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Rao AS, Scalea TM, Feliciano DV, Harfouche MN. More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury. Am Surg 2024:31348241244629. [PMID: 38590003 DOI: 10.1177/00031348241244629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). METHODS Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. RESULTS Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). CONCLUSIONS In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.
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DuBose JJ, Feliciano DV. Howard Atwood Kelly (1858-1943) and the Kelly Clamp. Am Surg 2024; 90:521-522. [PMID: 36169090 DOI: 10.1177/00031348221129513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While the Kelly clamp remains one of the most utilized instruments in a host of surgical procedures, the namesake of this instrument has become unfamiliar to many modern practitioners and trainees. Howard Atwood Kelly was one of the "Big Four" founding professors at the Johns Hopkins University School of Medicine.
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Affiliation(s)
- Joseph J DuBose
- University of Texas - Austin, Dell School of Medicine, Austin, TX, USA
| | - David V Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center - Baltimore, Baltimore, MD, USA
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Fox CJ, Feliciano DV, Hartwell JL, Ley EJ, Coimbra R, Schellenberg M, de Moya M, Moore LJ, Brown CVR, Inaba K, Keric N, Peck KA, Rosen NG, Weinberg JA, Martin MJ. Extremity vascular injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2024; 96:265-269. [PMID: 37926992 DOI: 10.1097/ta.0000000000004186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Charles J Fox
- From the R Adams Cowley Shock Trauma Center (C.J.F., D.V.F.), Baltimore, Maryland; University of Kansas Medical Center (J.L.H.), Kansas City, Kansas; Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Riverside University Health System Medical Center (R.C.), Riverside, California; University of Southern California (M.S., K.I., M.J.M.), Los Angeles, California; Medical College of Wisconsin (M.M.), Milwaukee, Wisconsin; University of Texas McGovern Medical School (L.J.M.), Houston, Texas; Dell Medical School, University of Texas at Austin (C.V.R.B.), Austin, Texas; University of Arizona College of Medicine (N.K.), Phoenix, Arizona; Scripps Mercy Hospital (K.A.P.), San Diego, CA; Children's Hospital (N.G.R.), Cincinnati, Ohio; and St. Joseph's Hospital and Medical Center (J.A.W.), Phoenix, Arizona
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Radding S, Harfouche MN, Dhillon NK, Ko A, Hawley KL, Kundi R, Maddox JS, Radowsky JS, DuBose JJ, Feliciano DV, Kozar RA, Scalea TM. A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms? J Trauma Acute Care Surg 2024; 96:313-318. [PMID: 37599423 DOI: 10.1097/ta.0000000000004117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. METHODS We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. RESULTS Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. CONCLUSION There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sydney Radding
- From the Department of Surgery (S.R.), Virginia Commonwealth University, Richmond, VA; R Adams Cowley Shock Trauma Center (M.N.H., N.K.D., K.L.H., R.K., J.S.M., J.S.R., D.V.F., R.A.K., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (A.K.), Stanford University, Stanford, California; and Department of Surgery (J.J.DB.), University of Texas at Austin, Austin, Texas
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Walker PF, Galvagno SM, Sachdeva A, Feliciano DV, Scalea TM, O'Connor JV. Operative Management of Aerodigestive Injuries: Improved Survival Over two Decades. Am Surg 2023; 89:5982-5987. [PMID: 37283249 DOI: 10.1177/00031348231180917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Non-iatrogenic aerodigestive injuries are infrequent but potentially fatal. We hypothesize that advances in management and adoption of innovative therapies resulted in improved survival. METHODS Trauma registry review at a university Level 1 center from 2000 to 2020 that identified adults with aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted. Univariate analysis was performed, P < .05 was statistically significant. RESULTS 95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined). Mean age 30.9 (± 14), 87.4% male, 82.1% penetrating, and 28.4% with vascular injuries. Median ISS, chest AIS, admission BP, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, .8 (.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively. There were 46 cervical and 22 thoracic airway injuries; 5 patients in extremis required preoperative ECMO. 66 airway injuries were surgically repaired and 2 definitively managed with endobronchial stents. There were 24 cervical, 11 thoracic, 2 abdominal esophageal injuries-all repaired surgically. Combined tracheoesophageal injuries were individually managed and buttressed. 4 airway complications were successfully managed, and 11 esophageal complications managed conservatively, stented, or resected. Mortality was 9.6%, half from intraoperative hemorrhage. Specific mortality: tracheobronchial 8.8%, esophageal 10.8%, and combined 20%. Mortality was significantly associated with higher ISS (P = .01), vascular injury (P = .007), blunt mechanism (P = .01), bronchial injury (P = .01), and years 2000-2010 (P = .03), but not combined tracheobronchial injury. CONCLUSION Mortality is associated with several variables, including vascular trauma and years 2000-2010. The use of ECMO and endoluminal stents in highly selected patients and institutional experience may account for 97.8% survival over the past decade.
