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Choron RL, Rallo M, Piplani C, Youssef S, Teichman AL, Bargoud CG, Sciarretta JD, Smith RN, Hanos DS, Afif IN, Beard JH, Dhillon NK, Zhang A, Ghneim M, Devasahayam RJ, Gunter OL, Smith AA, Sun BL, Cao C, Reynolds JK, Hilt LA, Holena D, Chang G, Jonikas M, Echeverria K, Fung N, Anderson A, Dumas RP, Fitzgerald CA, Levin J, Trankiem C, Yoon JJ, Blank J, Hazelton J, McLaughlin CJ, Al-Aref R, Kirsch JM, Howard DS, Scantling DR, Dellonte K, Vella M, Hopkins B, Shell C, Udekwu PO, Wong EG, Joseph BA, Lieberman H, Ramsey W, Stewart C, Alvarez C, Berne JD, Nahmias J, Puente I, Patton JP, Rakitin I, Perea LL, Pulido OR, Ahmed H, Keating J, Kodadek L, Wade J, Henry R, Schreiber M, Benjamin A, Khan A, Mann LK, Mentzer C, Mousafeiris V, Mulita F, Reid-Gruner S, Sais E, Foote C, Palacio-Lascano C, Argandykov D, Kaafarani H, Bover Manderski M, Narayan M, Seamon MJ. The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial. J Trauma Acute Care Surg 2024:01586154-990000000-00739. [PMID: 38745354 DOI: 10.1097/ta.0000000000004303] [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: 05/16/2024]
Abstract
BACKGROUND Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(β -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE IV.
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Harrell KN, Grimes AD, Gill H, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias. Injury 2024; 55:111204. [PMID: 38039636 DOI: 10.1016/j.injury.2023.111204] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.
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Affiliation(s)
- Kevin N Harrell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States.
| | | | - Harkanwar Gill
- University of Oklahoma, Oklahoma City, OK, United States
| | | | - Walker R Ueland
- University of Kentucky School of Medicine, Lexington, KY, United States
| | | | | | - Marc D Trust
- University of Texas at Austin, Austin, TX, United States
| | - Marielle Ngoue
- University of Texas at Austin, Austin, TX, United States
| | - Bradley W Thomas
- Atrium Health Carolinas Medical Center, Charlotte, NC, United States
| | - Sullivan A Ayuso
- Atrium Health Carolinas Medical Center, Charlotte, NC, United States
| | | | | | | | | | - Basil S Karam
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Marc A de Moya
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mark J Lieser
- Research Medical Center, Kansas City, MO, United States
| | - John M Chipko
- Research Medical Center, Kansas City, MO, United States
| | - James M Haan
- Ascension Via Christi on St. Francis Hospital, Wichita, KS, United States
| | - Kelly L Lightwine
- Ascension Via Christi on St. Francis Hospital, Wichita, KS, United States
| | | | | | | | | | - Hasan B Alam
- University of Michigan, Ann Arbor, MI, United States
| | | | - Gloria D Sanin
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Amy N Hildreth
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, La Jolla, CA, United States
| | | | - Gary Marshall
- Medical City Plano Hospital, Plano, TX, United States
| | - Omaer Muttalib
- University of California, Irvine, Orange, CA, United States
| | - Jeffry Nahmias
- University of California, Irvine, Orange, CA, United States
| | - Niti Shahi
- Children's Hospital Colorado, Denver, CO, United States
| | | | - Robert A Maxwell
- University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, United States
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Ghneim M, Kufera J, Zhang A, Penaloza-Villalobos L, Swentek L, Watras J, Smith A, Hahn A, Rodriguez Mederos D, Dickhudt TJ, Laverick P, Cunningham K, Norwood S, Fernandez L, Jacobson LE, Williams JM, Lottenberg L, Azar F, Shillinglaw W, Slivinski A, Nahmias J, Donnelly M, Bala M, Egodage T, Zhu C, Udekwu PO, Norton H, Dunn JA, Baer R, McBride K, Santos AP, Shrestha K, Metzner CJ, Murphy JM, Schroeppel TJ, Stillman Z, O'Connor R, Johnson D, Berry C, Ratner M, Reynolds JK, Humphrey M, Scott M, Hickman ZL, Twelker K, Legister C, Glass NE, Siebenburgen C, Palmer B, Semon GR, Lieser M, McDonald H, Bugaev N, LeClair MJ, Stein D. Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial. J Trauma Acute Care Surg 2023; 95:516-523. [PMID: 37335182 DOI: 10.1097/ta.0000000000004095] [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: 06/21/2023]
