Vascular surgery during U.S. combat operations from 2002 to 2016: Analysis of vascular procedures performed to inform military training

Endovascular surgery in the French role 3 medical treatment facility: Is there a need? A 10-year retrospective analysis

OBJECTIVE

Vascular surgery for war-related traumatic injuries represents 3 to 17.6 % of all emergency surgical procedures, and around 5 % in French Medical Treatment Facilities (MTFs). Most of these lesions are treated by open surgery, but the role of endovascular surgery in French MTFs has not been assessed yet. The aims of this study are to assess the possible role of endovascular surgery by describing vascular surgical management in recent conflicts, and identify potential gaps in vascular surgery training.

METHODS

Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2011 to 2021. All patients treated in French Role 2 Enhanced or 3 MTFs requiring emergency surgery for peripheral vascular injury were included. The mechanism of injury, type of vascular injury and surgical management were reported. Patients eligible to receive endovascular surgery were described as a subgroup, and surgical management was described according to surgeon's specialty.

RESULTS

Out of the 2137 patients admitted for emergency or delayed emergency surgery, we reported 21 patients (0.98 %) with peripheral vascular injuries requiring emergency surgery, of which 19 (90.5 %) with at least one arterial lesion. Most injuries were combat-related (n = 18 [86 %]). Arterial injuries involved mainly femoral (n = 8 [38.1 %]) or humeral (n = 5 [23.8 %]) arteries, primarily handled by vascular shunting or bypass. Arteriography before or after surgery was not a was not common practice (n = 4 [19 %]). Six patients (28.6 %) were deemed eligible for endovascular surgery.

CONCLUSION

Peripheral vascular lesion requiring emergency surgery are relatively uncommon in French MTFs. However, they require specific surgical training to deal with their complexity. Endovascular surgery does not appear to offer sufficient benefit for systematic deployment in French MTFs, and pre- and post-operative arteriography may be of interest for diagnostic use. The establishment of a French vascular mobile unit for complex cases may be of interest.

An Analysis of Head and Neck Surgical Workload During Recent Combat Operations From 2002 to 2016

INTRODUCTION

In battle-injured U.S. service members, head and neck (H&N) injuries have been documented in 29% who were treated for wounds in deployed locations and 21% who were evacuated to a Role 4 MTF. The purpose of this study is to examine the H&N surgical workload at deployed U.S. military facilities in Iraq and Afghanistan in order to inform training, needed proficiency, and MTF manning.

MATERIALS AND METHODS

A retrospective analysis of the DoD Trauma Registry was performed for all Role 2 and Role 3 MTFs, from January 2002 to May 2016; 385 ICD-9 CM procedure codes were identified as H&N surgical procedures and were stratified into eight categories. For the purposes of this analysis, H&N procedures included dental, ophthalmologic, airway, ear, face, mandible maxilla, neck, and oral injuries. Traumatic brain injuries and vascular injuries to the neck were excluded.

RESULTS

A total of 15,620 H&N surgical procedures were identified at Role 2 and Role 3 MTFs. The majority of H&N surgical procedures (14,703, 94.14%) were reported at Role 3 facilities. Facial bone procedures were the most common subgroup across both roles of care (1,181, 75.03%). Tracheostomy accounted for 16.67% of all H&N surgical procedures followed by linear repair of laceration of eyelid or eyebrow (8.23%) and neck exploration (7.41%). H&N caseload was variable.

CONCLUSIONS

H&N procedures accounted for 8.25% of all surgical procedures performed at Role 2 and Role 3 MTFs; the majority of procedures were eye (40.54%) and airway (18.50%). These data can be used as planning tools to help determine the medical footprint and also to help inform training and sustainment requirements for deployed military general surgeons especially if future contingency operations are more constrained in terms of resources and personnel.

Nonfatal Injuries From Falls Among U.S. Military Personnel Deployed for Combat Operations, 2001-2018

INTRODUCTION

Falls are a leading mechanism of injury. Hospitalization and outpatient clinic visits due to fall injury are frequently reported among both deployed and non-deployed U.S. Military personnel. Falls have been previously identified as a leading injury second only to sports and exercise as a cause for non-battle air evacuations.

MATERIALS AND METHODS

This retrospective study analyzed the Department of Defense Trauma Registry fall injury data from September 11, 2001 to December 31, 2018. Deployed U.S. Military personnel with fall listed as one of their mechanisms of injury were included for analysis.

