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Le KDR, Martin K, Read D. The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis. ANZ J Surg 2024; 94:604-613. [PMID: 38456319 DOI: 10.1111/ans.18925] [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: 01/08/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. METHODS A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. RESULTS Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. DISCUSSION This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.
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Affiliation(s)
- Khang Duy Ricky Le
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
- Department of Surgical Oncology, The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Katherine Martin
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Read
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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Brillantino A, Sandoval Sotelo ML, Cricrì AM, Geraci A, Cricrì M, Scardi F, Monte G, Fusco F, Atelli PF, Antropoli M, Lanza M, Squillante S, Benassai G, Quarto G, Castriconi M. Hand-Sewn Versus Stapled Small Bowel Anastomoses in Patients With Secondary Mesenteric Ischemia. J Surg Res 2023; 281:52-56. [PMID: 36115149 DOI: 10.1016/j.jss.2022.08.007] [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: 01/25/2022] [Revised: 06/18/2022] [Accepted: 08/15/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Although stapled anastomoses have been widely evaluated in the context of the elective surgery, few reports compared manual with stapled anastomoses in patients undergoing emergency surgery. The aim of this study is to compare the outcome of hand-sewn end-to-end anastomoses with stapled side-to-side and stapled end-to-side anastomoses in patients undergoing small bowel resection for acute mesenteric ischemia secondary to intestinal obstruction. METHODS From January 2015 to June 2021 all the hemodynamically stable patients undergoing emergency surgery with small bowel resection for intestinal obstruction were enrolled in this study. According to surgical technique in performing anastomosis, the patients were divided into three groups: group 1: hand-sewn end-to-end anastomosis, group 2: stapled end-to-side anastomosis, and group 3: stapled side-to-side anastomosis. RESULTS Although the anastomosis failure rate was higher in group 3, it was not significantly different between the three groups (P = 0.78: chi-square test). Likewise, no significant differences in the median hospital stay were found between the patients' groups (P = 0.87: Kruskal-Wallis test). The median operating time was similar in patients undergoing stapled anastomoses and was significantly higher in patients undergoing hand-sewn anastomoses (P = 0.0009: Kruskal-Wallis test). CONCLUSIONS In patients undergoing emergency small bowel resection for complicated intestinal obstruction, a similar outcome in terms of dehiscence rate and hospital stay can be achieved performing stapled or hand-sewn anastomoses, even if restoring the intestinal continuity with stapled technique is associated with lower operating time.
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Affiliation(s)
| | | | | | - Antonella Geraci
- Emergency Surgery Department "A. Cardarelli" Hospital, Naples Italy
| | | | - Francesco Scardi
- Emergency Surgery Department "A. Cardarelli" Hospital, Naples Italy
| | - Giovanni Monte
- Emergency Surgery Department "A. Cardarelli" Hospital, Naples Italy
| | - Ferdinando Fusco
- Emergency Surgery Department "A. Cardarelli" Hospital, Naples Italy
| | | | | | - Michele Lanza
- Emergency Surgery Department "A. Cardarelli" Hospital, Naples Italy
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Smyth L, Bendinelli C, Lee N, Reeds MG, Loh EJ, Amico F, Balogh ZJ, Di Saverio S, Weber D, Ten Broek RP, Abu-Zidan FM, Campanelli G, Beka SG, Chiarugi M, Shelat VG, Tan E, Moore E, Bonavina L, Latifi R, Hecker A, Khan J, Coimbra R, Tebala GD, Søreide K, Wani I, Inaba K, Kirkpatrick AW, Koike K, Sganga G, Biffl WL, Chiara O, Scalea TM, Fraga GP, Peitzman AB, Catena F. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 2022; 17:13. [PMID: 35246190 PMCID: PMC8896237 DOI: 10.1186/s13017-022-00418-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023] Open
Abstract
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
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Affiliation(s)
- Luke Smyth
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Lee
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Matthew G Reeds
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Eu Jhin Loh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dieter Weber
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Fikri M Abu-Zidan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Solomon Gurmu Beka
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Massimo Chiarugi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vishal G Shelat
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Edward Tan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ernest Moore
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Luigi Bonavina
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Rifat Latifi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andreas Hecker
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jim Khan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Giovanni D Tebala
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kjetil Søreide
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Imtiaz Wani
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenji Inaba
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Kaoru Koike
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gabriele Sganga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gustavo P Fraga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew B Peitzman
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Fausto Catena
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11020279. [PMID: 35203881 PMCID: PMC8868062 DOI: 10.3390/antibiotics11020279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/26/2023] Open
Abstract
Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.