Abstract
OBJECTIVE This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Mira Ghneim
- From the R Adams Cowley Shock Trauma Center (M.G., D.S.), Program in Trauma, Department of Surgery, University of Maryland School of Medicine; National Study Center for Trauma and Emergency Medical Systems, Program in Trauma, Center for Shock, Trauma and Anesthesiology Research (J.K.), University of Maryland School of Medicine; University of Maryland School of Medicine (A.Z.); Department of Surgery (L.P.-V., L.S.), Loma Linda University Medical Center; Inova Fairfax Hospital (J.W.); LSUHCS (A.S.); Ochsner Medical Center (A.H.); Broward Health Medical Center (D.R.M., T.J.D.); Atrium Health Carolinas Medical Center (P.L., K.C.); University of Texas Health Science Center (S.N., L.F.); Ascension St. Vincent Hospital (L.E.J., J.M.W.); St. Mary's Medical Center (L.L., F.A.), Florida Atlantic University, Schmidt College of Medicine; Mission Hospital (W.S., A.S.); University of California, Irvine (J.N., M.D.); Hadassah Medical Center and Faculty of Medicine (M.B.), Hebrew University of Jerusalem; Cooper University Health Care (T.E.); Cooper University Health Care (C.Z.); WakeMed Health and Hospitals (P.O.U., H.N.); Medical Center of the Rockies (J.A.D.), University of Colorado Health North; Orthopedic Center of the Rockies (R.B.); Memorial University Medical Center (K.M.); Texas Tech University Health Sciences Center (A.P.S., K.S.); Spartanburg Regional Medical Center (C.J.M., J.M.M.); Memorial Hospital Central (T.J.S., Z.S.); Yale School of Medicine (R.O., D.J.); NYU Grossman School of Medicine (C.B., M.R.,); University of Kentucky (J.K.R., M.H.); St. Mary's Medical Center (M.S.), Essentia Health; NYC Health + Hospitals/Elmhurst (Z.L.H., K.T.), Icahn School of Medicine at Mount Sinai; Rutgers New Jersey Medical School (C.L., N.E.G.); Kettering Health Main Campus (C.S., B.P.); Wright State University Boonshoft School of Medicine (G.R.S.); Research Medical Center (M.L., H.M.); Tufts Medical Center (N.B.), Tuft University School of Medicine; and Tufts Medical Center (M.J.L.)
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Portelli Tremont JN, Adams UC, Holloway AD, Kratzke IM, McIntyre SA, Udekwu PO, Pressley CM. The Effect of Area Social Deprivation on Health Behavior and Health Care Utilization in an Adult Trauma Population. Am Surg 2023; 89:3253-3255. [PMID: 37501309 DOI: 10.1177/00031348231157854] [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: 07/29/2023]
Abstract
Social determinants of health may mediate health disparities, but these variables are not routinely measured in clinical practice. This is a retrospective, single-institution study that evaluates the effect of area deprivation on outcomes after trauma admission. Adult trauma patients 18 years and older were eligible. Patients were stratified into high-area (HSD) or low-area (LSD) social deprivation cohorts using zip code of residence. Regression modeling was used to explain the association between HSD, sociodemographic characteristics, and clinical outcomes. Patients who resided in HSD areas made up 29.5% of the study population, were more likely to be younger, male, and identify as a non-White race. Patients in the HSD cohort were also less likely to be admitted to the ICU (OR 0.84, CI 0.71-0.98) and discharged with additional services (OR 0.73, CI 0.57-0.94). We found that independently, area social deprivation affects trauma outcomes and the resources a patient is provided after discharge.
