgery, Show Chwan Memorial Hospital, 524 Sec. 1 Chung-Shan Rd., Changhua, 500, Taiwan. .,College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan.
| | - Po-Ting Wu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liou branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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15
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Lacey J, d’Arville A, Walker M, Hendel S, Lancman B. Considerations for the Older Trauma Patient. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00510-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Prins JTH, Wijffels MME, Pieracci FM. What is the optimal timing to perform surgical stabilization of rib fractures? J Thorac Dis 2021; 13:S13-S25. [PMID: 34447588 PMCID: PMC8371546 DOI: 10.21037/jtd-21-649] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022]
Abstract
The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.
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Affiliation(s)
- Jonne T H Prins
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
| | - Mathieu M E Wijffels
- Trauma Research Unit Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, CO, USA
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17
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Schulz-Drost S, Ekkernkamp A, Stengel D. [Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. Unfallchirurg 2019; 121:605-614. [PMID: 30073550 DOI: 10.1007/s00113-018-0532-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed. OBJECTIVE A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options. MATERIAL AND METHODS Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed. RESULTS AND DISCUSSION Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.
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Affiliation(s)
- S Schulz-Drost
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland.
| | - A Ekkernkamp
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| | - D Stengel
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
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Wijffels MME, Prins JTH, Polinder S, Blokhuis TJ, De Loos ER, Den Boer RH, Flikweert ER, Pull Ter Gunne AF, Ringburg AN, Spanjersberg WR, Van Huijstee PJ, Van Montfort G, Vermeulen J, Vos DI, Verhofstad MHJ, Van Lieshout EMM. Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial. World J Emerg Surg 2019; 14:38. [PMID: 31384292 PMCID: PMC6668138 DOI: 10.1186/s13017-019-0258-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/22/2019] [Indexed: 12/22/2022] Open
Abstract
Background Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures. Methods The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months. Discussion With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures. Trial registration www.trialregister.nl, NTR7248. Registered May 31, 2018.
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Affiliation(s)
- Mathieu M E Wijffels
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jonne T H Prins
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Suzanne Polinder
- 2Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Taco J Blokhuis
- 3Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Erik R De Loos
- 4Department of Surgery, Zuyderland Medisch Centrum, P.O. Box 5500, 6130 MB Sittard-Geleen, The Netherlands
| | - Roeland H Den Boer
- 5Department of Surgery, Spaarne Gasthuis, P.O. Box 417, 2000 AK Haarlem, The Netherlands
| | - Elvira R Flikweert
- 6Department of Surgery, Deventer Ziekenhuis, P.O. Box 5001, 7400 GC Deventer, The Netherlands
| | | | - Akkie N Ringburg
- 8Department of Surgery, Ikazia Ziekenhuis, P.O. Box 5009, 3008 AA Rotterdam, The Netherlands
| | | | - Pieter J Van Huijstee
- Department of Surgery, Haga Ziekenhuis, P.O. Box 40551, 2504 LN The Hague, The Netherlands
| | - Gust Van Montfort
- 11Department of Surgery, Catharina Ziekenhuis, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - Jefrey Vermeulen
- 12Department of Surgery, Maasstad Ziekenhuis, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands
| | - Dagmar I Vos
- 13Department of Surgery, Amphia Ziekenhuis, P.O. Box 90158, 4800 RK Breda, The Netherlands
| | - Michael H J Verhofstad
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Abstract
INTRODUCTION Flail chest is considered a highly morbid condition with reported mortality ranging from 10 to 20%. It is often associated with other severe injuries, which may complicate management and interpretation of outcomes. The physiologic impact and prognosis of isolated flail chest injury is poorly defined. METHODS This is a National Trauma Databank study. All patients from 1/2007 to 12/2014 admitted with flail chest were extracted. Patients with head or abdominal AIS ≥3, dead on arrival, or transferred, were excluded. Primary outcome was mortality; secondary outcomes were need for mechanical ventilation and pneumonia. RESULTS Of the 1,047,519 patients with blunt chest injury, 14,718 (1.4%) patients presented with flail chest, and 8098 (0.77%) met inclusion criteria. The most commonly associated intrathoracic injuries were hemothorax (57.9%) and lung contusions (63.0%), while sternal fracture (8.8%) and cardiac contusion (2.5%) were less common. In total, 29.8% of patients required mechanical ventilation, and 11.2% developed pneumonia. Overall mortality was 5.6%. On multivariable analysis, age >65 and need for mechanical ventilation were independent risk factors for mortality (OR 6.02, 3.75, respectively, p < 0.001). Independent predictors for mechanical ventilation included cardiac or pulmonary contusion and sternal fractures (OR 3.78, 2.38, 2.29, respectively, p < 0.001). Need for mechanical ventilation was an independent predictor of pneumonia (OR 13.18, p < 0.001). CONCLUSIONS Mortality in isolated flail chest is much lower than previously reported. Fewer than 30% of patients require mechanical ventilation. Need for mechanical ventilation, however, is independently associated with mortality and pneumonia. Age >65 is an independent risk factor for adverse outcomes, and these patients may benefit by more aggressive monitoring and treatment.