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Abstract
Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.
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DePompeo CM, Bond L, George YE, Mezzles MJ, Brourman JD, Chandler JC, Murphy SM, Pike F, Mason DR. Intra-abdominal complications following intestinal anastomoses by suture and staple techniques in dogs. J Am Vet Med Assoc 2019; 253:437-443. [PMID: 30058972 DOI: 10.2460/javma.253.4.437] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare the incidence of intra-abdominal complications in dogs following resection and functional end-to-end stapled anastomosis (FEESA) versus anastomosis with an end-to-end sutured technique for treatment of enteric lesions. DESIGN Multicenter, retrospective descriptive cohort study. ANIMALS 180 dogs. PROCEDURES Medical records of dogs undergoing intestinal resection and anastomosis at 3 nonaffiliated private practice specialty centers were retrospectively reviewed. Preoperative clinical variables, indication for surgery, surgical technique (sutured end-to-end anastomosis vs FEESA), and evidence of postoperative anastomosis site leakage (dehiscence) were recorded. Variables of interest were analyzed for associations with dehiscence. RESULTS Dehiscence rates of sutured and stapled anastomoses were 12 of 93 (13%) and 4 of 87 (5%), respectively; odds of postoperative dehiscence were significantly lower for dogs with FEESAs than for dogs with sutured anastomoses (OR, 0.28; 95% confidence interval, 0.09 to 0.94). Among dogs that underwent surgery for treatment of intestinal dehiscence after surgery at another facility, subsequent dehiscence developed in 3 of 5 with sutured anastomoses and 0 of 11 with stapled anastomoses. Dehiscence rates varied significantly among clinics. No other variable was associated with risk of dehiscence. Eleven of 16 dogs with dehiscence were euthanized without additional surgery. Impaction at the anastomosis site was identified months or years after surgery in 3 dogs (4 anastomosis sites) that had FEESAs. CONCLUSIONS AND CLINICAL RELEVANCE Odds for dehiscence were significantly greater for sutured end-to-end anastomoses than FEESAs, and dogs undergoing surgery for previous dehiscence were significantly more likely to experience a subsequent dehiscence with a sutured anastomosis. However, variability of procedure types and dehiscence rates among clinics suggested further research is needed to confirm these findings. Obstruction at the anastomosis site was identified as a potential long-term complication of FEESA.
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Mahmood I, Mustafa F, Younis B, Ahmed K, El-Menyar A, Asim M, Al-Hassani A, Peralta R, Al-Thani H. Postoperative complications of intestinal anastomosis after blunt abdominal trauma. Eur J Trauma Emerg Surg 2018; 46:599-606. [PMID: 30251153 DOI: 10.1007/s00068-018-1013-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/19/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma. METHOD We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications. RESULTS A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications. CONCLUSION Repair of traumatic blunt bowel injury remains a surgical challenge.
