Outcomes for sigmoid volvulus managed with and without early definitive surgery: 20-year experience in a tertiary referral centre

BACKGROUND

Sigmoid volvulus is rare in Western countries. Patients at risk of sigmoid volvulus are often older with significant co-morbidity. Without sigmoid colectomy there is a high recurrence rate, but indications for surgery are controversial.

METHODS

A retrospective observational study was conducted by reviewing clinical records of patients admitted to Waikato Hospital 1 January 2000 to 1 January 2020 with a diagnosis of sigmoid volvulus. Patient characteristics, clinical features, investigations, management, and outcomes were recorded.

RESULTS

One hundred and thirty-two patients (87 male) were included with 203 volvulus episodes. Median age 76 years, median Charlson co-morbidity index (CCI) 4. Median follow-up 11 years. 44/132 (33.3%) had surgery during the index admission, two had elective surgery and the remainder had planned non-operative management. 73/132 (55.3%) had surgery at any stage. 42/86 (48.8%) patients managed non-operatively recurred; 66.7% of recurrences were within 6 months. Forty-three (32.6%) died within 12 months of index admission; 28 (21.2%) died during an admission for volvulus. On univariate analysis higher age and abnormal vital signs were associated with inpatient and 12-month mortality; higher CCI was associated with 12-month mortality. On multi-variate analysis increasing age in years was associated with increased risk of death (HR 1.089 [1.052-1.128, P < 0.001]). Normal vital signs at presentation were associated with decreased risk of death (HR 0.147 [0.065-0.334, P < 0.001]).

CONCLUSION

Sigmoid colectomy should be considered at index presentation with sigmoid volvulus. Half of patients managed non-operatively recurred, with two-thirds recurring within 6 months. The mortality rate remains high for subsequent volvulus episodes.

The "weekend effect" does not impact on outcome of trauma laparotomy - Experience from a level 1 trauma centre in New Zealand

PURPOSE

Trauma centres have been proven to provide better outcomes in developed countries for overall trauma, but there is limited literature on the systematic factors that describe any discrepancies in outcomes for trauma laparotomies in these centres. This study was conducted to examine and interrogate the effect of systematic factors on patients undergoing a trauma laparotomy in a developed country, intending to identify potential discrepancies in the outcome.

METHODS

This was a retrospective study of all laparotomies performed for trauma at a level 1 trauma centre in New Zealand. All adult patients who had undergone an index laparotomy for trauma between February 2012 and November 2020 were identified and laparotomies for both blunt and penetrating trauma were included. Repeat laparotomies and trauma laparotomies in children were excluded. The primary clinical outcomes reviewed included morbidity, length of hospital stay, and mortality. All statistical analysis was performed using R v.4.0.3.

RESULTS

During the 9-year study period, 204 trauma laparotomies were performed at Waikato hospital. The majority (83.3%) were performed during office hours (170/204), and the remaining 16.7% were performed after hours (34/204). And 61.3% were performed on a weekday (125/204), whilst 38.7% were performed on the weekend/public holiday (79/204). Most of the parameters in office hours and after hours groups had no statistically significant difference, except lactate (p = 0.026). Most of the variables in weekday and weekend groups had no statistically significant difference, except pH, lactate, length of stay, and gastrointestinal complications (p = 0.012, p < 0.001, p = 0.003, p = 0.020, respectively).

CONCLUSION

The current trauma system at Waikato hospital is capable of delivering care for trauma laparotomy patients with the same outcome regardless of working hours or after hours, weekday or weekend. This confirms the importance of a robust trauma system capable of responding to the sudden demands placed on it.

Contemporary management of isolated free fluid on computed tomography scan in blunt abdominal trauma-experience from a Level 1 trauma centre in New Zealand

AIMS

The management of patients with blunt abdominal trauma (BAT) who have isolated free fluid (IFF) with no solid organ injury (SOI) on computed tomography (CT) remains controversial. This study aims to determine if the volume of free fluid (FF) is a predictor of the need for operative management of traumatic intra-abdominal injuries, by reviewing the local cumulative experience with IFF at a major trauma centre in New Zealand.