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21
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Su YH, Yang SM, Huang CH, Ko HJ. Early versus late surgical stabilization of severe rib fractures in patients with respiratory failure: A retrospective study. PLoS One 2019; 14:e0216170. [PMID: 31022284 PMCID: PMC6483262 DOI: 10.1371/journal.pone.0216170] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/14/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure. Methods This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost. Results A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant. Conclusion Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.
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Affiliation(s)
- Ying-Hao Su
- Department of Orthopedics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
| | - Shun-Mao Yang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
| | - Chun-Hsiung Huang
- Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
| | - Huan-Jang Ko
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
- * E-mail:
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Ingoe HM, Coleman E, Eardley W, Rangan A, Hewitt C, McDaid C. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open 2019; 9:e023444. [PMID: 30940753 PMCID: PMC6500198 DOI: 10.1136/bmjopen-2018-023444] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews. DESIGN A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation. RESULTS Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non-operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI (-5.54 to -3.5) to -7.5 days, 95% CI (-9.9 to -5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain. CONCLUSIONS Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures. PROSPERO REGISTRATION NUMBER CRD42016053494.
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Affiliation(s)
- Helen Ma Ingoe
- York Trials Unit, Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | | | - William Eardley
- York Trials Unit, Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | - Amar Rangan
- York Trials Unit, Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Catriona McDaid
- York Trials Unit, Health Sciences, University of York, York, UK
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Liu X, Xiong K. Surgical management versus non-surgical management of rib fractures in chest trauma:a systematic review and meta-analysis. J Cardiothorac Surg 2019; 14:45. [PMID: 30813961 PMCID: PMC6391832 DOI: 10.1186/s13019-019-0865-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/17/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered mechanics of respiration. Several studies have shown that the ventilation requirements and incidence of pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate the effect of surgical fixation treatments for rib fractures through systematic review and meta-analysis. Methods A literature search was performed in the PubMed, EMBASE, Web of Science and Cochrane Library databases for information from February 1958 to April 2018. Studies comparing the benefits of surgical management with that of non-surgical management of rib fractures were included. Statistical heterogeneity was evaluated by the X2 test with the significance set to P < 0.10 or I2 > 50%. Results Fourteen studies consisting of 839 patients were included (407 patients in the surgical management group; 432 patients in the non-surgical management group). The results showed that the surgical management group experienced a significant decrease in hospitalization time, intensive care time, mechanical ventilation time, mortality rate, pulmonary infection rate and tracheotomy rate compared with the non-surgical management group. However, the surgical management group incurred extra costs, and there was no significant difference in the duration of antibiotic use between the two groups. Conclusions Compared with non-surgical management, surgical management methods are of great value in the treatment of rib fractures despite the added expense.