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Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Fuad Mustafa
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Clinical research, Trauma and Vascular Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Mohammad Asim
- Clinical research, Trauma and Vascular Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
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Bowel Anastomosis in Acute Care Surgery. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Nemeth ZH, Lazar EL, Paglinco SR, Hicks AS, Lei J, Barratt-Stopper PA, Rolandelli RH. Experience of General Surgery Residents in the Creation of Small Bowel and Colon Anastomoses. JOURNAL OF SURGICAL EDUCATION 2016; 73:844-850. [PMID: 27321982 DOI: 10.1016/j.jsurg.2016.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/04/2016] [Accepted: 04/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND With the introduction of stapling devices (SDs), the proportion of hand-sewn (HS) intestinal anastomoses (IAs) has declined. As more IAs are constructed with SDs, there are fewer opportunities for general surgery residents (GSRs) to acquire the skills for HS techniques during their training. STUDY DESIGN Data for this study were extracted from an existing database of all IAs performed at the Department of Surgery of the Morristown Medical Center since 2003. For the purposes of this study, a 5.5-year timeframe was used between July 2006 and 2011, which contained 1659 IA operations on adult patients with resident involvement. GSRs of the 5-year general surgery residency program were grouped by postgraduate year (PGY) for further analysis. RESULTS The number of all IAs created by each resident during the 5-year training was 67.2 on average. Most of these operations were done in the last 2 years of the training: 45.1% of all IAs in PGY5 and 37.3% of all IAs in PGY4. Of all, 1659 IAs performed in the study period, 711 (42.9% of total) were done laparoscopically and 948 (57.1% of all IAs) were done as open operations. Laparoscopic operations had a proportionally higher rate of SD use when compared to open cases (90.9% vs 82.4%). On average, each resident constructed 9.4 HS IAs (13.98% of all IAs) and 57.8 SD IAs (86.02% of total). Out of all anastomoses, ostomy reversals (30.7%) had the highest percentage of HS suturing followed by right colectomies (27.5%), ileal pouch-anal anastomoses and total colectomies and proctocolectomies (23.3%), small bowel resection (17.0%), and left colectomies (5.5%). Regardless of the location of the operation, stapled and sutured anastomoses had similar outcomes measured by the rate of anastomotic leaks. Residents used significantly more SDs in the creation of anastomoses than HS suturing in the PGY3, PGY4, and PGY5 years. We also documented that attending surgeons who are older more often used HS suturing than their younger colleagues when creating IAs. CONCLUSIONS The experiences of GSRs in IA operations are heavily weighted toward the use of SDs. There are select cases, however, when HS suturing can have an advantage over stapler use in anastomosis creation. Therefore, we believe that GSRs should continue learning, perfecting, and using the both techniques.
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Affiliation(s)
- Zoltan H Nemeth
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey.
| | - Eric L Lazar
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
| | | | - Addison S Hicks
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
| | - Jason Lei
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
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Najah H, Noullet S, Godiris-Petit G, Menegaux F, Trésallet C. Management of traumatic small bowel injury by mechanical anastomosis "without resection" during damage control laparotomy. J Visc Surg 2016; 153:209-12. [PMID: 27256903 DOI: 10.1016/j.jviscsurg.2016.03.003] [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]
Affiliation(s)
- H Najah
- Service de chirurgie générale viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, Paris 6, Pierre-et-Marie-Curie-Sorbonne universités, 75013 Paris, France
| | - S Noullet
- Service de chirurgie générale viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, Paris 6, Pierre-et-Marie-Curie-Sorbonne universités, 75013 Paris, France
| | - G Godiris-Petit
- Service de chirurgie générale viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, Paris 6, Pierre-et-Marie-Curie-Sorbonne universités, 75013 Paris, France
| | - F Menegaux
- Service de chirurgie générale viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, Paris 6, Pierre-et-Marie-Curie-Sorbonne universités, 75013 Paris, France
| | - C Trésallet
- Service de chirurgie générale viscérale et endocrinienne, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, Paris 6, Pierre-et-Marie-Curie-Sorbonne universités, 75013 Paris, France.