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Affiliation(s)
- Jaclyn N Portelli Tremont
- Department of Surgery, WakeMed Health and Hospitals, Raleigh, NC, USA
- Department of Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Ursula C Adams
- Department of Surgery, WakeMed Health and Hospitals, Raleigh, NC, USA
- Department of Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Alexa D Holloway
- Department of Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Ian M Kratzke
- Department of Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Sarah A McIntyre
- Department of Surgery, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Pascal O Udekwu
- Department of Surgery, WakeMed Health and Hospitals, Raleigh, NC, USA
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Choron RL, Teichman A, Bargoud C, Sciarretta JD, Smith R, Hanos D, Afif IN, Beard JH, Dhillon NK, Zhang A, Ghneim M, Devasahayam RJ, Gunter OL, Smith AA, Sun B, Cao CS, Reynolds JK, Hilt LA, Holena DN, Chang G, Jonikas M, Echeverria-Rosario K, Fung NS, Anderson A, Dumas RP, Fitzgerald CA, Levin JH, Trankiem CT, Yoon J, Blank J, Hazelton JP, McLaughlin CJ, Al-Aref R, Kirsch JM, Howard DS, Scantling DR, Dellonte K, Vella M, Hopkins B, Shell C, Udekwu PO, Wong EG, Joseph B, Lieberman H, Ramsey WA, Stewart CH, Alvarez C, Berne JD, Nahmias J, Puente I, Patton JH, Rakitin I, Perea L, Pulido O, Ahmed H, Keating J, Kodadek LM, Wade J, Henry R, Schreiber MA, Benjamin AJ, Khan A, Mann LK, Mentzer CJ, Mousafeiris V, Mulita F, Reid-Gruner S, Sais E, Foote C, Palacio CH, Argandykov D, Kaafarani H, Coyle S, Macor M, Bover Manderski MT, Narayan M, Seamon MJ. Outcomes Among Trauma Patients with Duodenal Leak Following Primary vs Complex Repair of Duodenal Injuries: An EAST Multicenter Trial. J Trauma Acute Care Surg 2023:01586154-990000000-00340. [PMID: 37072889 DOI: 10.1097/ta.0000000000003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Duodenal leak is a feared complication of repair and innovative, complex repairs with adjunctive measures(CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak is sparse and its impact on duodenal leak outcomes nonexistent. We hypothesized primary repair alone (PRA) would be associated with decreased duodenal leak rates, however CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS A retrospective, multicenter analysis from 35 Level-1 trauma centers included patients older than 14 with operative, traumatic duodenal injuries(1/2010-12/2020). The study sample compared duodenal operative repair strategy: primary repair alone(PRA) vs CRAM(any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS The sample(n = 861) was primarily young(33 years) male(84%) with penetrating injuries(77%); 523 underwent PRA and 338 underwent CRAM. CRAM were more critically injured than PRA and had higher leak rates(CRAM 21% vs PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more IR drains, prolonged NPO and LOS, greater mortality, and more readmissions than PRA(all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, NPO duration, need for IR drainage, HLOS, or mortality between PRA leak vs CRAM leak patients(all p > 0.05). CRAM leaks had longer antibiotic duration, more GI complications, and longer duration until leak resolution(all p < 0.05). PRA was associated with 60% lower odds of leak, whereas injury grade II-IV, damage control, and BMI had higher odds of leak(all p < 0.05). There were no leaks among patients with grade IV-V injuries repaired by PRA. CONCLUSIONS CRAM did not prevent duodenal leaks and moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest CRAM is not a protective operative duodenal repair strategy and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE IV, Multicenter retrospective comparative study.
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Harrell KN, Grimes AD, Gill H, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study. Am J Surg 2022; 225:1069-1073. [PMID: 36509587 DOI: 10.1016/j.amjsurg.2022.12.006] [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] [Received: 10/12/2022] [Revised: 11/30/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.
