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Ambrose M, Schulman JE, Kuenze C, Hymes RA, Holzman M, Malekzadeh AS, Ray-Zack M, Gaski GE. Early Acetabular Fracture Repair Through an Anterior Approach Is Associated With Increased Blood Loss. J Orthop Trauma 2024; 38:e126-e132. [PMID: 38206759 DOI: 10.1097/bot.0000000000002769] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVES To determine whether the timing of acetabular fracture fixation through an anterior approach influences estimated and calculated perioperative blood loss. METHODS DESIGN Retrospective cohort study. SETTING Level 1 trauma center from 2013 to 2021. PATIENT SELECTION CRITERIA Patients aged ≥18 years treated with acetabular fracture fixation through an anterior-based approach. OUTCOME MEASURES AND COMPARISONS The primary outcome was calculated blood loss (CBL). Secondary outcomes were estimated blood loss reported by surgeon and anesthesia, and blood transfusion requirements. Comparisons of blood loss were made at discrete postinjury time thresholds (24, 36, and 48 hours) and on a continuous basis. RESULTS One hundred eight patients were studied. The mean age was 65 years, and 73% of patients were male. Earlier fixation of acetabular fractures resulted in greater CBL and estimated blood loss (surgeon and anesthesia) compared with later fixation when analyzed on a continuum and at specific time points (24, 36, and 48 hours). Mean CBL in patients treated earlier (<48 hours, 2539 ± 1194 mL) was significantly greater than those treated later (≥48 hours, 1625 ± 909 mL; P < 0.001). Fracture repair before 48 hours postinjury was associated with a 3 times greater risk of >2000 mL of CBL ( P = 0.006). This did not result in differences in transfusion rates between groups at 24 hours ( P = 0.518), 36 hours ( P = 1.000), or 48 hours ( P = 0.779). CONCLUSIONS Delaying fixation of acetabular fractures treated through an anterior approach for 48 hours postinjury may significantly reduce perioperative blood loss. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael Ambrose
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
- University of Virginia School of Medicine, Charlottesville, VA; and
| | - Jeff E Schulman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Robert A Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Michael Holzman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - A Stephen Malekzadeh
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Mohamed Ray-Zack
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Greg E Gaski
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
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Qian S, Vasileiou G, Pust GD, Zakrison T, Rattan R, Zielinski M, Ray-Zack M, Zeeshan M, Namias N, Yeh DD. Prophylactic Drainage after Appendectomy for Perforated Appendicitis in Adults: A Post Hoc Analysis of an EAST Multi-Center Study. Surg Infect (Larchmt) 2021; 22:780-786. [PMID: 33877912 DOI: 10.1089/sur.2019.258] [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: 12/28/2022] Open
Abstract
Background: We sought to assess the efficacy of prophylactic abdominal drainage to prevent complications after appendectomy for perforated appendicitis. Methods: In this post hoc analysis of a prospective multi-center study of appendicitis in adults (≥ 18 years), we included patients with perforated appendicitis diagnosed intra-operatively. The 634 subjects were divided into groups on the basis of receipt of prophylactic drains. The demographics and outcomes analyzed were surgical site infection (SSI), intra-abdominal abscess (IAA), Clavien-Dindo complications, secondary interventions, and hospital length of stay (LOS). Multivariable logistic regression for the cumulative 30-day incidence of IAA was performed controlling for age, Charlson Comorbidity Index (CCI), antibiotic duration, presence of drains, and Operative American Association for the Surgery of Trauma (AAST) Grade. Results: In comparing the Drain (n = 159) versus No-Drain (n = 475) groups, there was no difference in the frequency of male gender (61% versus 55%; p = 0.168), weight (87.9 ± 27.9 versus 83.8 ± 23.4 kg; p = 0.071), Alvarado score (7 [6-8] versus 7 [6-8]; p = 0.591), white blood cell (WBC) count (14.8 ± 4.8 versus 14.9 ± 4.5; p = 0.867), or CCI (1 [0-3] versus 1 [0-2]; p = 0.113). The Drain group was significantly older (51 ± 16 versus 48 ± 17 years; p = 0.017). Drain use increased as AAST EGS Appendicitis Operative Severity Grade increased: Grade 3 (62/311; 20%), Grade 4 (46/168; 27%), and Grade 5 (51/155; 33%); p = 0.007. For index hospitalization, the Drain group had a higher complication rate (43% versus 28%; p = 0.001) and longer LOS (4 [3-7] versus 3 [1-5] days; p < 0.001). We could not detect a difference between the groups in the incidence of SSI, IAA, or secondary interventions. There was no difference in 30-day emergency department visits, re-admissions, or secondary interventions. Multi-variable logistic regression showed that only AAST Grade (odds ratio 2.7; 95% confidence interval7 1.5-4.7; p = 0.001) was predictive of the cumulative 30-day incidence of IAA. Conclusions: Prophylactic drainage after appendectomy for perforated appendicitis in adults is not associated with fewer intra-abdominal abscesses but is associated with longer hospital LOS. Increasing AAST EGS Appendicitis Operative Grade is a strong predictor of intra-abdominal abscess.
