Trauma Quality Improvement Program: A Retrospective Analysis from A Middle Eastern National Trauma Center

BACKGROUND

The Trauma Quality Improvement Program (American College of Surgery (ACS-TQIP)) uses the existing infrastructure of the Committee on Trauma programs and provides feedback to participating hospitals on risk-adjusted outcomes. This study aimed to analyze and compare the performance of the Level I Hamad Trauma Centre (HTC) with other TQIP participating centers by comparing TQIP aggregate database reports. The primary goal was to pinpoint the variations in adult trauma outcomes and quality measures, identify areas that need improvement, and leverage existing resources to facilitate quality improvement.

METHODS

A retrospective analysis was performed for the TQIP data from April 2019-March 2020 to April 2020-March 2021. We used the TQIP methodology, inclusion and exclusion criteria, and outcomes.

RESULTS

There were 915 patients from Fall 2020 and 884 patients from Fall 2021 that qualified for the TQIP database. The HTC patients' demographics differed from the TQIP's aggregate data; they were younger, more predominantly male, and had significantly different mechanisms of injury (MOI) with more traffic-related blunt trauma. Penetrating injuries were more severe in the other centers. During the TQIP Fall 2020 report, the HTC was a low outlier (good performer) in one cohort (all patients) and an average performer in the remaining cohorts. However, during Fall 2021, the HTC showed an improvement and was a low outlier in two cohorts (all patients and severe TBI patients). Overall, the HTC remained an average performer during the report cycles.

CONCLUSIONS

There was an improvement over time in the risk-adjusted mortality, which reflects the continuous and demanding effort put together by the trauma team. The ACS-TQIP for the external benchmarking of quality improvement could be a contributor to better monitored patient care. Evaluating the TQIP data with emphases on appropriate methodologies, quality measurements, corrective measures, and accurate reporting is warranted.

Traumatic lung laceration secondary to avulsed lung adhesion - A case report

Background

Pulmonary lacerations caused by an avulsion force on an adhesion between the lung and chest wall following blunt thoracic injury are very rare. They may result in pneumothorax and/or hemothorax and may not be immediately apparent clinically or radiologically.

Case presentation

We present the case of a healthy 34-year-old male who sustained blunt thoracic injury. He was clinically stable, and his initial routine images were unremarkable. The patient was discharged home on the same day. He presented a week later with a massive hemothorax requiring surgical intervention which revealed bleeding from an avulsed adhesion between the lung and chest wall. Bleeding was successfully controlled by hemostatic agent, and the patient had an uneventful recovery.

Conclusion

Hemothorax requiring intervention from an avulsed adhesion may occur following blunt thoracic trauma. Initial imaging and clinical finding may be misleading. Close follow up and adequate patient education should be ensured prior to discharge following seemingly trivial trauma.

Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma

INTRODUCTION

Shock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT.

METHODS

We conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality.

RESULTS

A total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = -0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = -0.377), Trauma and Injury Severity Score (r = -0.144), Revised Trauma Score (r = -0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02).

CONCLUSIONS

The present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.

Beta blocker use in traumatic brain injury based on the high-sensitive troponin status (BBTBBT): methodology and protocol implementation of a double-blind randomized controlled clinical trial

Background

Beta-adrenergic receptor blockers (BB) play an important role in the protection of organs that are susceptible for secondary injury due to stress-induced adrenergic surge. However, the use of BB in traumatic brain injury (TBI) patients is not yet the standard of care which necessitates clear scientific evidence to be used. The BBTBBT study aims to determine whether early administration of propranolol based on the high-sensitive troponin T(HsTnT) status will improve the outcome of TBI patients. We hypothesized that early propranolol use is effective in reducing 10- and 30-day mortality in TBI patients. Secondary outcomes will include correlation between serum biomarkers (troponin, epinephrine, cytokines, enolase, S100 calcium binding protein B) and the severity of injury and the impact of BB use on the duration of hospital stay and functional status at a 3-month period.

Methods

The BBTBBT study is a prospective, randomized, double-blinded, placebo-controlled three-arm trial of BB use in mild-to-severe TBI patients based on the HsTnT status. All enrolled patients will be tested for HsTnT at the first 4 and 6 h post-injury. Patients with positive HsTnT will receive BB if there is no contraindication (group 1). Patients with negative HsTnT will be randomized to receive either propranolol (group 2) or placebo (group 3). The time widow for receiving the study treatment is the first 24 h post-injury.