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Affiliation(s)
| | - Samuel M Galvagno
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | | | - David V Feliciano
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - James V O'Connor
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
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Feliciano DV, DuBose JJ. Robert James Graves (1796-1853), The Irish School of Medicine, and Graves' Disease. Am Surg 2023; 89:6282-6283. [PMID: 36787212 DOI: 10.1177/00031348231156771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Robert James Graves, a native of Dublin, Ireland, was a physician rather than a surgeon; however, his name is well-known to all general and endocrine surgeons. He was born in Dublin, Ireland, and received his BA and MB degrees from Trinity College (formerly, Dublin University). After further studies throughout Europe, he received his "licentiate" from the Royal College of Physicians of Ireland in 1820 and was appointed Physician to the Meath Hospital in Dublin in 1821. Graves received many honors during his career including the following: King's Professor in the Institute of Medicine (1824); President of the Royal College of Physicians of Ireland (1843-44); and a Fellow of the Royal Society (FRS, 1849). In addition, he was a prominent member of the Irish School of Medicine which also included William Stokes (1804-1878) (Cheyne-Stokes breathing, Stokes-Adams attacks) and Dominic Corrigan (1802-1880) (Corrigan's pulse). Graves' description of exophthalmic goiter was in 1835, some 49 years after that of Caleb Hillier Parry (1755-1822) of Bath, England; however, Bath's report was not published till 1825 or 3 years after his death. Graves' disease is still the eponym applied to this form of hyperthyroidism in the United States.
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Affiliation(s)
- David V Feliciano
- University of Maryland School of Medicine, Baltimore, MD, USA
- Shock Trauma Center/Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Dell School of Medicine, University of Texas-Austin, Austin, TX, USA
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Rozycki GF, Sakran JV, Manukyan MC, Feliciano DV, Radisic A, You B, Hu F, Wooster M, Noll K, Haut ER. Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries. Am Surg 2023; 89:5492-5500. [PMID: 36786019 DOI: 10.1177/00031348231157416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries. METHODS Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS. RESULTS From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years. CONCLUSIONS AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.
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Affiliation(s)
- Grace F Rozycki
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariuxi C Manukyan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Shock Trauma Center/University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda Radisic
- Department of Surgery, School of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Bin You
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fang Hu
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan Wooster
- Southeast Iowa Regional Medical Center, Burlington, IA, USA
| | - Kathy Noll
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Donald Church Balfour, MD (1882-1963), a legendary general surgeon at the Mayo Clinic in Rochester, Minnesota, first described the Balfour self-retaining abdominal retractor in 1912. The retractor remains in use in 2022, 110 years after its development.
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Affiliation(s)
- David V Feliciano
- University of Maryland School of Medicine, Baltimore, MD, USA
- Shock Trauma Center/Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Dell School of Medicine, University of Texas-Austin, Austin, TX, USA
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Stonko DP, Betzold RD, Azar FK, Edwards J, Abdou H, Elansary NN, Gerling KA, White J, Feliciano DV, DuBose JJ, Morrison JJ. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular 2023; 31:777-783. [PMID: 35430941 DOI: 10.1177/17085381221082371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Richard D Betzold
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, Florida Atlantic University, Boca Raton, FL USA
| | - Joseph Edwards
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Hossam Abdou
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Noha N Elansary
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | | | - Joseph White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David V Feliciano
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan J Morrison
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Harfouche MN, Feliciano DV, Kozar RA, DuBose JJ, Scalea TM. A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database. J Am Coll Surg 2023; 236:1208-1216. [PMID: 36847370 DOI: 10.1097/xcs.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.