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Affiliation(s)
- Kevin N Harrell
- University of Tennessee College of Medicine Chattanooga, 979 E 3rd Street Suite B 401, Chattanooga, TN, 37403, USA.
| | - Arthur D Grimes
- University of Oklahoma, 800 Stanton L. Young Blvd #9000, Oklahoma City, OK, 73104, USA.
| | - Harkanwar Gill
- University of Oklahoma, 800 Stanton L. Young Blvd #9000, Oklahoma City, OK, 73104, USA.
| | - Jessica K Reynolds
- University of Kentucky School of Medicine, 800 Rose St, MN268A, Lexington, KY, 40536, USA.
| | - Walker R Ueland
- University of Kentucky School of Medicine, 800 Rose St, MN268A, Lexington, KY, 40536, USA.
| | - Jason D Sciarretta
- Grady Health System, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Samual R Todd
- Grady Health System, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Marc D Trust
- University of Texas at Austin, 1501 Red River St, Austin, TX, 78712, USA.
| | - Marielle Ngoue
- University of Texas at Austin, 1501 Red River St, Austin, TX, 78712, USA.
| | - Bradley W Thomas
- Atrium Health Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Sullivan A Ayuso
- Atrium Health Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Aimee LaRiccia
- Grant Medical Center, 111 S Grant Ave, Columbus, OH, 43215, USA.
| | | | | | - Bryan R Collier
- Carilion Clinic, 1906 Belleview Ave SE, Roanoke, VA, 24014, USA.
| | - Basil S Karam
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA.
| | - Marc A de Moya
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA.
| | - Mark J Lieser
- Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO, 64132, USA.
| | - John M Chipko
- Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO, 64132, USA.
| | - James M Haan
- Ascension Via Christi on St. Francis Hospital, 929 St Francis, Wichita, KS, 67214, USA.
| | - Kelly L Lightwine
- Ascension Via Christi on St. Francis Hospital, 929 St Francis, Wichita, KS, 67214, USA.
| | | | | | - Ryan C Phillips
- Denver Health Medical Center, 777 Bannock St, Denver, CO, 80204, USA.
| | - Michael T Kemp
- University of Michigan, 1500 E Medical Center Dr Ann Arbor, MI, 48109, USA.
| | - Hasan B Alam
- University of Michigan, 1500 E Medical Center Dr Ann Arbor, MI, 48109, USA.
| | | | - Gloria D Sanin
- Wake Forest School of Medicine, 1 Medical Center Blvd Winston-Salem, NC, 27157, USA.
| | - Amy N Hildreth
- Wake Forest School of Medicine, 1 Medical Center Blvd Winston-Salem, NC, 27157, USA.
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, La Jolla, CA, 92037, USA.
| | - Kathryn B Schaffer
- Scripps Memorial Hospital La Jolla, 9888 Genesee Ave, La Jolla, CA, 92037, USA.
| | - Gary Marshall
- Medical City Plano Hospital, 3901 W 15th St, Plano, TX, 75075, USA.
| | - Omaer Muttalib
- University of California, Irvine, 101 The City Dr S Orange, CA, 92868, USA.
| | - Jeffry Nahmias
- University of California, Irvine, 101 The City Dr S Orange, CA, 92868, USA.
| | - Niti Shahi
- Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA.
| | - Steven L Moulton
- Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO, 80045, USA.
| | - Robert A Maxwell
- University of Tennessee College of Medicine Chattanooga, 979 E 3rd Street Suite B 401, Chattanooga, TN, 37403, USA.
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Rojas B, Stiles A, Roy S, Udekwu PO, Rutherford EJ. Does "Sludge" Require Cholecystectomy? Am Surg 2022; 88:1018-1021. [PMID: 35266807 DOI: 10.1177/00031348211050287] [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
Biliary sludge is a subjective, ill-defined term. Surgery is often consulted for laparoscopic cholecystectomy, regarded as a low risk procedure.After IRB approval, a word search was used to identify "sludge" in all ultrasounds performed in 2016. The number of patients undergoing cholecystectomy, complications, pathologic findings, and risk factors were identified. Non-operative patients were evaluated for subsequent symptoms and studies or procedures related to biliary pathology.2769 patients underwent RUQ US; 253 patients were found to have sludge. Of 48 (19%) cholecystectomy patients, 9 had cholelithiasis. No deaths occurred in the cholecystectomy group. Two surgical complications occurred. Fifty (24.4%) of the 205 non-operative patients underwent subsequent US imaging: 44% residual sludge, 28% normal, 18% stones, and 10% other.Sludge may resolve 28% of the time. Repeat ultrasound is prudent before proceeding with cholecystectomy. If an abnormality is seen on repeat imaging and risk factors persist, cholecystectomy may be reasonable.