Discussion

Early BB use may reduce the catecholamine storm and subsequently the cascade of immune and inflammatory changes associated with TBI. HsTnT could be a useful fast diagnostic and prognostic tool in TBI patients. This study will be of great clinical interest to improve survival and functional outcomes of TBI patients.

Trial registration

ClinicalTrials.gov NCT04508244. Registered on 7 August 2020. Recruitment started on 29 December 2020 and is ongoing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05872-8.

Utility of extracorporeal membrane oxygenation (ECMO) in the management of traumatic tracheobronchial injuries: case series

Tracheobronchial injury is a rare, but potentially life-threatening condition, and in most cases requires urgent treatment to restore normal respiratory physiology. Over the past decades, extracorporeal membrane oxygenation (ECMO) has evolved as an important adjunct in airway surgery. We presented three cases of traumatic tracheobronchial injury managed with ECMO support at a level-1 trauma center and emphasized the benefits of anticipation and early institution of ECMO support perioperatively, in these high-risk cases. The management of traumatic tracheobronchial injuries requires early measures to guarantee adequate ventilation. Anticipation and early institution of ECMO in these patients may support respiratory physiology, facilitate repair and improve survival. The time factor and multidisciplinary communication and plan prior to intervention should be considered. ECMO support, whenever available, plays important role in the management of complicated tracheobronchial surgical procedure and thereby reduces risk of mortality.