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Affiliation(s)
- Melike N Harfouche
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - David V Feliciano
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Rosemary A Kozar
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Joseph J DuBose
- Dell Medical School, University of Texas at Austin, Austin, TX (DuBose)
| | - Thomas M Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
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Chipman AM, Ottochian M, Ricaurte D, Gunter G, DuBose JJ, Stonko DP, Feliciano DV, Scalea TM, Morrison J. Contemporary management and time to revascularization in upper extremity arterial injury. Vascular 2023; 31:284-291. [PMID: 35418267 DOI: 10.1177/17085381211062726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. METHODS The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. RESULTS The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). CONCLUSION Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.
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Affiliation(s)
- Amanda M Chipman
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Marcus Ottochian
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Daniel Ricaurte
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Grahya Gunter
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph J DuBose
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - David P Stonko
- Department of Surgery, 160877Johns Hopkins Hospital, Baltimore, MD, United States
| | - David V Feliciano
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Thomas M Scalea
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Jonathan Morrison
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
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Harfouche MN, Dhillon NK, Hawley KL, DuBose JJ, Kozar RA, Feliciano DV, Scalea TM. Time to Splenic Angioembolization Does Not Impact Splenic Salvage Rates. Am Surg 2023:31348231161674. [PMID: 36878008 DOI: 10.1177/00031348231161674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
We aimed to determine whether early (<6 hours) vs delayed (≥6 hours) splenic angioembolization (SAE) after blunt splenic trauma (grades II-V) impacted splenic salvage rates at a level I trauma center (2016-2021). The primary outcome was delayed splenectomy by timing of SAE. Mean time of SAE was determined for those who failed vs those who had successful splenic salvage. We retrospectively identified 226 individuals, from which 76 (33.6%) were in the early group and 150 (66.4%) were in the delayed group. The early group had higher AAST grade, greater amount of hemoperitoneum on CT, and 3.9x greater odds of undergoing delayed splenectomy (P = .046). Time to embolization was shorter in the group that failed splenic salvage (5 vs 10 hours, P = .051). On multivariate analysis, timing of SAE had no effect on splenic salvage. This study supports performing SAE on an urgent rather than emergent basis in stable patients after blunt splenic injury.
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Affiliation(s)
- Melike N Harfouche
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Navpreet K Dhillon
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristy L Hawley
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph J DuBose
- Department of Surgery, Dell Medical School, 21976University of Texas at Austin, Austin, TX, USA
| | - Rosemary A Kozar
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Feliciano DV. 2022 Excelsior Surgical Society/Edward D Churchill Lecture: Extraordinary Evolution of Surgery for Abdominal Trauma. J Am Coll Surg 2023; 236:439-448. [PMID: 36730657 DOI: 10.1097/xcs.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David V Feliciano
- From the Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Feliciano DV. Trauma: The most progressive subspecialty of all. J Trauma Acute Care Surg 2023; 94:8-14. [PMID: 36221176 DOI: 10.1097/ta.0000000000003819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- David V Feliciano
- From the University of Maryland School of Medicine; Shock Trauma Center/Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Feliciano DV. Where is the femoral vein? A vascular case report. Trauma Surg Acute Care Open 2022; 7:e000979. [PMID: 35891679 PMCID: PMC9260837 DOI: 10.1136/tsaco-2022-000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Abstract
Despite significant interest in trauma to the spleen over the past 130 years, splenectomy remained the preferred approach to splenic injures in children till the late 1950s and even later in adults. With recognition of the immunologic importance of the spleen and improvements in diagnostic imaging and angioembolization, there are now four pathways for the child or adult admitted with a possible, likely, or diagnosed injury to the spleen. These include the following: (1) operation with splenectomy; (2) operation with splenorrhaphy or partial splenectomy; (3) nonoperative management (observation); and (4) nonoperative management with splenic arteriography and possible angioembolization. This review will focus on the latter two options.
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Affiliation(s)
- Melike N Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Navpreet K Dhillon
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David V Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, Maryland, USA
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Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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DuBose JJ, Feliciano DV. Frederic Eugene Basil Foley (1891-1966) and the Foley-type Balloon Catheter. Am Surg 2022:31348221088969. [PMID: 35435012 DOI: 10.1177/00031348221088969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The history and physician behind the eponym for the commonly utilized Foley catheter.