RESULTS

Of 31,791 injured U.S. Military personnel captured by the Department of Defense Trauma Registry within the study time frame, a total of 3,101 (9.8%) incurred injuries from falls. Those who had fall injuries were primarily 21 to 30 years old (55.4%), male (93.1%), Army (75.6%), and enlisted personnel (56.9%). The proportion of casualties sustaining injuries from falls generally increased through the years of the study. Most fall injuries were classified as non-battle injury (91.9%). Falls accounted for 24.2% of non-battle injury hospital admissions with a median hospital stay of 2 days. More non-battle-related falls were reported in Iraq-centric military operations (62.7%); whereas more battle-related falls were reported in Afghanistan-centric military operations (58.3%).

CONCLUSIONS

This study is the largest analysis of deployed U.S. Military personnel injured by falls to date. Highlighted are preventive strategies to mitigate fall injury, reduce workforce attrition, and preserve combat mission capability.

LEVEL OF EVIDENCE

Level III Epidemiologic.

Venous shunting and limb outcomes in military lower extremity combined arterial and venous injuries

Introduction

Combined arterial and venous lower extremity (LE) injuries present complex management challenges. Temporary arterial shunting is widely accepted, but vein shunting is not well studied. We examined the influence of vein shunting on limb outcomes in military femoropopliteal arterial and venous combined injuries.

Methods

A retrospective cohort study of Iraq and Afghanistan LE vascular injuries from 2004-2012 was performed and combined arterial and venous femoropopliteal injuries selected. Vein shunted and non-vein shunted groups were identified and pertinent variables compared.

Results

Of 135 arteriovenous injuries, 61 (45%) had vein ligation (5 after shunting), leaving 74 injuries undergoing venous repair (37 grafts (3 synthetic), 34 local repairs, 3 patches). The vein was shunted in 16 (22%). The shunt and no shunt cohorts had similar demographics, mechanism (70% blast), and ISS (median 18, IQR 10-26). Tourniquets and fasciotomy were used equally. Venous shunts were used almost exclusively in cases in which the artery was shunted (94% vs 22% no shunt, P<0.001) and more commonly in cases with bilateral LE vascular injuries (25% shunt vs 3.4% no shunt, P=0.01). Shunted veins more frequently underwent grafting (88% vs 40%, P<0.001). Median MESS was 8, IQR 7-9 in shunted vs. 6 (5-7) in unshunted limbs. Outcomes were similar, with amputation in 13% of shunted and 26% (P=0.33) unshunted and arterial repair complications in 44% and 28% (P=0.24).

Conclusion

In combat casualties with combined arterial and venous femoropopliteal injury, vein shunting was used primarily in severely injured limbs in conjunction with arterial shunts and in injuries ultimately undergoing autologous grafting. Limb salvage was statistically equivalent with the use of venous shunts, suggesting equipoise in outcomes with and without venous shunting. Temporary venous shunting should be considered but does not appear to be mandatory in severe lower extremity combined arterial and venous injuries.

The Isolated Surgeon: A Scoping Review

BACKGROUND

Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care.

METHODS

We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role.

RESULTS

From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings.

CONCLUSIONS

This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.

Review of a Role 2 in Afghanistan: Understanding the Data on Medical and Surgical Volumes in a Deployed Setting

INTRODUCTION

The U.S. forward military surgical assets have deployed throughout the Iraq and Afghanistan theaters of operations to maintain surgical support for injured service members in compliance with the "golden hour" as specified in the Gates Memorandum. The support of evacuation times of less than 60 minutes to a surgical capability has resulted in smaller surgical teams being deployed to an increased number of locations. Over the last 5 years, the combat trauma patient encounters have decreased. Although some Role 2 medical treatment facilities (MTFs) maintain a medical mission, most of them are set up to provide trauma care. The largest and busiest Role 2 MTF is located near Kabul and serves the NATO population. The aims of this review are to examine the epidemiological data of the largest Role 2 MTF in theater, to examine damage control surgical capability optimization in a facility with a largely medical mission, and to analyze what this may mean in the context of surgical skill atrophy.

METHODS

As part of a performance improvement project, a retrospective review of prospectively collected data at the Hamid Karzai NATO Role 2 MTF was conducted. Four years of clinical and epidemiological data were reviewed. Independent source verification of the records was conducted by validating records via comparison to the ancillary services' records. When available, data on other MTFs in Afghanistan were used for comparison. Descriptive statistics were used to analyze demographics, evacuations, surgeries, and admissions.