Trauma intensive care unit (TICU) at Hamad General Hospital

Trauma is a leading cause of mortality and morbidity worldwide, and thus represents a great global health challenge. The World Health Organization (WHO) estimated that 9% of deaths in the world are the result of trauma.1 In addition, approximately 100 million people are temporarily or permanently disabled every year.2 The situation is no different in Qatar, and injury related morbidity and mortality is increasing in the entire region, with road traffic collisions (RTCs) being the most common mechanism.1 It is well recognized now that trauma care provided in high-volume, dedicated, level-one trauma centers, improves outcome. Studies have also looked at what are the components of a trauma system that contribute to their effectiveness2. However, in general, it usually implies a high-volume of cases, dedicated full-time trauma qualified professionals, a solid pre-hospital system, a multidisciplinary team, and excellent rehabilitation services. Similarly, critically injured trauma patients managed in a dedicated trauma intensive care unit (TICU), has been shown to improve outcomes, especially for polytrauma patients with traumatic brain injury (TBI).3 In fact, the American College of Surgeons (ACS) Committee on Trauma requires verified trauma centers to have a designated ICU, and that a trauma surgeon be its director.4 Furthermore, studies have shown that for TBI, it is not necessary for this ICU to be a neurocritical care unit, but rather it should be a unit that is dedicated to trauma, that has standardized protocols for TBI management.5,6 In fact, the outcomes are better in the latter, with lower mortality in multiple-injured patients with TBI, when admitted to a TICU (versus a medical-surgical ICU or neurocritical care unit).3 These benefits were shown to increase, with increased injury severity. The proposed reason for this is thought to be due to the associated injuries being managed better.7 The aim of this editorial is to describe the TICU at Hamad General Hospital (HGH), at Hamad Medical Corporation (HMC), including a comparison of its data and outcomes with other similar trauma centers in the world. The Qatar Trauma Registry, as well as previous publications from our Trauma Center,1,8 were used to obtain HGH TICU and worldwide Level-1 Trauma Center standards, respectively. With respect to HGH, the TICU is part of an integrated trauma program, the only level-1 trauma centre in Qatar. It provides the highest standard of care for critically-ill trauma patients admitted at HGH, striving to achieve the best outcomes, excellence in evidence-based patient care, up to date technology, and a high level of academics in research and teaching. This integrated program includes an excellent pre-hospital unit, emergency and trauma resuscitation unit, TICU, trauma step-down unit (TSDU), inpatient ward, and rehabilitation unit. The new TICU is a closed 19-bed unit, that was inaugurated in 2016, is managed 24/7 by highly qualified and experienced intensivists (9 senior consultants and consultants), along with 24 well-trained and experienced associate consultants or specialists, and fellows and residents in training, as well as expert nursing staff (1:1 nurse to patient ratio) and allied health professionals (respiratory therapists, pharmacists, dieticians, physiotherapists, occupational therapists, social workers, case managers, and psychologists). It is supported by all medical and surgical subspecialty services. It is equipped with the latest state-of-the-art technology and equipment, including 'intelligent ventilators", neuro-monitoring devices, ultrasound, point-of-care testing such as arterial blood gas and rotational thromboelastrometry (ROTEM), and video airway devices. The TICU is a teaching unit, linked to the HMC Medical Education department, with presence of fellows, and residents (see below for details). Medical students (Clerkship level) from Weill-Cornell Medicine Qatar also complete a one-week rotation in the TICU, as part of their exposure to critical care. The first batch of clerks from Qatar University College of Medicine are expected to start rotating in the TICU soon. The Trauma Critical Care Fellowship Program (TCCFP) is an ACGME (Accreditation Council for Graduate Medical Education) fellowship that was established over seven years ago. To date, over 40 physicians from both within, and out of, the trauma department have completed the program. Up to seven fellows, including international candidates, are trained each year. A number of physicians have succeeded in gaining the European Diploma of Intensive Care Medicine (EDIC). The program continues to attract many applicants from various specialties including surgery, anesthesia, and emergency medicine. An increasing number of international physicians from Europe and South America have expressed interest in applying for our fellowship. The first international fellows are likely to join us from early 2020. Residents (from general surgery, ER, ENT, plastics, orthopedics, and neurosurgery) rotate (one to three months' rotations) in the TICU, and are actively part of the clinical team. There were 568 admissions to the TICU in 2018. The patients admitted were either mainly polytrauma patients with varying degrees and combinations of head, chest, abdominal, pelvic, spine, and orthopedic injuries, or isolated-TBI. Of these patients, 378 were severely injured with an injury severity score (ISS)9 greater than 16. According to previously published data from our Trauma Centre,1,8 our mortality rates (overall approximately 6-7%, as well as when looked at in terms of early and late deaths) compare favorably with other trauma centers around the world, when looking at similarly sized retrospective studies. The TICU continues to be an active member of the Critical Care Network of HMC.10 This network involves all of the ICU's in all the HMC facilities. The main processes that the TICU is presently involved in as part of this network are: patient flow, clinical practice guidelines, evaluation and procurement of technologies, HMC sepsis program, and in general, taking part in any process that pertains to critical care at HMC. A number of quality improvement projects are being undertaken in the TICU. Examples of such projects include: - Decreasing rates of infection in TICU- Score-guided sedation orders to decrease sedation use, ventilator days and length of stay- Reducing blood taking and associated costs- Sepsis alert response and bundle compliance- Medical and surgical management of rib fracturesA multidisciplinary team of physicians, nurses, and allied health professionals participate in these projects, and meet once a month to review all projects. Similarly, many research projects are taking place in the TICU, in coordination with the Trauma Research program, and often in collaboration with other departments (local and international). Examples of some of the research projects include: - The "POLAR" study (RCT on Hypothermia in TBI)11- B-blockers in TBI (RCT-ongoing)- Tranexamic acid (TXA) for bleeding in trauma (RCT-ongoing) The team is also involved in conducting systematic reviews in relation to the role of transcranial doppler in TBI,12 sepsis in TBI patients (ongoing), self-extubation in TBI patients,13 safety and efficacy of phenytoin in TBI (ongoing), and optic nerve diameter for predicting outcome in TBI (submitted). The TICU at HGH is a high-volume, high acuity unit that manages all the severely injured trauma patients in Qatar. It is well staffed with highly trained and qualified personnel, and utilizes the latest in technology and state-of-the-art equipment. It performs very well, when compared to other similar units in the world, and achieves a comparable, or even lower mortality rate. With continued great support from the hospital, corporation administration, and Ministry of Public Health, the future goals of the TICU will be to maintain and improve upon the high standards of clinical care it provides, as well as perform a high quality and quantity of research, quality improvement initiatives, and educational work, in order for it to be amongst the best trauma critical care units in the world.

