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Alnumay A, Caminsky N, Eustache JH, Valenti D, Beckett AN, Deckelbaum D, Fata P, Khwaja K, Razek T, McKendy KM, Wong EG, Grushka JR. Feasibility of intraoperative angioembolization for trauma patients using C-arm digital subtraction angiography. Eur J Trauma Emerg Surg 2021; 48:315-319. [PMID: 33398439 DOI: 10.1007/s00068-020-01530-x] [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: 06/19/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Hemodynamically unstable trauma patients who would benefit from angioembolization (AE) typically also require emergent surgery for their injuries. The critical decision of transferring a patient to the operating room versus the interventional radiology (IR) suite can be bypassed with the advent of intra-operative AE (IOAE). Previously limited by the availability of costly rooms termed RAPTOR (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using C-arm digital subtraction angiography (DSA) is a comparable alternative. This case series aims to establish the feasibility and safety of IOAE. METHODS We conducted a retrospective analysis of all trauma patients at our level 1 trauma center who underwent IOAE with a concomitant surgical intervention from January 2011 to May 2019. Descriptive analyses were conducted. RESULTS A total of 49 patients (80% male, 44 ± 17 years, 92% blunt) underwent IOAE using the C-arm DSA during the study period. All but one patient underwent exploratory laparotomy, 56% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopedic). Either Gelfoam® (Pfizer, New York, USA) (90%), coils (2.0%), or a combination (8.2%) were used for embolization. Internal iliac embolization was performed in 88% of cases (59% bilateral). IOAE was successful in all but four cases (8.2%) and thirty-day mortality was 31%. CONCLUSION IOAE appears to be a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control.
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Affiliation(s)
- Abdulaziz Alnumay
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Natasha Caminsky
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Jules Hugo Eustache
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - David Valenti
- Division of Interventional Radiology, Department of Radiology, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar, Ave Room C5-118, Montreal, QC, H3G 1A4, Canada
| | - Andrew Neil Beckett
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Dan Deckelbaum
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Paola Fata
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Kosar Khwaja
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Tarek Razek
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Katherine Marlene McKendy
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Evan Gordon Wong
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada
| | - Jeremy Richard Grushka
- Division of Trauma and General Surgery, McGill University Health Centre, Montreal General Hospital Site, 1650 Cedar Ave Room L9-421, Montreal, QC, H3G 1A4, Canada.
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Abstract
OBJECTIVE Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject. DESIGN A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. RESULTS The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ). CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.
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Voiglio EJ, Dubuisson V, Massalou D, Baudoin Y, Caillot JL, Létoublon C, Arvieux C. Abbreviated laparotomy or damage control laparotomy: Why, when and how to do it? J Visc Surg 2016; 153:13-24. [PMID: 27542655 DOI: 10.1016/j.jviscsurg.2016.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The goal of abbreviated laparotomy is to treat severely injured patients whose condition requires an immediate surgical operation but for whom a prolonged procedure would worsen physiological impairment and metabolic failure. Indeed, in severely injured patients, blood loss and tissue injuries enhance the onset of the "bloody vicious circle", triggered by the triad of acidosis-hypothermia-coagulopathy. Abbreviated laparotomy is a surgical strategy that forgoes the completeness of operation in favor of a physiological approach, the overriding preference going to rapidity and limiting the procedure to control the injuries. Management is based on sequential association of the shortest possible preoperative resuscitation with surgery limited to essential steps to control injury (stop the bleeding and contamination), without definitive repair. The latter will be ensured during a scheduled re-operation after a period of resuscitation aiming to correct physiological abnormalities induced by the trauma and its treatment. This strategy necessitates a pre-defined plan and involvement of the entire medical and nursing staff to reduce time loss to a strict minimum.
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Affiliation(s)
- E J Voiglio
- Centre Hospitalier Lyon-Sud, Service de Chirurgie d'Urgence, 69495 Pierre-Bénite cedex, France; Université de Lyon, Université Lyon 1, Faculté de Médecine Lyon-Est, UMR 9405, 69008 Lyon, France.