RESULTS

Over the studied period, 0.7% of patients were seen for battle injuries. The average number of patients seen was 636 per month with 184 per month in 2016 and a steady increase to 805 per month in 2019. The operative volume was a mean of 2.8 surgeries per month with a median of 2 surgeries per month (orthopedic and general surgery combined). Other Role 2 facilities were on average seeing even fewer operative patients, although there were some treating more operative patients. From available data, no other Role 2 MTFs were treating close to as many total patients (all types combined). The two Role 3 facilities evaluated saw significantly more operative patients at an average of 53 surgeries per month.

CONCLUSION

The ratio of operative cases per surgeon is substantially higher at these Role 3 facilities, when compared to Role 2 facilities, although still significantly lower than would be expected at an U.S. Level 1 trauma center. This is consistent with other larger epidemiological studies on forward MTF workload. The vast majority of patient care is related to treatment of disease and preventative medicine. Only 0.7% of the large volume of patient visits evaluated were for battle injuries. There is a scarcity of both surgical and trauma patients, with a more pronounced reduction at Role 2 compared to Role 3 facilities. This is especially evident here with a facility that has such a large patient population but low trauma or surgical patient volume. Sustaining trauma and surgical skills for both surgeons and trauma teams with a paucity of trauma patients is a significant concern.

Maintaining vascular trauma proficiency for military non-vascular surgeons

Background

Vascular injuries in combat casualty patients are common and remain an ongoing concern. In civilian trauma centers, vascular surgeons are frequently available to treat vascular injuries. Within the military, vascular surgeons are not available at all locations where specialty expertise may be optimal. This study aims to determine if a visiting surgeon model, where a general surgeon can visit a civilian trauma center, would be practical in maintaining proficiency in vascular surgery.

Methods

All vascular trauma relevant cases done by any surgical service were identified during a 2-year period at Saint Louis University Hospital between October 1, 2016 and September 30, 2018. These included cases performed by trauma/general, thoracic, vascular, and orthopedic surgery. Predictions on the number of call days to experience an operative case were then calculated.

Results

A total of 316 vascular cases were performed during the time period. A surgeon on call for five 24-hour shifts would experience 2.1 urgent vascular cases with 95% certainty. To achieve five cases with 95% certainty, a surgeon would have to be on call for 34 24-hour shifts.

Discussion

A visiting surgeon model would be very difficult to maintain to acquire or maintain proficiency in vascular surgery. High-volume trauma centers, or centers with significant open vascular cases in addition to trauma, may have more reasonable time requirements, but would have to be evaluated using these methods.

Level of evidence

Economic and value-based evaluations, level II.

Predictors and timing of amputations in military lower extremity trauma with arterial injury

INTRODUCTION

Military lower extremity arterial injuries present threats to life and limb. These injuries are common and limb salvage is a trauma system priority. Understanding the timing and predictors of amputation through the phases of casualty evacuation can help inform future limb salvage efforts. This study characterizes limbs undergoing amputation at different operationally relevant time points.

METHODS

A retrospective cohort study of casualties with lower extremity arterial injuries undergoing initial vascular limb salvage in Iraq and Afghanistan was undertaken. Amputations were grouped as having been performed early (in theater at Role 2 or 3) or late (after evacuation to Role 4 or 5). Further distinction was made between late and delayed (after discharge from initial hospitalization) amputations.

RESULTS

Four hundred fifty-five casualties met inclusion criteria with 103 amputations (23%). Twenty-one (20%) were performed in theater and 82 (80%) were performed following overseas evacuation. Twenty-one (26% of late amputations) were delayed, a median of 359 days from injury (interquartile range, 176-582). Most amputations were performed in the first 4 days following injury. Amputation incidence was highest in popliteal injuries (28%). Overall, amputation was predicted by higher incidence of blast mechanism and fracture and greater limb and casualty injury severity. Early amputations had higher limb injury severity than late amputations. Delayed amputations had greater incidence of motor and sensory loss and contracture than early amputations.

CONCLUSION

Casualty and limb injury severity predict predictors and timing of amputation in military lower extremity arterial injury. Amputation following overseas evacuation was more common than in-theater amputation, and functional loss is associated with delayed amputation. Future limb salvage efforts should focus on postevacuation and rehabilitative care.

LEVEL OF EVIDENCE

Epidemiologic study, level III.