Pancreaticoatmospheric fistula following severe acute necrotising pancreatitis

Severe acute necrotising pancreatitis is associated with numerous local and systemic complications. Abdominal compartment syndrome requiring urgent decompressive laparotomy is a potential complication of this disease process and is associated with increased morbidity and mortality. We describe the case of a pancreaticoatmospheric fistula following decompressive laparotomy in a patient with severe acute necrotising pancreatitis. While this fistula was managed successfully using the current standard of care for pancreatic fistulas, the wound care for in this patient with drainage of the fistula through an open abdomen, is a significant challenge.

A descriptive study of bicycle helmet use in Montreal, 2011

OBJECTIVE

The purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming.

METHODS

Using a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1-3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated.

RESULTS

A total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47-52 vs. 44%, 95% CI 42-45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52).

CONCLUSIONS

Although above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.

Successful Resection of a Large Incidentally Found Primary Mediastinal Liposarcoma

Primary liposarcoma of the mediastinum is an uncommon tumour. We report a case of a 45-year-old female who was found incidentally to have a large anterior mediastinal mass. Complete removal of the tumour was accomplished successfully. Appropriate immunohistochimical stains were performed, confirming the presence of a well-differentiated liposarcoma of the mediastinum. We describe an unusual case of a large asymptomatic primary liposarcoma of the mediastinum.

Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases

BACKGROUND

Blunt diaphragmatic rupture (BDR) is a rare event and represents a diagnostic challenge. The purpose of our study was to review our experience with BDR at the Sunnybrook Health Sciences Centre (Sunnybrook), the largest trauma centre in Canada, and to highlight recent changes in the diagnosis and management of the condition.

METHODS

We retrospectively reviewed the cases of patients with BDR who were admitted to Sunnybrook between January 1986 and December 2003 using our trauma registry. We performed Student t and Fisher exact tests to compare our findings on patients with BDR with those on the entire cohort of blunt trauma patients admitted to our centre.

RESULTS

Most patients with BDR were men (64.4%) with a mean age of 42 years. Left-sided tears were most common (65.0%). Patients with BDR had a very high Injury Severity Score (38) and very high mortality (28.8%). Of those who were injured as a result of motor vehicle collisions (MVCs), a significantly greater percentage of patients in the BDR group than in the entire cohort of blunt trauma patients were drivers or front-seat passengers. Patients with BDR were also significantly less likely to be pedestrians, to have experienced a fall or to be involved in a motorcycle collision. Patients with BDR had a higher chest, abdomen, pelvis and extremity Abbreviated Injury Scale score than all blunt trauma patients in general. Most of our patients underwent laparotomy (93.3%). The most common causes of death among patients with BDR were head injury (25.0%), intra-abdominal bleeding (23.3%) and pelvic hemorrhage (18.3%).

CONCLUSION

Blunt diaphragmatic rupture is rare and difficult to diagnose; however, certain MVC characteristics along with severe associated injuries should raise the index of suspicion. These associated injuries include injuries to the head, chest (including the aorta), abdomen and pelvis. Computed tomographic angiography is essential to rule out associated aortic injury and to increase the diagnostic accuracy of BDR.

Association Between Alcohol and Mortality in Patients With Severe Traumatic Head Injury

HYPOTHESIS

Admission blood alcohol concentration (BAC) is associated with in-hospital death in patients with severe brain injury from blunt head trauma.

DESIGN

Retrospective cohort study.

SETTING

Academic level I trauma center in Toronto, Ontario.

PATIENTS

Using trauma registry data, between January 1, 1988, and December 31, 2003, we identified 1158 consecutive patients with severe brain injury from blunt head trauma.

INTERVENTION

There was no active intervention. The primary exposure of interest was the BAC at admission, stratified into the following 3 levels: 0, no BAC; 0 to less than 230 mg/dL, low to moderate BAC; and 230 mg/dL or greater, high BAC.

MAIN OUTCOME MEASURE

In-hospital death.

RESULTS

In patients with severe brain injury, low to moderate BAC was associated with lower mortality than was no BAC (27.9% vs 36.3%; P = .008). High BAC was associated with higher mortality than was no BAC (44.7% vs 36.3%), although this was not statistically significant (P = .10). These associations were all statistically significant after adjusting for demographic data and injury factors using logistic regression analysis. The odds ratio for death was 0.76 (95% confidence interval, 0.52-0.98) for low to moderate BAC compared with no BAC. The odds ratio for death was 1.73 (95% confidence interval, 1.05-2.84) for high BAC compared with no BAC.