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Affiliation(s)
- Brian Rojas
- Osceola Surgical Trauma Group, 10848Osceola Regional Medical Center, Kissimmee, FL, USA
| | - Anquonette Stiles
- Department of Surgery, 10848WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Sara Roy
- Department of Surgery, 10848WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Pascal O Udekwu
- Department of Surgery, 10848WakeMed Health and Hospitals, Raleigh, NC, USA
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Harrell KN, Grimes AD, Albrecht RM, Reynolds JK, Ueland WR, Sciarretta JD, Todd SR, Trust MD, Ngoue M, Thomas BW, Ayuso SA, LaRiccia A, Spalding MC, Collins MJ, Collier BR, Karam BS, de Moya MA, Lieser MJ, Chipko JM, Haan JM, Lightwine KL, Cullinane DC, Falank CR, Phillips RC, Kemp MT, Alam HB, Udekwu PO, Sanin GD, Hildreth AN, Biffl WL, Schaffer KB, Marshall G, Muttalib O, Nahmias J, Shahi N, Moulton SL, Maxwell RA. Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study. J Trauma Acute Care Surg 2021; 91:834-840. [PMID: 34695060 DOI: 10.1097/ta.0000000000003250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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 Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE Therapeutic/care management, Level IV.
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Affiliation(s)
- Kevin N Harrell
- From the Department of Surgery (K.N.H., R.A.M.), University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee; Department of Surgery (A.D.G., R.M.A.), University of Oklahoma, School of Medicine, Oklahoma City, Oklahoma; Department of Surgery (J.K.R., W.R.U.), University of Kentucky College of Medicine, Lexington, Kentucky; Department of Surgery (J.D.S., S.R.T.), Grady Health System, Emory University School of Medicine, Atlanta, Georgia; University of Texas at Austin (M.D.T., M.N.), Austin, Texas; Atrium Health Carolinas Medical Center (B.W.T., S.A.A.), Charlotte, North Carolina; Grant Medical Center (A.LR., M.C.S.), Columbus, Ohio; Department of Surgery (M.J.C., B.R.C.), Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery (B.S.K., M.A.dM.), Medical College of Wisconsin Milwaukee, Wisconsin; Research Medical Center (M.J.L., J.M.C.), Kansas City, Missouri; Ascension Via Christi on St. Francis Hospital (J.M.H., K.L.L.), Wichita, Kansas; Department of Surgery (D.C.C., C.R.F.), Maine Medical Center, Portland, Maine; Department of Surgery (R.C.P.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.T.K., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (P.O.U.), WakeMed Health Raleigh; Department of General Surgery (G.D.S., A.N.H.), Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Trauma/Acute Care Surgery (W.L.B., K.B.S.), Scripps Memorial Hospital La Jolla, La Jolla, California; Medical City Plano Hospital (G.M.) Plano, Texas; Department of Surgery (O.M., J.N.), University of California, School of Medicine, Irvine, Orange, California; Department of Pediatric Surgery (N.S., S.L.M.), Children's Hospital Colorado, Denver, Colorado
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Udekwu PO, Sullivan WG. Contemporary Experience with Cholecystectomy: Establishing ‘Benchmarks’ Two Decades after the Introduction of Laparoscopic Cholecystectomy. Am Surg 2020. [DOI: 10.1177/000313481307901215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
With quality and public reporting of increasing importance, benchmarks are anticipated to grow in relevance. We studied cholecystectomy in a practice in an urban tertiary care hospital. A total of 1083 cholecystectomies were performed in 2008 and 2009. Laparoscopic cholecystectomy was performed in 97.8 per cent of patients with a 2.2 per cent conversion rate. A planned open procedure was performed in only 2.2 per cent of patients. Approximately half of procedures were urgent and performed during an acute hospitalization. Most patients (74%) were female and most patients were overweight or obese (64.8%). Ages into the tenth decade of life were represented. Comorbidities included hypertension, 28.7 per cent; coronary disease, 15.6 per cent; diabetes mellitus, 13.4 per cent; gastroesophageal reflux disease, 10.7 per cent; and asthma, 5.5 