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Snowdon KA, Smeak DD, Chiang S. Risk Factors for Dehiscence of Stapled Functional End-to-End Intestinal Anastomoses in Dogs: 53 Cases (2001-2012). Vet Surg 2015; 45:91-9. [PMID: 26565990 DOI: 10.1111/vsu.12413] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To identify risk factors for dehiscence in stapled functional end-to-end anastomoses (SFEEA) in dogs. STUDY DESIGN Retrospective case series. ANIMALS Dogs (n = 53) requiring an enterectomy. METHODS Medical records from a single institution for all dogs undergoing an enterectomy (2001-2012) were reviewed. Surgeries were included when gastrointestinal (GIA) and thoracoabdominal (TA) stapling equipment was used to create a functional end-to-end anastomosis between segments of small intestine or small and large intestine in dogs. Information regarding preoperative, surgical, and postoperative factors was recorded. RESULTS Anastomotic dehiscence was noted in 6 of 53 cases (11%), with a mortality rate of 83%. The only preoperative factor significantly associated with dehiscence was the presence of inflammatory bowel disease (IBD). Surgical factors significantly associated with dehiscence included the presence, duration, and number of intraoperative hypotensive periods, and location of anastomosis, with greater odds of dehiscence in anastomoses involving the large intestine. CONCLUSION IBD, location of anastomosis, and intraoperative hypotension are risk factors for intestinal anastomotic dehiscence after SFEEA in dogs. Previously suggested risk factors (low serum albumin concentration, preoperative septic peritonitis, and intestinal foreign body) were not confirmed in this study.
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Affiliation(s)
- Kyle A Snowdon
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
| | - Daniel D Smeak
- College of Veterinary Medicine, Colorado State University, Fort Collins, Colorado
| | - Sharon Chiang
- Department of Statistics, Rice University, Houston, Texas
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Stapled versus hand-sewn anastomoses in emergency general surgery. J Trauma Acute Care Surg 2013; 74:1187-92; discussion 1192-4. [DOI: 10.1097/ta.0b013e31828cc9c4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Stapled versus hand-sewn anastomoses in emergency general surgery: A retrospective review of outcomes in a unique patient population. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 688] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Goulder F. Bowel anastomoses: The theory, the practice and the evidence base. World J Gastrointest Surg 2012; 4:208-13. [PMID: 23293735 PMCID: PMC3536859 DOI: 10.4240/wjgs.v4.i9.208] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/04/2012] [Accepted: 09/17/2012] [Indexed: 02/06/2023] Open
Abstract
Since the introduction of stapling instruments in the 1970s various studies have compared the results of sutured and stapled bowel anastomoses. A literature search was performed from 1960 to 2010 and articles relating to small bowel, colonic and colorectal anastomotic techniques were reviewed. References from these articles were also reviewed, and relevant articles obtained. Either a stapled or sutured gastrointestinal tract anastomosis is acceptable in most situations. The available evidence suggests that in the following situations, however, particular anastomotic techniques may result in fewer complications: A stapled side-to-side ileocolic anastomosis is preferable following a right hemicolectomy for cancer. A stapled side-to-side anastomosis is likely also preferable after an ileocolic resection for Crohn’s disease. Colorectal anastomoses can be sutured or stapled with similar results, although the incidence of strictures is higher following stapled anastomoses. Following reversal of loop ileostomy there is some evidence to suggest that a stapled side-to-side anastomosis or sutured enterotomy closure (rather than spout resection and sutured anastomosis) results in fewer complications. Non-randomised data has indicated that small bowel anastomoses are best sutured in the trauma patient. This article reviews the theory, practice and evidence base behind the various gastrointestinal anastomoses to help the practising general surgeon make evidence based operative decisions.