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Affiliation(s)
- Joseph J DuBose
- University of Texas-Austin Dell School of Medicine, Austin, TX, USA
| | - David V Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
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Feliciano DV, Perrier ND, van Heerden JA. The Southern Surgical Association and the Mayo Brothers of Rochester, Minnesota: An Enduring Legacy. J Am Coll Surg 2022; 234:708-712. [PMID: 35290292 DOI: 10.1097/xcs.0000000000000083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- David V Feliciano
- Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, MD (Feliciano)
| | - Nancy D Perrier
- Section of Surgical Endocrinology, University of Texas MD Anderson Cancer Center, Houston, TX (Perrier)
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Harfouche MN, Madurska MJ, Elansary N, Abdou H, Lang E, DuBose JJ, Kundi R, Feliciano DV, Scalea TM, Morrison JJ. Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock. PLoS One 2022; 17:e0265778. [PMID: 35324991 PMCID: PMC8947416 DOI: 10.1371/journal.pone.0265778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of trauma patients in shock undergoing REBOA versus no-REBOA. Methods This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000–2019). REBOA (R; 2015–2019) patients were propensity matched 2:1 to historic (H; 2000–2012) and contemporary (C; 2013–2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively. Results A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups. Conclusion In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
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Affiliation(s)
- Melike N. Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Joseph J. DuBose
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - David V. Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
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21
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Harfouche MN, Kauvar DS, Feliciano DV, Dubose JJ. Managing Vascular Trauma: Trauma Surgeons versus Vascular Surgeons. Am Surg 2022; 88:1420-1426. [DOI: 10.1177/00031348221080427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Changes in vascular trauma care and trainee exposure to vascular surgery have raised questions regarding who should take care of vascular trauma patients. This study aimed to determine nationwide trends and perceptions regarding the management of vascular trauma amongst vascular and trauma surgeons. Material and Methods Online surveys were administered to trauma surgeons through the American Association for the Surgery of Trauma (AAST) and to vascular surgeons through the Vascular and Endovascular Surgery Society (VESS) and Western Vascular Society (WVS) in February 2021. Demographics, practice-related information, and interest in, experience and comfort level with vascular trauma were queried. Trainees and those practicing outside the United States were excluded. Results were analyzed using Stata/BE v16.1. Results 247 surgeons were included in the final study population, of which 163 (66%) were trauma surgeons (T) and 84 (34%) were vascular surgeons (V). Vascular surgeons were younger (46 v 51y, P < .001) and had fewer years in practice (10 v 17y, P < .001). Vascular surgeons had greater experience and comfort with managing vascular trauma, but less interest in both vascular and endovascular trauma care when compared to trauma surgeons. Inability to maintain skillset (27%) and unfamiliarity with techniques (32%) were the most common barriers to practicing vascular trauma cited by trauma surgeons. Discussion Despite significant interest in practicing vascular trauma amongst trauma surgeons compared to vascular surgeons, most feel unprepared to do so. Collaboration between vascular and trauma surgeons could close the experience gap and appeal to the interests of both groups.
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Affiliation(s)
- Melike N Harfouche
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - David V Feliciano
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Joseph J Dubose
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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22
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Kim KT, Clark J, Ghneim M, Feliciano DV, Diaz JJ, Harfouche M. Not All Fluid Collections Are Created Equal: Clinical Course and Outcomes of Pancreatic Pseudocysts and Acute Peripancreatic Fluid Collections Requiring Intervention. Am Surg 2022:31348221078955. [DOI: 10.1177/00031348221078955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. Methods Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition. Results Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups ( P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups ( P = .04). Conclusion Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.
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Affiliation(s)
- Kevin T Kim
- University of Maryland School of Medicine, Baltimore, ML, USA
| | - Jaclyn Clark
- University of Maryland School of Medicine, Baltimore, ML, USA
| | - Mira Ghneim
- University of Maryland School of Medicine, Baltimore, ML, USA
| | | | - Jose J Diaz
- University of Maryland School of Medicine, Baltimore, ML, USA
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Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Grace F Rozycki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Stonko DP, Betzold RD, Abdou H, Edwards J, Azar FK, Elansary NN, Treffalls RN, Savidge SG, DuBose JJ, Feliciano DV, Morrison JJ. In-hospital outcomes in autogenous vein versus synthetic graft interposition for traumatic arterial injury: A propensity-matched cohort from PROOVIT. J Trauma Acute Care Surg 2022; 92:407-412. [PMID: 34789705 DOI: 10.1097/ta.0000000000003465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention. METHODS The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences. RESULTS Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same. CONCLUSION American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG. LEVEL OF EVIDENCE Prognostic and Epidemiolgic, Level III.