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Affiliation(s)
- Xin Liu
- The Second Hospital of TianJin Medical University, Ping Jiang Road No.23, Hexi District, Tianjin, 300211, China.
| | - Kai Xiong
- Tianjin Medical University General Hospital, An Shan Road No.154, Heping District, Tianjin, 300192, China
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24
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Olland A, Puyraveau M, Guinard S, Seitlinger J, Kadoche D, Perrier S, Renaud S, Falcoz PE, Massard G. Surgical stabilization for multiple rib fractures: whom the benefit? -a prospective observational study. J Thorac Dis 2019; 11:S130-S140. [PMID: 30906577 DOI: 10.21037/jtd.2018.10.122] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Surgical repair has demonstrated a beneficial effect on outcome for patients presenting with flail chest or with multiple rib fractures. We hypothesized that benefit on outcome parameters concerns predominantly patients being extubated within 24 hours post-operatively. Methods We prospectively recorded all patients presenting with chest traumatism eligible for surgical repair with anticipated early extubation according to our institutional consensus (flail chest, major deformity, poor pain control, associated lesions requiring thoracotomy). We compared outcomes of patients extubated within 24 hours post-operatively to those who required prolonged ventilator support. We tested predictive factors for prolonged intubation with univariate and multivariate analysis. Results From 2010 to 2014, 132 patients required surgical repair. Two thirds were extubated within 24 hours following surgical repair. Pneumonia was the main complication and occurred in 30.3% of all patients. Patients extubated within 24 hours following surgical repair had significantly shorter ICU stay and shorter in-hospital stay (P<0.0001 both). Pneumonia occurred significantly more often in patients with longer mechanical ventilation (over 24 hours) (P<0.0001) and the overall post-operative complications rate was higher (P=0.0001). Main independent risk factors for delayed extubation were bilateral chest rib fractures and initially associated pneumothorax. Conclusions We conclude that patients extubated within 24 hours after repair have an improved outcome with reduced complication rate and shorter hospital stay. The initial extent of the trauma is an important risk factor for delayed extubation and high complication rate despite surgical stabilization.
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Affiliation(s)
- Anne Olland
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
| | - Marc Puyraveau
- Clinical Methodology Center, University Hospital Besançon, Besançon, France
| | - Sophie Guinard
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Joseph Seitlinger
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
| | - Déborah Kadoche
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Stéphanie Perrier
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Stéphane Renaud
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Pierre-Emmanuel Falcoz
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
| | - Gilbert Massard
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
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Does Surgery Reduce the Risk of Complications Among Patients with Multiple Rib Fractures? A Meta-analysis. Clin Orthop Relat Res 2019; 477:193-205. [PMID: 30247228 PMCID: PMC6345288 DOI: 10.1097/corr.0000000000000495] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial. QUESTIONS/PURPOSES The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores. METHODS We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed. RESULTS The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470). CONCLUSIONS This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life. LEVEL OF EVIDENCE Level I, therapeutic study.
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Early results after operatively versus non-operatively treated flail chest: a retrospective study focusing on outcome and complications. Eur J Trauma Emerg Surg 2018; 46:539-547. [PMID: 29785655 PMCID: PMC7280328 DOI: 10.1007/s00068-018-0961-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/29/2018] [Indexed: 12/22/2022]
Abstract
Purpose Flail chest was traditionally treated non-operatively using mechanical ventilation and pain control. In order to reduce the occurrence of ventilation-associated complications and long-term disability, operative rib fixation is becoming a proven standard therapy for these patients. However, the consequences of the surgical complications may influence success rates negatively. The aim of this study was to compare the outcome of flail chest treatment by surgical rib fixation with non-operative treatment, with special focus on the impact of surgical complications. Methods A retrospective case series of operatively treated flail chest patients was compared with non-operatively treated patients. Patients’ injury and treatment characteristics and outcome parameters (e.g., duration of mechanical ventilation, length of Intensive Care stay (ICLOS) and hospital length of stay (HLOS), mortality, surgery-related complications and pneumonia) were collected from the patients’ medical files. Crude and matched-pairs analyses were performed in SPSS. Results Twenty-three operatively and 47 non-operatively treated patients were enrolled. Operatively treated patients required significantly shorter mechanical ventilation; median 4 days versus 12 days for the non-operative group (p = 0.011). The matched-pairs analysis also showed a lower pneumonia rate (35% versus 80%; p = 0.035) and a shorter HLOS (median 21 versus 23 days; p = 0.028) in the operative group. No significant differences in duration of ICLOS, and occurrence of other injury-related adverse events were found between both groups.
Seven surgery-related complications occurred, of which three required invasive solutions. Conclusions Operative fixation of a flail chest in trauma patients results in a lower rate of pneumonia, less mechanical ventilation days and shorter hospital stay, compared with non-operative treatment, but at the cost of surgery-related complications requiring invasive solutions in some cases.