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Affiliation(s)
- Frances Goulder
- Frances Goulder, Department of Colorectal Surgery, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH, United Kingdom
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Takata M, Watanabe G, Ohtake H, Ushijima T, Yamaguchi S, Kikuchi Y, Yamamoto Y. Automatic aortic anastomosis with an innovative computer-controlled circular stapler for surgical treatment of aortic aneurysm. J Thorac Cardiovasc Surg 2011; 141:1265-9. [DOI: 10.1016/j.jtcvs.2010.05.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 04/28/2010] [Accepted: 05/05/2010] [Indexed: 10/19/2022]
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Proudman CJ, Edwards GB, Barnes J. Differential survival in horses requiring end-to-end jejunojejunal anastomosis compared to those requiring side-to-side jejunocaecal anastomosis. Equine Vet J 2010; 39:181-5. [PMID: 17378448 DOI: 10.2746/042516407x171354] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY Horses requiring different methods of intestinal anastomosis during equine colic surgery may have differences in mortality and morbidity. HYPOTHESES Horses requiring side-to-side jejunocaecal anastomosis have a higher mortality and morbidity rate than those requiring end-to-end jejunojejunal anastomosis. Morbidity and mortality of handsewn vs. stapled side-to-side jejunocaecal anastomoses are not significantly different. METHODS A prospective, nonrandomised, observational study was conducted. Clinical and surgical details were recorded during hospitalisation and survival data acquired by periodic telephone questionnaire. Differences in mortality and morbidity rate were evaluated by survival analysis. RESULTS A total of 184 horses underwent end-to-end jejunojejunal anastomosis and 178 underwent side-to-side jejunocaecal anastomosis. Horses with a jejunocaecal anastomosis had a significantly higher mortality rate. The incidence of post operative colic in horses requiring side-to-side jejunocaecal anastomoses was greater than those requiring end-to-end jejunojejunal anastomoses. Within the group undergoing side-to-side jejunocaecal anastomosis there was no evidence of differential survival between horses with handsewn vs. stapled anastomoses. CONCLUSIONS Mortality rate is higher in horses that have required side-to-side jejunocaecal anastomosis than in those that needed end-to-end jejunojejunal anastomosis; and post operative colic is more common after side-to-side jejunocaecal anastomosis. No difference in mortality was found between horses with handsewn and stapled side-to-side jejunocaecal anastomoses. POTENTIAL RELEVANCE Surgeons should be aware of the increased mortality and morbidity in horses requiring side-to-side jejunocaecal anastomosis. Our finding of no difference in mortality between handsewn and stapled side-to-side jejunocaecal anastomoses justifies surgeons exercising personal preference in their selection of anastomosis method.
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Affiliation(s)
- C J Proudman
- Equine Division, Faculty of Veterinary Science, University of Liverpool, 'Leahurst', Neston, Cheshire CH64 7TE, UK
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Abstract
BACKGROUND We reviewed our experience with stapled intestinal anastomoses in infants younger than 1 year and compared operative data and outcome to that of infants who underwent hand-sewn anastomoses. METHODS Infants younger than 1 year who underwent an intestinal anastomosis over an 8-year period were identified. Stapled anastomoses were constructed in a side-to-side fashion using standard or endoscopic linear cutters. Outcome variables including operative time, anastomotic failure, and death were recorded. RESULTS Two hundred ninety-five subjects were identified. Hand-sewn anastomoses were performed in 189 cases and stapled anastomoses in 106. Patients who had a stapled anastomosis were older (105 vs 44 days) and larger (5.2 vs 3.1 kg), although 25 stapled anastomoses were performed in infants between 600 and 1000 g. When a stapled anastomosis was used operative time was significantly reduced overall (102 vs 128 minutes) and for individual procedures including resection for necrotizing enterocolitis (85 vs 132 minutes) and colostomy closure (104 vs 141 minutes). There was no difference between hand-sewn and stapled anastomoses in the incidence of adhesive obstruction, stricture, or leak. CONCLUSIONS When permitted by intestinal size in infants younger than 1 year, stapled anastomoses were safe and effective and significantly reduced operative time.
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White RN. Modified functional end-to-end stapled intestinal anastomosis: technique and clinical results in 15 dogs. J Small Anim Pract 2008; 49:274-81. [DOI: 10.1111/j.1748-5827.2007.00499.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Salim A, Teixeira PGR, Inaba K, Brown C, Browder T, Demetriades D. Analysis of 178 Penetrating Stomach and Small Bowel Injuries. World J Surg 2008; 32:471-5. [DOI: 10.1007/s00268-007-9350-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury. METHODS Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine. RESULTS Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this. DISCUSSION Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.