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Affiliation(s)
- David P Stonko
- From the Department of Surgery (D.P.S.), The Johns Hopkins Hospital; Department of Surgery, University of Maryland (D.P.S., R.D.B., H.A., J.E., N.N.E., R.N.T., S.G.S., J.J.D., D.V.F., J.J.M.), R. Adams Cowley Shock Trauma Center, Baltimore, Maryland; and Department of Surgery, St. Mary's Medical Center (F.K.A.), West Palm Beach; Florida Atlantic University (F.K.A.), Boca Raton, Florida; and University of Maryland School of Medicine (S.G.S.), Baltimore, Maryland
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Feliciano DV, Schwaitzberg SD, DuBose JJ. Aortoduodenal fistula after repair of a stab injury to the abdominal aorta. Trauma Surg Acute Care Open 2022; 7:e000882. [PMID: 35128070 PMCID: PMC8785199 DOI: 10.1136/tsaco-2022-000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Joseph J DuBose
- Department of Surgery, Dell Seton Medical Center at The University of Texas, Austin, Texas, USA
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26
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Feliciano DV. Abdominal vascular hemorrhage. Surg Open Sci 2022; 7:52-57. [PMID: 35028551 PMCID: PMC8741595 DOI: 10.1016/j.sopen.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/11/2021] [Indexed: 12/03/2022] Open
Abstract
Major abdominal vascular injuries are noted in 5%–10% of patients undergoing laparotomy for blunt trauma. In contrast, injuries to named abdominal vessels are present in 20%–25% of patients undergoing laparotomy after gunshot wounds and in 10% after stab wounds. Hence, all surgeons performing laparotomies after abdominal trauma must be familiar with techniques for exposure and management of these injuries.
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Affiliation(s)
- David V Feliciano
- University of Maryland School of Medicine, Shock Trauma Center/Department of Surgery, University of Maryland Medical Center, Baltimore, MD
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Affiliation(s)
- Sayuri P Jinadasa
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David V Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ko A, Radding S, Feliciano DV, DuBose JJ, Kozar RA, Morrison J, Kundi R, Maddox J, Scalea TM. Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma. Am Surg 2021; 88:429-433. [PMID: 34732074 DOI: 10.1177/00031348211050591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. METHODS The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). RESULTS From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. CONCLUSION The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be "lost arts" in modern trauma care.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Section of Acute Care Surgery, 10624Stanford University, Stanford, CA, USA
| | - Sydney Radding
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - David V Feliciano
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Joseph J DuBose
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Rosemary A Kozar
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Jonathan Morrison
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Rishi Kundi
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - John Maddox
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
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Stonko DP, Betzold RD, Morrison JJ, Scalea TM, Feliciano DV, DuBose JJ. Contralateral vs Ipsilateral Vein Graft for Traumatic Arterial Injury Repair: A Multicenter Prospective Cohort Study. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roberts DJ, Faris PD, Ball CG, Kirkpatrick AW, Moore EE, Feliciano DV, Rhee P, D'Amours S, Stelfox HT. Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia. World J Emerg Surg 2021; 16:53. [PMID: 34649583 PMCID: PMC8515656 DOI: 10.1186/s13017-021-00396-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year. Conclusions The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00396-7.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Room A-280, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,The Ottawa Hospital Trauma Program, The Ottawa Hospital, Ottawa, ON, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada. .,The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Peter D Faris
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Health Services Statistical and Analytic Methods, Data and Analytics (DIMR), Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Chad G Ball
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Ernest E Moore
- Department of Surgery, School of Medicine and the Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - David V Feliciano
- Department of Surgery and Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Peter Rhee
- Department of Surgery, Westchester Medical Center, Section of Trauma and Acute Care Surgery, New York Medical College, Valhalla, NY, USA
| | - Scott D'Amours
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia.,Acute Care Surgery Unit, Liverpool Hospital, Liverpool, NSW, Australia
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Guntur G, DuBose JJ, Bee TK, Fabian T, Morrison J, Skarupa DJ, Inaba K, Kundi R, Scalea T, Feliciano DV. Contemporary Management of Axillosubclavian Arterial Injuries Using Data from the AAST PROOVIT Registry. JEVTM 2021. [DOI: 10.26676/jevtm.v5i2.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background: Endovascular repair has emerged as a viable repair option for axillosubclavian arterial injuries in select patients; however, further study of contemporary outcomes is warranted.