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Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest. Eur Radiol 2017; 28:4122-4127. [PMID: 29124382 DOI: 10.1007/s00330-017-5117-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 12/16/2022]
Abstract
AIMS AND OBJECTIVES We have recently implemented a dedicated sudden cardiac arrest (SCA) - whole-body computed tomography (WBCT) protocol to evaluate SCA patients with return of spontaneous circulation (ROSC) following cardiopulmonary resuscitation (CPR). The aim of this study is to evaluate the number and pattern of CPR-related injuries in ROSC patients with SCA-WBCT. METHODS AND MATERIALS Single-centre retrospective review of 39 patients (13 female; 20 male, mean age 51.8 years) with non-traumatic, out-of-hospital SCA and ROSC and evaluation with dedicated SCA-WBCT over a 10-month period. RESULTS In-hospital mortality was 54%. CPR-related injuries were detected in 85% (33/39). Chest injuries were most common on WBCT: 85% (33) subjects had rib fractures (mean of 8.5 fractures/subject); 31% (12) sternal fractures; 13% (5) mediastinal haematoma; 10% (4) pneumothorax; 8% (3) pneumomediastinum and 3% (1) haemothorax. Three subjects (8%) had abdominal injuries on WBCT, including one hepatic haematoma with active haemorrhage. CONCLUSION CPR-related injuries on WBCT after ROSC are common, with serial rib fractures detected most commonly. An unexpectedly high rate of abdominal injuries was detected on SCA-WBCT. Radiologists need to be attuned to the spectrum of CPR-related injuries in WBCT, including abdominal injuries and subtle rib fractures. KEY POINTS • CPR frequently causes injuries. • Radiologists should be aware of the spectrum of CPR related injuries. • Rib fractures are frequent and radiologic findings often subtle. • Clinically unexpected abdominal injuries may be present.
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Abstract
Management of chest trauma is integral to patient outcomes owing to the vital structures held within the thoracic cavity. Understanding traumatic chest injuries and appropriate management plays a pivotal role in the overall well-being of both blunt and penetrating trauma patients. Whether the injury includes rib fractures, associated pulmonary injuries, or tracheobronchial tree injuries, every facet of management may impact the short- and long-term outcomes, including mortality. This article elucidates the workup and management of the thoracic cage, pulmonary and tracheobronchial injuries.
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Affiliation(s)
- Bradley M Dennis
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Seth A Bellister
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
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Abstract
PURPOSE Flail chest (FC) injuries represent a significant burden on trauma services because of its high morbidity and mortality. Current gold standard conservative management strategies for FC, are now being challenged by renewed interest in surgical rib fixation. This retrospective epidemiological study sets out to evaluate FC patients, and quantify the natural history of this injury by studying the injury patterns, epidemiology and mortality of patients sustaining FC injuries admitted to a major trauma centre (MTC). METHODS A retrospective cohort analysis has been conducted at an MTC with full trauma service. All patients (age > 16 years) sustaining FC were included. Patient demographics, injury characteristics and inpatient stay information were extracted. RESULTS Two hundred and ninety-three patients were identified, with a mean injury severity score (ISS) of 28.9 (range 9-75), average age of 56.1 years (range of 16-100), and a male predominance (78%). Road traffic accidents accounted for 45% (n = 132) of injuries, whilst 44% were fall or jump from height (n = 129). Associated lung contusion was present in 133 patients (45%) while 76% of patients were found to have 5 or more ribs involved in the flail segment (n = 223) with 96% (n = 281) having a unilateral FC. Inpatient treatment was required 19.9 days (range 0-150 days) with 59% of patients (n = 173) requiring intensive care unit (ICU) level care for 8.4 days (range 1-63) with 61.8% requiring mechanical ventilation (n = 107) for 10.5 days (range 1-54), and 7.8% underwent rib fixation with rib plates (n = 23). The mortality rate was found to be 14% (n = 42). A non-significant trend towards improved outcomes in the conservative group was found when compared with the fixation group; ventilation days (6.94 vs 10.06, p = 0.18) intensive treatment unit (ITU) length of stay (LOS) (12.56 vs 15.53, p = 0.28) and hospital LOS (32.62 vs 35.24, p = 0.69). CONCLUSION This study has successfully described the natural history of flail chest injuries, and has found a nonsignificant trend towards better outcomes with conservative management. With the cohort and management challenges now defined, work on outcome improvement can be targeted. In addition the comparability of results to other studies makes collaboration with other MTCs a realistic proposal.