CONCLUSIONS

Low to moderate BAC may be beneficial in patients with severe brain injury from blunt head trauma. In contrast, high BAC seems to have a deleterious effect on in-hospital death in these patients, which may be related to its detrimental hemodynamic and physiologic effects. Alcohol-based fluids may have a role in the management of patients with severe brain injury after they have been well resuscitated.

Evaluation of Bowel and Mesenteric Blunt Trauma with Multidetector CT

Bowel and mesenteric injuries are detected in 5% of blunt abdominal trauma patients at laparotomy. Computed tomography (CT) has been shown to be accurate for the diagnosis of bowel and mesenteric injuries and is the diagnostic test of choice in the evaluation of blunt abdominal trauma in hemodynamically stable patients. Specific CT findings of bowel and mesenteric injuries include bowel wall defect, intraperitoneal and mesenteric air, intraperitoneal extraluminal contrast material, extravasation of contrast material from mesenteric vessels, and evidence of bowel infarct. Specific signs of mesenteric injury are vascular beading and abrupt termination of mesenteric vessels. Less specific signs of bowel and mesenteric injuries include focal bowel wall thickening, mesenteric fat stranding with focal fluid and hematoma, and intraperitoneal or retroperitoneal fluid. When only nonspecific signs of bowel and mesenteric injuries are seen on CT images, correlation of CT features with clinical findings is necessary. A repeat CT examination after 6-8 hours if the patient's condition is stable may help determine the significance of these nonspecific findings.

Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?

BACKGROUND

Low Glasgow Coma Scale score (GCS) and pupillary status predict poor outcomes in head injury (HI) patients. We compared the mortality of GCS 3 patients having bilateral fixed and dilated pupils (BFDP) with GCS 3 patients having reactive pupils (RP). We then determined if trauma system or patient factors were responsible for the difference in mortality.

METHODS

We reviewed all adult, blunt HI patients with GCS=3, admitted to our institution from January 1, 2001 to December 31, 2003. Demographics, injury data, prehospital times, procedures, and outcomes were recorded.

RESULTS

During this period, 245 patients were admitted with GCS of 3, and met inclusion criteria. In all, 173 patients were analyzed, after excluding 23 patients who were dead-on-arrival, and 45 others, who were intoxicated with alcohol, or received paralytic agents in the trauma room. All BFDP patients died, whereas 42.0% of reactive pupil (RP) patients died (p < 0.0001). With regards to patient factors, BFDP patients were more likely to be unstable, have extra-axial bleeding, and evidence of midline shift and/or herniation. Trauma system factors, however, may also have had an impact on outcome. Despite having more extra-axial bleeding, BFDP patients were less likely to have a neurosurgical operation than RP patients.

CONCLUSION

Patients with GCS of 3 and BFDP have a dismal prognosis. These patients have suffered devastating brain injuries and tend to be hemodynamically unstable. Clinicians, however, are less likely to aggressively treat BFDP patients than RP patients. Further prospective studies are required to determine which patients with GCS of 3 and BFDP are likely to benefit from aggressive treatment.

The emerging role of recombinant activated Factor VII (rFVIIa) in the treatment of blunt traumatic haemorrhage

Recombinant activated Factor VII (rFVIIa; eptacog alpha [activated], NovoSeven) is currently used for the management of a subgroup of haemophilia patients with inhibitors to Factors VIII or IX, and is under investigation as an adjuvant therapy for critical bleeding from other causes, including trauma. rFVIIa has a mode of action founded on physiological coagulation processes, and causes localised haemostasis at injury sites, both spontaneous and traumatic, with the capacity to correct the systemic coagulopathy associated with massive blood loss and its management. This review charts the development of rFVIIa as a new and potent adjuvant therapy for severe bleeding and coagulopathy caused by blunt trauma, where it is reported to produce rapid and significant haemostasis, reducing transfusion requirements and improving clinical outcome.

Primary cardiac tumours: eighteen years of surgical experience on 21 patients

BACKGROUND

The literature on primary cardiac tumours is relatively limited because of their rare occurrence.