Methods: The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was used to identify patients with axillo-subclavian arterial injuries from 2013 – 2019. Demographics and outcomes were compared between patients undergoing endovascular repair versus open repair.
Results: 167 patients were identified, with intervention required in 107 (64.1%). Among these, 24 patients underwent open damage control surgery (primary amputation = 3, ligation = 17, temporary vascular shunt = 4). The remaining 83 patients (91.6% male; mean age 26.0 ± 16) underwent either endovascular repair (36, 43.4%) or open repair (47, 56.6%). Patients managed with definitive endovascular or open repair had similar demographics and presentation, with the only exception that endovascular repair was more commonly employed for traumatic pseudoaneurysms (p=0.004). Endovascular repair was associated with lower 24-hour transfusion requirements (p=0.012), but otherwise the two groups were similar with regards to in-hospital outcomes.
Conclusion: Endovascular repair is now employed in > 40% of axillo-subclavian arterial injuries undergoing repair at initial operation and is associated with lower 24 hour transfusion requirements, but otherwise outcomes are comparable to open repair.
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Feliciano DV. Salvage of the injured upper extremity. Trauma Surg Acute Care Open 2021; 6:e000799. [PMID: 34595354 PMCID: PMC8424860 DOI: 10.1136/tsaco-2021-000799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Abstract
ABSTRACT This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed. LEVEL OF EVIDENCE Review article, levels IV and V.
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Affiliation(s)
- David V Feliciano
- From the Department of Surgery (D.V.F.), Shock Trauma Center, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (M.P.K.), University of Florida Health Jacksonville Medical Center, Jacksonville, Florida; and Division of Acute Care Surgery, Department of Surgery (G.F.R.), John Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Stonko DP, Azar FK, Betzold RD, Morrison JJ, Fransman RB, Holcomb J, Bee T, Fabian TC, Skarupa DJ, Stein DM, Kozar RA, O'Connor JV, Scalea TM, DuBose JJ, Feliciano DV. Contemporary Management and Outcomes of Injuries to the Inferior Vena Cava: A Prospective Multicenter Trial From PROspective Observational Vascular Injury Treatment. Am Surg 2021:31348211038556. [PMID: 34384266 DOI: 10.1177/00031348211038556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury. METHODS The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics. RESULTS 140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay. CONCLUSIONS Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.
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Affiliation(s)
- David P Stonko
- Department of Surgery, 588543The Johns Hopkins Hospital, Baltimore, MD, USA.,137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, FL, USA; 1782Florida Atlantic University, Boca Raton, FL, USA
| | - Richard D Betzold
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Ryan B Fransman
- Department of Surgery, 588543The Johns Hopkins Hospital, Baltimore, MD, USA
| | - John Holcomb
- The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tiffany Bee
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Deborah M Stein
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA.,University of California, San Francisco, CA, USA
| | - Rosemary A Kozar
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - James V O'Connor
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Joseph J DuBose
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - David V Feliciano
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
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Moran BJ, Quintana MT, Michael Scalea T, DuBose J, Feliciano DV. Two Urgency Categories, Same Outcome: No Difference After "Therapeutic" vs. "Prophylactic" Fasciotomy. Am Surg 2021:31348211031860. [PMID: 34278829 DOI: 10.1177/00031348211031860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Fasciotomy to treat or prevent compartment syndromes in patients with truncal or peripheral arterial injuries is a valuable adjunct. The objective of this study was to document the current incidence, indications, and outcomes of below knee fasciotomy in patients with femoropopliteal arterial injuries. METHODS The PROspective Observational Vascular Injury Treatment registry of the American Association for the Surgery of Trauma was utilized to identify patients undergoing two-incision four-compartment fasciotomy of the leg after repair of a femoropopliteal arterial injury. Outcomes after therapeutic versus prophylactic (surgeon label) fasciotomy were compared as was the technique of closure, that is, primary skin closure or application of a split-thickness skin graft (STSG). RESULTS From 2013 to 2018, fasciotomy was performed in 158 patients overall, including 95.6% (151/158) at the initial operation. In the group of 139 patients who survived to discharge, fasciotomies were labeled as therapeutic in 58.3% (81/139) and prophylactic in 41.7% (58/139). There were no significant differences between the therapeutic and prophylactic groups in amputation rates (14.8% vs. 8.6%, P = .919). Primary skin closure was achieved at a median of 5.0 days vs. 11.0 days for STSG (P = .001). CONCLUSIONS Over 55% of patients undergoing repair of an injury to a femoral or popliteal artery have a fasciotomy performed at the same operation. A "therapeutic" indication for fasciotomy continues to be more common than "prophylactic," while outcomes are identical in both groups.