per cent. Of female patients, 98 (12.2%) were postpartum and five (0.6%) were pregnant. Of 137 patients without gallstones, 59.1 per cent had biliary dyskinesia and 27 per cent had acalculous cholecystitis. Preoperative magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in most patients with suspected choledocholithiasis. Intraoperative cholangiograms were performed in 6.9 per cent of patients, 3.3 per cent for abnormal liver function studies. Postoperative ERCP was used in most patients with positive intraoperative cholangiograms. All-cause mortality was 0.8 per cent and attributable mortality was 0.2 per cent. Complications occurred in 7.5 per cent of patients, including retained common bile duct stones in 1.1 per cent, bile duct leak in 0.3 per cent, and common bile duct injury in 0.1 per cent.
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Hsu CH, Haac BE, Drake M, Bernard AC, Aiolfi A, Inaba K, Hinson HE, Agarwal C, Galante J, Tibbits EM, Johnson NJ, Carlbom D, Mirhoseini MF, Patel MB, O’Bosky KR, Chan C, Udekwu PO, Farrell M, Wild JL, Young KA, Cullinane DC, Gojmerac DJ, Weissman A, Callaway C, Perman SM, Guerrero M, Aisiku IP, Seethala RR, Co IN, Madhok DY, Darger B, Kim DY, Spence L, Scalea TM, Stein DM. EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest. J Trauma Acute Care Surg 2018; 85:37-47. [PMID: 29677083 PMCID: PMC6026030 DOI: 10.1097/ta.0000000000001945] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study. METHODS We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome. RESULTS A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy. CONCLUSION Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic study, level III.
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Affiliation(s)
- Cindy H. Hsu
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
- University of Michigan, Ann Arbor, Michigan
| | - Bryce E. Haac
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mack Drake
- University of Kentucky, Lexington, Kentucky
| | | | - Alberto Aiolfi
- Los Angeles County/University of Southern California Medical Center, Los Angeles, CA
| | - Kenji Inaba
- Los Angeles County/University of Southern California Medical Center, Los Angeles, CA
| | | | | | - Joseph Galante
- University of California Davis Medical Center, Davis, California
| | - Emily M. Tibbits
- University of California Davis Medical Center, Davis, California
| | | | - David Carlbom
- University of Washington/Harborview Medical Center, Seattle, Washington
| | | | - Mayur B. Patel
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Christian Chan
- Loma Linda University Medical Center, Loma Linda, California
| | | | | | | | | | | | | | | | - Clifton Callaway
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | - Ivan N. Co
- University of Michigan, Ann Arbor, Michigan
| | - Debbie Y. Madhok
- San Francisco General Hospital/University of California San Francisco, San Francisco, California
| | - Bryan Darger
- San Francisco General Hospital/University of California San Francisco, San Francisco, California
| | | | - Lara Spence
- Harbor UCLA Medical Center, Torrance, California
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah M. Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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Udekwu PO, Sullivan WG. Contemporary experience with cholecystectomy: establishing 'benchmarks' two decades after the introduction of laparoscopic cholecystectomy. Am Surg 2013; 79:1253-1257. [PMID: 24351351] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
With quality and public reporting of increasing importance, benchmarks are anticipated to grow in relevance. We studied cholecystectomy in a practice in an urban tertiary care hospital. A total of 1083 cholecystectomies were performed in 2008 and 2009. Laparoscopic cholecystectomy was performed in 97.8 per cent of patients with a 2.2 per cent conversion rate. A planned open procedure was performed in only 2.2 per cent of patients. Approximately half of procedures were urgent and performed during an acute hospitalization. Most patients (74%) were female and most patients were overweight or obese (64.8%). Ages into the tenth decade of life