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Bemelman M, de Kruijf MW, van Baal M, Leenen L. Rib Fractures: To Fix or Not to Fix? An Evidence-Based Algorithm. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:229-234. [PMID: 28795026 PMCID: PMC5548197 DOI: 10.5090/kjtcs.2017.50.4.229] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/21/2017] [Accepted: 07/22/2017] [Indexed: 12/19/2022]
Abstract
Rib fractures are a common injury resulting from blunt chest trauma. The most important complications associated with rib fractures include death, pneumonia, and the need for mechanical ventilation. The development of new osteosynthesis materials has stimulated increased interest in the surgical treatment of rib fractures. Surgical stabilisation, however, is not needed for every patient with rib fractures or for every patient with flail chest. This paper presents an easy-to-use evidence-based algorithm, developed by the authors, for the treatment of patients with flail chest and isolated rib fractures.
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Affiliation(s)
| | | | | | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht
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31
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Divisi D, Barone M, Crisci R. Surgical Management of Flail Chest: State of Art and Future Perspectives. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0184-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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32
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Dunham GM, Perez-Girbes A, Linnau KF. Core curriculum illustration: rib fractures. Emerg Radiol 2016; 24:325-327. [PMID: 27785614 DOI: 10.1007/s10140-016-1458-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 11/29/2022]
Abstract
This is the 24th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .
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Affiliation(s)
- Gregor M Dunham
- Department of Radiology, University of Washington, 1959 N.E. Pacific Street, Box 357115, Seattle, WA, 98195-7115, USA.
| | - Alexandre Perez-Girbes
- Department of Radiology, Hospital Universitari i Politecnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Ken F Linnau
- Department of Radiology, University of Washington, 1959 N.E. Pacific Street, Box 357115, Seattle, WA, 98195-7115, USA
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Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg 2016; 43:163-168. [PMID: 27572897 PMCID: PMC5378742 DOI: 10.1007/s00068-016-0721-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/22/2016] [Indexed: 11/29/2022]
Abstract
Purpose Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities with pneumonia and often leads to extended Intensive Care Unit (ICU) stay, due to insufficient respiratory function and complications. The aim of this literature study was to investigate how operative management improves patient care for adults with flail chest. Methods Randomized-controlled trials comparing operative management versus non-operative management of flail chest were included in this systematic review and meta-analysis. PubMed, Trip Database, and Google Scholar were used for study identification. We compared operative-to-non-operative management in adult flail chest patients. Mean difference and risk ratio for mortality, pneumonia rate, duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, tracheostomy rate, and treatment costs were calculated by pooling these publication results. Results Three randomized-controlled trials were included in this systematic review. In total, there were 61 patients receiving operative management compared to 62 patients in the non-operative management group. A positive effect of surgical rib fracture fixation was observed for pneumonia rate [ES 0.5, 95 % CI (0.3, 0.7)], duration of mechanical ventilation (DMV) [ES −6.5 days 95 % CI (−11.9, −1.2)], duration of ICU stay [ES −5.2 days 95 % CI (−6.2, −4.2)], duration of hospital stay (DHS) [ES −11.4 days 95 % CI (−12.4, −10.4)], tracheostomy rate (TRCH) [ES 0.4, 95 % CI (0.2, 0.7)], and treatment costs (saving $9.968,00–14.443,00 per patient). No significant difference was noted in mortality rate [ES 0.6, 95 % CI (0.1, 2.4)] between the two treatment strategies. Conclusions Despite the relatively small number of patients included, different methodologies and differences in presentation of outcomes, operative management of flail chest seems to be a promising treatment strategy that improves patients’ outcomes in various ways. However, the effect on mortality rate remains inconclusive. Therefore, research should continue to explore operative management as a viable method for flail chest injuries.
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Affiliation(s)
- Jaap Schuurmans
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - T Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
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Zardo P, Zhang R, Tawab G, Busk H, Kreft T, Schilling T, Schreiber J, Kutschka I. Chest Wall Resection and Reconstruction. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0154-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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