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Affiliation(s)
- G Matthes
- Ernst-Moritz-Arndt-Universität Greifswald, Unfall- und Wiederherstellungschirurgie, Sauerbruchstrasse, 17475 Greifswald.
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Caporossi C, Cecconello I, Aguilar-Nascimento JE, Venço F, Gama-Rodrigues JJ. Hand-sewn and stapled esophageal anastomosis: experimental study in dogs. Acta Cir Bras 2004. [DOI: 10.1590/s0102-86502004000400002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE: To compare experimentally, the healing of cervical oesophageal anastomoses performed either with stapler or 2-layer hand-sewn sutures. METHODS: Thirty six dogs were randomised to two groups: stapled anastomoses (n = 18); hand-sewn anastomoses (n = 18). Each group was divided into three subgroups, corresponding to the day of sacrifice (3rd, 7th and 14th postoperative day). Healing was assessed by: a) anatopathology b) anastomotic resistance to bursting pressure test; c) quantification of hidroxyproline RESULTS: Group 1 heal by second intention, group 2 showed a healing by first intention. Bursting pressure was similar between groups at day 3, though group 1 animals showed it significantly higher at day 7and day 14 compared with group 2. Statiscally, there were no interaction between the day of sacrifice and groups, as well as there was no difference among the dates of observation regarding the results of hidroxyproline CONCLUSIONS: a) mechanical suture is more resistant than hand-sewn; b) In stapler anastomoses, healing was as secondary union, whereas in hand-sewn anastomoses, healing was by first intention; c) no correlation was found in the results of bursting pressure and hidroxyproline quantification.
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Kirkpatrick AW, Baxter KA, Simons RK, Germann E, Lucas CE, Ledgerwood AM. Intra-abdominal Complications after Surgical Repair of Small Bowel Injuries: An International Review. ACTA ACUST UNITED AC 2003; 55:399-406. [PMID: 14501878 DOI: 10.1097/01.ta.0000060248.87046.ee] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The ideal method of repairing serious small bowel injuries remains unknown. Prior reports suggest a higher rate of enteric anastomotic-related complications (EACs) with stapled posttraumatic bowel anastomosis but did not specifically focus on the small bowel or clarify fully the actual anastomotic construction. METHODS This was a retrospective review of patients requiring surgical repair of small bowel perforations at a Level I urban American center (Detroit Receiving Hospital [DRH]) and a Canadian provincial trauma center (Vancouver Hospital and Health Sciences Center [VHHSC]). All patients requiring a primary repair and/or resection were included. Anastomoses were hand-sewn, stapled, or combined stapling and sewing with mucosal inversion. Leaks, anastomotic fistulae, and intra-abdominal abscesses were considered specific EACs. A sample size of 53 per group was obtained to detect a 17% difference at alpha = 0.05 (one-sided) and beta = 0.2. RESULTS Full-thickness small bowel injuries were repaired in 232 patients (DRH, 165; VHHSC, 67). Injuries were penetrating at DRH (91.5%) and blunt at VHHSC (65.7%). Anastomotic repairs in 127 patients (158 anastomotic repairs [DRH, 113; VHHSC, 55]) were 64 (40.5%) stapled, 38 (24.1%) hand-sewn, and 56 (35.4%) combined. Also, 105 patients had 349 primary closures of an injury. Overall, there were 24 EACs. After anastomosis, there were 11 intra-abdominal abscesses: 6 after stapling, 3 after being sewn, and 2 after a combined construction. There were four small bowel anastomotic fistulae: three after stapled-only anastomosis and one after hand-sewing. After enteroenterostomy, the EAC rate was 10.2% per patient, or 8.4% per anastomosis. After primary repairs, one patient had an anastomotic fistula, which closed spontaneously, and 11 had intra-abdominal abscesses, yielding an EAC rate of 10.6% per patient or 3.4% per repair. A primary repair was significantly less likely to be associated with an EAC than any anastomosis (p = 0.035). No method of anastomosis was statistically safer in relation to EACs, whether analyzed by patient, by anastomosis, or by considering primarily either the use of a linear stapler or the principle of inverting the mucosal approximation. Only damage control procedures and associated pancreaticoduodenal injuries were identified as statistically significant predictors using multiple logistic regression analysis. CONCLUSION Anastomotic complications after enteroenterostomy or primary repair for trauma are uncommon regardless of the technique, but surgeons must be especially cautious during or after damage control. Primary repairs are desirable, but when anastomosis is unavoidable, the method of repair should reflect that with which the surgeon is the most comfortable.