| | - V Dubuisson
- CHU de Bordeaux, Hôpital Pellegrin-Tripode, Service de Chirurgie Vasculaire et Générale, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - D Massalou
- CHU de Nice, Université de Nice Sophia-Antipolis, Hôpital St-Roch, Pôle Urgences-SAMU-SMUR, UCSU Chirurgie, 5, rue Pierre-Dévoluy, CS 81319, 06006 Nice cedex 1, France; Aix-Marseille Université, IFSTTAR, Laboratoire de Biomécanique appliquée LBA, UMRT 24, boulevard Pierre-Dramard, 13005 Marseille, France
| | - Y Baudoin
- Hôpital d'instruction des armées Percy, Service de Chirurgie Digestive, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - J L Caillot
- Centre Hospitalier Lyon-Sud, Service de Chirurgie d'Urgence, 69495 Pierre-Bénite cedex, France
| | - C Létoublon
- CHU A.-Michallon, Clinique Universitaire de Chirurgie Digestive et de l'Urgence, Pôle Digi-DUNE, BP 217, 38043 Grenoble cedex 09, France
| | - C Arvieux
- CHU A.-Michallon, Clinique Universitaire de Chirurgie Digestive et de l'Urgence, Pôle Digi-DUNE, BP 217, 38043 Grenoble cedex 09, France
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Kisat M, Zafar SN, Hashmi ZG, Pardhan A, Mir T, Shah A, Haider AH, Zafar H. Experience of damage control trauma laparotomy in a limited resource healthcare setting: A retrospective Cohort Study. Int J Surg 2016; 28:71-6. [PMID: 26889970 DOI: 10.1016/j.ijsu.2016.02.042] [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: 10/05/2015] [Revised: 01/19/2016] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Damage control surgery (DCS) is an established option for managing severely injured trauma patients. However, its role in the management of similar patients in the developing world is debatable. The purpose of this study is to describe characteristics and outcomes of patients undergoing DCS. METHODS All trauma patients requiring laparotomies from 1996 to 2011 at a tertiary care hospital in South Asia were reviewed. DCS was defined in a patient who underwent a truncated laparotomy where the fascia was primarily left open, with the intention of physiological optimization in the Intensive Care Unit, followed by definitive surgery. The primary outcome was in-hospital mortality. Multivariate logistic regression was used to determine the independent predictors of mortality after adjustment for potential confounders. RESULTS Of 258 patients, 47 underwent DCS. 40% patients were transferred from other hospitals. The time between injury and operation was 152 minutes (IQR: 90-330). Intra-operative laboratory parameters revealed a median pH of 7.16 (IQR: 7.10-7.27), median temperature of 34.7 (IQR: 34.0-35.4) and median PT of 15.9 (IQR: 12.4-21.2). 55% of the patients survived to discharge from hospital. Of those who died, 86% died before the first take back operation. Packed red blood cell transfusion and vascular injury were independently associated with mortality. DISCUSSION Damage control surgery is feasible in developing countries, with more than 50% survival reported at one hospital. Future research should focus on critical care management. CONCLUSION Damage Control trauma laparotomy is feasible in tertiary care hospitals with multidisciplinary trauma teams in lesser-developed countries.
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Affiliation(s)
- Mehreen Kisat
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan; Aga Khan University-Johns Hopkins Trauma Outcomes Research Collaboration, Pakistan.
| | - Syed Nabeel Zafar
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan; Aga Khan University-Johns Hopkins Trauma Outcomes Research Collaboration, Pakistan
| | - Zain G Hashmi
- Center for Surgery Trials and Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Aga Khan University-Johns Hopkins Trauma Outcomes Research Collaboration, Pakistan
| | - Amyn Pardhan
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Tahreem Mir
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Adil Shah
- Center for Surgery Trials and Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Aga Khan University-Johns Hopkins Trauma Outcomes Research Collaboration, Pakistan
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Hasnain Zafar
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Kataoka Y, Minehara H, Kashimi F, Hanajima T, Yamaya T, Nishimaki H, Asari Y. Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma. Injury 2016; 47:59-63. [PMID: 26508437 DOI: 10.1016/j.injury.2015.09.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 09/12/2015] [Accepted: 09/25/2015] [Indexed: 02/02/2023]
Abstract
OBJECT To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. PATIENTS AND METHODS The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). RESULTS Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group. CONCLUSION Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.
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Affiliation(s)
- Yuichi Kataoka
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Hiroaki Minehara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Fumie Kashimi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Tasuku Hanajima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Tatsuhiro Yamaya
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
| | - Hiroshi Nishimaki
- Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Japan.
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Japan.
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Abstract
Significant advancements in nonsurgical and surgical approaches to control bleeding in severely injured patients have also improved the treatment of critical trauma-related coagulopathy. Nonsurgical procedures such as angiographic embolization are progressively considered to terminate arterial bleeding from pelvic fractures. The disturbance of coagulation may aggravate bleeding and hamper surgical procedures. The administration of coagulation factors and factor concentrates may be useful for correcting systemic coagulopathy and reducing the need for fresh frozen plasma, platelet, and red blood cell transfusions, which are associated with various adverse outcomes. In this review, nonsurgical management of critical trauma bleeding is discussed.
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Affiliation(s)
- Christian Zentai
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany.
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