OBJECTIVE

To report the authors' experience with primary cardiac tumours at McGill University teaching hospitals, Montreal, Quebec. In addition, four exceedingly rare primary cardiac tumours are presented--three valve myxomas and the seventh reported case of a primary synovial sarcoma.

METHODS

Twenty-one patients resected for primary cardiac tumours were retrospectively reviewed in terms of their clinical presentation, surgical treatment, histopathological findings and outcome. Postoperative success was defined by disease-free survival after resection. A survival analysis was performed using the Kaplan-Meier life-table method.

RESULTS

The mean age at the time of resection was 45.5 years (range birth to 74 years). The most common clinical presentation in adults was dyspnea (38%) or central nervous system/embolic phenomena (24%), and in the pediatric group, it was hypoxia (50%). All but one of the tumours were visualized using transthoracic echocardiography. Coronary angiography was performed in 11 patients, with a diagnosis of coronary artery disease in five patients (45%), all of whom underwent coronary artery bypass grafting. The surgical approach was uniatrial in 10 patients (48%)--seven (33%) via the left atrium and three (14%) via the right atrium. Eight patients (38%) required a biatrial approach; the remaining three patients (14%) with ventricular tumours required a ventricular approach. Of the 21 cases, 17 were adults and four were pediatric cases. There were 16 myxomas (76%), two rhabdomyomas (10%), one fibroma (5%), one angiosarcoma (5%) and one synovial sarcoma (5%). In adults, myxoma was the most common primary cardiac tumour (88%), whereas rhabdomyoma occurred most frequently in the pediatric population (50%). Three valve myxomas, two involving the mitral valve and one involving the tricuspid valve, were encountered; all underwent conservative leaflet resection and valve repair. The probability of disease-free survival for all patients was 80.7% (95% CI 63.6 to 97.7) at one year, and 75.6% (95% CI 57.0 to 94.3) at both five and 10 years after resection. For adult benign tumours, the probability of disease-free survival was 93% (95% CI 79.4 to 100.0) at one, five and 10 years. There was a total of five deaths.

CONCLUSIONS

The results suggest that complete surgical resection of primary cardiac tumours prolongs symptom-free survival and is associated with a low recurrence rate. Benign primary cardiac tumours have an excellent prognosis in the adult population compared with in the pediatric population (93% versus 50% survival, respectively, in the present cohort). Furthermore, conservative leaflet resection with valve repair of valve myxomas, rather than radical excision and valve replacement, should be strongly considered. Early identification and diagnosis of primary cardiac tumours are necessary for expeditious surgical resection if a cure is desired, especially when encountering malignant primary cardiac sarcomas.

Long-term effects of myotomy and partial fundoplication for esophageal achalasia

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.

Clips versus suture technique: is there a difference?

INTRODUCTION

Coronary artery bypass grafting (CABG) is one of the most common procedures performed today, and wound complications are a major source of morbidity and cost.

OBJECTIVE

To determine whether there is any difference in wound outcome (including cost in a Canadian context) between a subcuticular suture technique and skin stapling technique for closure of sternal and leg incisions in CABG patients.

PATIENTS AND METHODS

One hundred and sixty-two patients undergoing CABG were prospectively, randomly placed to have their sternal and leg incisions closed with either a subcuticular suture technique or with a skin clip. Data were obtained through chart review, in-hospital assessments and follow-up visits. Nonblinded assessments were made regarding wound leakage, inflammation, infection, necrosis, swelling, dehiscence and cosmesis. Each of the parameters was graded on a scale from 1 to 4. The cost was evaluated in Canadian dollars.

RESULTS

There were trends toward increased rates of in-hospital sternal (P=0.09) and leg (P=0.17) incision inflammation when the wounds were closed with skin clips. There was a significantly greater (P=0.05) rate of sternal wound infection with clips, as well as a tendency (P=0.15) toward a greater rate of mediastinitis at follow-up assessment. Cosmetic outcome was similar for both groups. The cost incurred was significantly greater when skin clips were used for closure. There was a greater than threefold difference, which translates to a greater than $10,000 difference over one year.

CONCLUSIONS

Closure with a subcuticular technique achieves better outcomes than the use of skin clips. When factoring in the increased cost incurred by using clips, as well as other intangible factors such as surgical skill acquisition, subcuticular suture closure appears to be a favourable method of wound closure in CABG patients compared with the use of skin stapling techniques.