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Affiliation(s)
- Sinong Qian
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Georgia Vasileiou
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Gerd Daniel Pust
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Tanya Zakrison
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Rishi Rattan
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | | | - Mohamed Ray-Zack
- Department if Surgery, University of Arizona College of Medicine, Tucson, Arizona USA
| | - Muhammad Zeeshan
- New York Medical College-Westchester Medical Center, Valhalla, New York, USA
| | - Nicholas Namias
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - D Dante Yeh
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
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Alnachoukati O, Ray-Zack M, Godin S, Apodaca T, Zielinski M, Dunn J. Optimal Timing of First Abdominal Radiography after Gastrografin Administration for Small Bowel Obstruction. J Surg Res 2020; 256:193-197. [PMID: 32711175 DOI: 10.1016/j.jss.2020.06.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/05/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Water-soluble contrast agent (WSCA) administration is commonly used to evaluate adhesive small bowel obstruction (SBO) either via a challenge or follow-through study. This analysis aimed to determine optimal timing to first abdominal radiograph after WSCA administration. MATERIALS AND METHODS A post hoc review of the Eastern Association for the Surgery of Trauma SBO database was used to compare data from two institutions using different methodologies, either the small bowel follow through method or the challenge method, from March 2015-January 2018. The primary outcome was timing of contrast into the colon. Outcomes were also analyzed. A multivariate regression analysis controlled for age, sex, body mass index, previous SBO admissions, and abdominal surgeries. RESULTS A total of 236 patients met inclusion and exclusion criteria (A, 119; B, 117). There were minor demographic differences between cohorts and no significant differences between institutions regarding the confirmed presence of WSCA in the colon, rates of operative intervention, length of operation, hospital length of stay, or 30-d readmission rates.Institution A, where the challenge method was practiced, had 95 (80%) patients with contrast to colon overall; four of 95 (4%) patients had confirmed contrast to colon at or before 7 h, and 89 of 95 (94%) patients had confirmed contrast to colon between 7.1 and 10 h. Institution B, where the small bowel follow through method was practiced, had 94 (80%) patients with contrast to colon overall; 73 of 94 (78%) patients had confirmed contrast to colon at or before 7 h, and 15 of 94 (16%) patients had confirmed contrast to colon between 7.1 and 10 h. CONCLUSIONS Either method is effective for evaluation of SBO. Adding a radiograph at 4 h is feasible, could promote earlier disposition, be conducted as part of an emergency department protocol, and possibly allow for the selection of patients who are candidates for outpatient treatment.
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Affiliation(s)
- Omar Alnachoukati
- Trauma and Acute Care Surgery, University of Colorado Health Medical Center of the Rockies, Loveland, Colorado
| | | | - Sam Godin
- Trauma and Acute Care Surgery, University of Colorado Health Medical Center of the Rockies, Loveland, Colorado
| | - Taylor Apodaca
- Trauma and Acute Care Surgery, University of Colorado Health Medical Center of the Rockies, Loveland, Colorado
| | | | - Julie Dunn
- Trauma and Acute Care Surgery, University of Colorado Health Medical Center of the Rockies, Loveland, Colorado.
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Younis M, Ray-Zack M, Haddad NN, Choudhry A, Hernandez MC, Wise K, Zielinski MD. Prothrombin Complex Concentrate Reversal of Coagulopathy in Emergency General Surgery Patients. World J Surg 2018; 42:2383-2391. [PMID: 29392436 DOI: 10.1007/s00268-018-4520-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone. METHODS Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed. RESULTS Coagulopathic EGS patients (n = 183) received the following blood products: PCC (n = 20, 11%), FFP alone (n = 119, 65%) and PCC/FFP (n = 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4-6), FFP = 5(4-7), PCC/FFP = 5(4-6), p = 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684, p = .09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h, p = 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0, p = 0.03). The incidence of thromboembolic complications was similar in all three groups. CONCLUSIONS PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone. LEVEL OF EVIDENCE IV single institutional retrospective review.
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Affiliation(s)
- Moustafa Younis
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA
| | - Mohamed Ray-Zack
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA
| | - Nadeem N Haddad
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA
| | - Asad Choudhry
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA
| | - Matthew C Hernandez
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA
| | - Kevin Wise
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA.
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Younis M, Hernandez M, Ray-Zack M, Haddad NN, Choudhry A, Reddy P, Zielinski MD. Validation of AAST EGS Grade for Acute Pancreatitis. J Gastrointest Surg 2018; 22:430-437. [PMID: 29340918 DOI: 10.1007/s11605-017-3662-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods. METHODS Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems. RESULTS There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay. CONCLUSIONS The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system. LEVEL OF EVIDENCE IV Study Type: Single institutional retrospective review.
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Affiliation(s)
- Moustafa Younis
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Matthew Hernandez
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Mohamed Ray-Zack
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Nadeem N Haddad
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Asad Choudhry
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Pooja Reddy
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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