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Affiliation(s)
- Benjamin J Moran
- Department of General Surgery, 6566Albert Einstein Medical Center, Philadelphia, PA, USA
| | | | - Thomas Michael Scalea
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Joseph DuBose
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - David V Feliciano
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
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Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Affiliation(s)
- David J Skarupa
- Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Matthew P Kochuba
- Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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Affiliation(s)
- Sayuri P Jinadasa
- Shock Trauma Center / Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Michael R Hall
- Shock Trauma Center / Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - David V Feliciano
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Skarupa DJ, Feliciano DV. Beware the circular saw. Trauma Surg Acute Care Open 2021; 6:e000704. [PMID: 33748429 PMCID: PMC7934763 DOI: 10.1136/tsaco-2021-000704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- David J Skarupa
- Department of Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
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Feliciano DV. Introduction-Literary Festschrift in Honor of J. David Richardson, MD, Former Editor-In-Chief of the American Surgeon. Am Surg 2021; 87:173-174. [PMID: 33517713 DOI: 10.1177/0003134821993159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Harfouche M, Feliciano DV. Intrahepatic vascular trauma. Trauma Surg Acute Care Open 2021; 6:e000675. [PMID: 33521325 PMCID: PMC7817797 DOI: 10.1136/tsaco-2021-000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Melike Harfouche
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David V Feliciano
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ivatury R, Feliciano DV, Herrera-Escobar JP. Damage control surgery: a constant evolution. Colomb Med (Cali) 2020; 51:e1014422. [PMID: 33795895 PMCID: PMC7968432 DOI: 10.25100/cm.v51i4.4422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The story of trauma resuscitation is similar to that of many other advances in medicine: described, forgotten, reinvented, ridiculed, and finally accepted. Even after acceptance, the concepts go through periods of neglect and indifference before they are tried and enhanced, till the next advance.
Damage control, a strategy for management of critically injured or ill patients, is a prime example of this phenomenon. It reminds us of the famous words of Oliver Goldsmith in 1761: “for he who fights and runs away, will live to fight another day, but he who is in battle slain, will never rise and fight again”. Damage control was based on the recognition of the lethal triad of hypothermia, acidosis, and a coagulopathy resulting from massive blood loss, large-volume resuscitation and ischemia-reperfusion. It was an approach that J. Hogarth Pringle from Glasgow, Scotland, suggested in 1908 with his principles of compression and hepatic packing for control of venous hemorrhage from the injured liver: temporary, expeditious and effective. Packing, however, was rarely utilized during World War II and the Vietnam War because of the presumed risk of rebleeding with removal of the packs. The ever-difficult challenge of “non-surgical bleeding” from a coagulopathy due to massive hepatic injuries did, eventually, lead to a resurrection of the concept of perihepatic packing in the 1980s in civilian centers and became one of the initial steps in damage control for patients with severe and/or multiple intra-abdominal injuries.
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Affiliation(s)
- Rao Ivatury
- Virginia Commonwealth University, Department of Surgery, Richmond, VA, USA
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Feliciano DV. A Review of "Changes in the Management of Injuries to the Liver and Spleen" (2005). Am Surg 2020; 87:212-218. [PMID: 33342252 DOI: 10.1177/0003134820979587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: The article "Changes in the Management of Injuries to the Liver and Spleen" was originally presented as the Scudder Oration on Trauma at the American College of Surgeons' (ACS) 90th Annual Clinical Congress in New Orleans, Louisiana, in October 2004. Charles L. Scudder, MD, a founding member of the College, was the originator and first Chairman of the Committee on the Treatment of Fractures from 1922 to 1933. The first "Fracture Oration" of the ACS by Dr Scudder was entitled "Oration on Fractures," was presented at the Clinical Congress in October 1929, and was published in Surg Gynecol Obstet 1930; 50:193-195. Fracture Orations were presented from 1929 to 1941 and 1946 to 1951, while an Oration on Trauma was presented from 1952 to 1962. From 1963 to present, the Scudder Oration on Trauma has been presented at the annual Clinical Congress by an individual with significant contributions to the field.