METHODS

A retrospective study was undertaken over nine years at a Level 1 trauma centre in New Zealand. Patients aged over 15 years who sustained BAT and had IFF with no SOI demonstrated on CT were included. All CT scans and patient notes were reviewed. The volume of free fluid was classified by the local interpreting radiologist on the CT report.

RESULTS

Eighty-two out of 1,177 BAT patients (7%) had IFF with no SOI on CT. Thirty-eight percent were males, with a median age of 31 years. Nineteen (23%) underwent immediate operative management (OM) at the time of presentation. The remaining 63 patients had a trial of non-operative management (NOM), 10 (16%) of which were unsuccessful and required an operation. Overall, 29 patients (35%) required operative management. Eighty-nine percent of the OM group and 90% who failed NOM had positive operative findings, giving an overall true positive of 32%.

CONCLUSIONS

The presence of IFF in itself is not an absolute indication for operative exploration and many patients with trace IFF can be managed non-operatively. Small amounts of IFF should be regarded with suspicion, and moderate or large amounts of fluid are likely to require operative exploration. Further work must make use of clinical scoring systems and laparoscopy or laparotomy to assess patients at high risk of surgically remediable intra-abdominal injury post BAT.

Blood alcohol screening and outcomes in trauma team activation patients at a level 1 trauma centre in New Zealand

OBJECTIVE

A causal relationship between alcohol consumption and injury exists and the prevalence of harmful alcohol intakes in New Zealand adults is high. The present study investigates compliance to blood alcohol (BA) screening policy and the epidemiological profile and hospital-related outcomes of trauma team activation (TTA) patients with positive BA at a New Zealand level 1 trauma centre.

METHODS

A retrospective review of Midland Trauma Registry hospitalisation data between January 2012 and December 2019 was conducted. Eligible patients (n = 2168) were ≥15 years who received TTA at Waikato Hospital. BA screening rates, demographic and event information, injury severity and hospital-related outcomes were examined.

RESULTS

The average BA screening rate was 94.0% (95% confidence interval 92.9-95.0%) and 17.9% of screened patients were BA⁺ . BA⁺ patients were younger than BA^- (34.7 and 40.5 years, P < 0.0001). More males than females (20.6 and 12.4%, P < 0.0001), Māori (30.8%) compared to non-Māori (<16.0%) and unemployed/beneficiaries (33.4%) compared to employed patients (15.5%) were BA⁺ . Road transport crashes accounted for the highest proportion (45.2%) but, in comparison there were higher odds of BA⁺ from interpersonal violence (odds ratio 4.48, P < 0.0001). No difference between BA⁺ and BA^- was observed in survival rate, injury severity scores, length of intensive care and total hospital stay.

CONCLUSION

Between 2012 and 2019, Waikato Hospital demonstrated high compliance to BA screening policy for TTA patients. Appropriate alcohol awareness initiatives that focus on road safety and interpersonal violence are required to reduce the preventable prevalence and burden of alcohol-related trauma in the Waikato region.

Ten-year experience of splenic trauma in New Zealand: the rise of non-operative management

AIM

The aim of this study was to describe the demographics, mechanisms of injury, management and outcomes in patients who suffered splenic trauma in Christchurch, New Zealand.

METHODS

A retrospective study included all splenic injury patients admitted to Christchurch Public Hospital between January 2005 and August 2015.

RESULTS

A total of 238 patients were included, with a median age of 26 years (4-88.7). Of these, 235 patients had blunt injuries. Eighty-nine had high-grade injuries. Yearly admissions of splenic trauma patients have gradually increased. A total of 173 (72.7%) patients were managed with observation; 28 patients (11.8%) had radiological intervention and 37 patients (15.5%) had splenectomy. Patients who died were significantly more likely to be older (median, 46.5 vs 25.2 years, p=0.04) and to have been admitted to ICU (100% vs 32%, p=<0.001).

CONCLUSION

Splenic injuries have shown a steady increase in the last decade. Splenectomy rates have decreased in favour of non-operative techniques. Radiological intervention with splenic artery embolisation was successful in all selected patients with high-grade injuries.