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Duarte AM, Santos EGD. Suturas mecânicas. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000500010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Demetriades D, Murray JA, Chan LS, Ordoñez C, Bowley D, Nagy KK, Cornwell EE, Velmahos GC, Muñoz N, Hatzitheofilou C, Schwab CW, Rodriguez A, Cornejo C, Davis KA, Namias N, Wisner DH, Ivatury RR, Moore EE, Acosta JA, Maull KI, Thomason MH, Spain DA. Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study. THE JOURNAL OF TRAUMA 2002; 52:117-21. [PMID: 11791061 DOI: 10.1097/00005373-200201000-00020] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although the use of stapling devices in elective colon surgery has been shown to be as safe as handsewn techniques, there have been concerns about their safety in emergency trauma surgery. The purpose of this study was to compare stapled with handsewn colonic anastomosis following penetrating trauma. METHODS This was a prospective multicenter study and included patients who underwent colon resection and anastomosis following penetrating trauma. Multivariate logistic regression analysis was used to identify independent risk factors for abdominal complications and compare outcomes between stapled and handsewn repairs. RESULTS Two hundred seven patients underwent colon resection and primary anastomosis. In 128 patients (61.8%) the anastomosis was performed with handsewing and in the remaining 79 (38.2%) with stapling devices. There were no colon-related deaths and the overall incidence of colon-related abdominal complications was 22.7% (26.6% in the stapled group and 20.3% in the handsewn group, p = 0.30). The incidence of anastomotic leak was 6.3% in the stapled group and 7.8% in the handsewn group (p = 0.69). Multivariate analysis adjusting for blood transfusions, fecal contamination, and type of antibiotic prophylaxis showed that the adjusted odds ratio (OR) of complications in the stapled group was 0.83 (95% CI, 0.38-1.74, p = 0.63). In a second multivariate analysis adjusting for blood transfusions, hypotension, fecal contamination, Penetrating Abdominal Trauma Index, and preoperative delays the adjusted OR in the stapled group was 0.99 (95% CI, 0.46-2.11, p = 0.99). CONCLUSION The results of this study suggest that the method of anastomosis following colon resection for penetrating trauma does not affect the incidence of abdominal complications and the choice should be surgeon's preference.
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Affiliation(s)
- Demetrios Demetriades
- Los Angeles County and University of Southern California Trauma Center, Los Angeles, California, USA.
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Brundage SI, Jurkovich GJ, Hoyt DB, Patel NY, Ross SE, Marburger R, Stoner M, Ivatury RR, Ku J, Rutherford EJ, Maier RV. Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial. THE JOURNAL OF TRAUMA 2001; 51:1054-61. [PMID: 11740250 DOI: 10.1097/00005373-200112000-00005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. METHODS Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. RESULTS A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). CONCLUSION Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.
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Affiliation(s)
- S I Brundage
- Department of Surgery, Baylor College Of Medicine, Houston, Texas 77030, USA.
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Brundage SI, Maier RV, Jurkovich GJ. Re; Witzke JD et al. Stapled versus hand sewn anastomes in patients with small bowel injury: a changing perspective. J Trauma. 2000;49:660--665. THE JOURNAL OF TRAUMA 2001; 51:180-2. [PMID: 11471536 DOI: 10.1097/00005373-200107000-00039] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Goettler CE, Fallon WF. Blunt thoraco-abdominal injury. Curr Opin Anaesthesiol 2001; 14:237-43. [PMID: 17016408 DOI: 10.1097/00001503-200104000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.
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Affiliation(s)
- C E Goettler
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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