were represented. Comorbidities included hypertension, 28.7 per cent; coronary disease, 15.6 per cent; diabetes mellitus, 13.4 per cent; gastroesophageal reflux disease, 10.7 per cent; and asthma, 5.5 per cent. Of female patients, 98 (12.2%) were postpartum and five (0.6%) were pregnant. Of 137 patients without gallstones, 59.1 per cent had biliary dyskinesia and 27 per cent had acalculous cholecystitis. Preoperative magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in most patients with suspected choledocholithiasis. Intraoperative cholangiograms were performed in 6.9 per cent of patients, 3.3 per cent for abnormal liver function studies. Postoperative ERCP was used in most patients with positive intraoperative cholangiograms. All-cause mortality was 0.8 per cent and attributable mortality was 0.2 per cent. Complications occurred in 7.5 per cent of patients, including retained common bile duct stones in 1.1 per cent, bile duct leak in 0.3 per cent, and common bile duct injury in 0.1 per cent.
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Smith AB, Udekwu PO, Biswas S, Harvey E, Bullock A, Barnes MA, Allred S. Implementation of a nurse-driven intensive insulin infusion protocol in a surgical intensive care unit. Am J Health Syst Pharm 2007; 64:1529-40. [PMID: 17617505 DOI: 10.2146/ajhp060249] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Angela B Smith
- Department of Pharmacy, Holly Hill Hospital, Raleigh, NC 27610, USA.
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Oller DW, Udekwu PO. Liver trauma: a victory for conservative approaches. Curr Surg 2004; 61:21-4. [PMID: 14972166 DOI: 10.1016/s0149-7944(03)00162-4] [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] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Dale W Oller
- Department of Surgery, Wake Med, Raleigh, North Carolina, USA
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Udekwu PO, Gurkin B, Oller DW. The use of computed tomography in blunt abdominal injuries. Am Surg 1996; 62:56-9. [PMID: 8540647] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A retrospective study was performed to evaluate the use of abdominopelvic computed tomography of the abdomen (CTA) in the initial evaluation of hemodynamically stable blunt trauma patients. Two hundred fifty-six of 2,047 injury admissions over a 2-year period underwent CTA. Sixty-two (24.2%) scans were positive for visceral injury. Sensitivity of CTA for patients with visceral injury was 92.4 per cent, specificity was 99.5 per cent, and overall accuracy was 97.6 per cent. Of all injuries documented by CTA or laparotomy, CTA detected 83.7 per cent. Injury-specific sensitivities were lowest in injuries of the pancreas (0%), intestinal tract (41.6%), and bladder (50%). False negative scans occurred in 1.9 per cent of patients, with no deaths or major complications attributable to delay in diagnosis. Nonoperative management was possible in 72 per cent of 57 patients with solid viscus injuries; splenic preservation was possible in 81.5 per cent of injured organs. Urine dipsticks and urinalysis performed poorly as predictors of either significant urological injury or intra-abdominal injury in general. When indications included early need for nonabdominal operation, only three of 41 scans were positive. Yield for patients scanned with obtundation as an isolated indication was diminished. Cost of CTA exceeds that of DPL, but lower procedure-related risk and lower estimated rate of nontherapeutic laparotomy leads to clinical favor of CTA in this group of patients.
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Affiliation(s)
- P O Udekwu
- Wake Area Health Education Center, Raleigh, North Carolina 27610-1255, USA
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Udekwu PO, Oller DW. Hematemesis as initial presentation of traumatic paraceliac pseudoaneurysm of the abdominal aorta. Cardiovasc Surg 1994; 2:781-2. [PMID: 7859001] [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] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- P O Udekwu
- Surgical Intensive Care Unit, Wake Medical Center, Raleigh, North Carolina 27620-4465
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