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Affiliation(s)
- David V Feliciano
- Department of Surgery, 12264University of Maryland School of Medicine, MD, USA
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Feliciano DV. Trauma surgeon as thoracic surgeon. Trauma Surg Acute Care Open 2020; 5:e000658. [PMID: 33376811 PMCID: PMC7745519 DOI: 10.1136/tsaco-2020-000658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- David V Feliciano
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Affiliation(s)
- Kathryn Tchorz
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA
| | - Grace Rozycki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ball CG, Feliciano DV. The Art and Craft of Reoperative Abdominal Surgery after Prior Trauma or Acute Care Surgery Operation. J Am Coll Surg 2020; 231:e1-e6. [DOI: 10.1016/j.jamcollsurg.2020.08.727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/28/2020] [Accepted: 08/04/2020] [Indexed: 12/29/2022]
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Romagnoli AN, Morrison JJ, DuBose JJ, Feliciano DV. Dichotomy in Fasciotomy: Practice Patterns Among Trauma/Acute Care Surgeons With Performing Fasciotomy With Peripheral Arterial Repair. Am Surg 2020; 86:1010-1014. [PMID: 32997952 DOI: 10.1177/0003134820942138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed. METHODS A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution. RESULTS The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair. CONCLUSIONS While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.
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Affiliation(s)
- Anna N Romagnoli
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan J Morrison
- Department of Trauma Surgery and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Joseph J DuBose
- Department of Trauma Surgery and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - David V Feliciano
- Department of Trauma Surgery and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
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Jeremy DuBose J, Azar F, Kundi R, Scalea TM, Kay Bee T, Fabian TC, Feliciano DV. Management and Outcomes of Injuries to the Inferior Vena Cava. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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DuBose JJ, Morrison J, Moore LJ, Cannon JW, Seamon MJ, Inaba K, Fox CJ, Moore EE, Feliciano DV, Scalea T. Does Clamshell Thoracotomy Better Facilitate Thoracic Life-Saving Procedures Without Increased Complication Compared with an Anterolateral Approach to Resuscitative Thoracotomy? Results from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry. J Am Coll Surg 2020; 231:713-719.e1. [PMID: 32947036 DOI: 10.1016/j.jamcollsurg.2020.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/12/2020] [Accepted: 09/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Resuscitative thoracotomy (RT) is life-saving in select patients and can be accomplished through a left anterolateral (AT) or clamshell thoracotomy (CT). CT may provide additional exposure, facilitating certain operative procedures, but the added blood and heat loss and time to perform it may increase complications. No prospective multicenter comparison of techniques has yet been reported. STUDY DESIGN The observational AAST Aortic Occlusion for Resuscitation in Trauma and Acute care surgery (AORTA) registry was used to compare AT and CT in RT. RESULTS AORTA recorded 1,218 RTs at 46 trauma centers from June 2014 to January 2020. Overall survival after RT was 6.0% (AT 6.6%; [59 of 900]; CT 4.2% [13 of 296], p = 0.132). Among all RTs, 11.1% (142 of 1,278) surviving at least 24 hours were used tocompare AT (112) and CT (30). There was no difference between the 2 groups withregard to age, sex, Injury Severity Score, or mechanism of injury (Table 1). CT was significantly more likely to be used in patients needing resection of the lung or cardiac repair. CT was not associated with increased local thoracic/systemic complications, higher transfusion requirement, or greater ventilator, ICU, or hospital days compared with AT. CONCLUSIONS Clamshell thoracotomy facilitates thoracic life-saving procedures withoutincreased systemic or thoracic complications compared with AT in patients undergoing RT.
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Affiliation(s)
- Joseph J DuBose
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| | - Jonathan Morrison
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Laura J Moore
- Department of Surgery, University of Texas Health Sciences Center-Houston, Houston, TX
| | - Jeremy W Cannon
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mark J Seamon
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Kenji Inaba
- Department of Surgery, Los Angeles County + University of Southern California Hospital, Los Angeles, CA
| | - Charles J Fox
- Department of Surgery, Denver Health and Hospital Authority, Denver, CO
| | - Ernest E Moore
- Department of Surgery, Denver Health and Hospital Authority, Denver, CO
| | - David V Feliciano
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Thomas Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
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