Galinos Barmparas

Prevention of postoperative peritoneal adhesions: a review of the literature.

BACKGROUND postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies. METHODS the National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions. RESULTS ileal pouch-anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence). CONCLUSIONS postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.

Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction.

This meta‐analysis assessed the diagnostic and therapeutic role of water‐soluble contrast agent (WSCA) in adhesive small bowel obstruction (SBO).

The Incidence and Risk Factors of Post-Laparotomy Adhesive Small Bowel Obstruction

IntroductionThe purpose of this review was to assess the incidence and risk factors for adhesive small bowel obstruction (SBO) following laparotomy.MethodsThe PubMed database was systematically reviewed to identify studies in the English literature delineating the incidence of adhesive SBO and reporting risk factors for the development of this morbidity.ResultsA total of 446,331 abdominal operations were eligible for inclusion in this analysis. The overall incidence of SBO was 4.6%. The risk of SBO was highly influenced by the type of procedure, with ileal pouch–anal anastomosis being associated with the highest incidence of SBO (1,018 out of 5,268 cases or 19.3%), followed by open colectomy (11,491 out of 121,085 cases or 9.5%). Gynecological procedures were associated with an overall incidence of 11.1% (4,297 out of 38,751 cases) and ranged from 23.9% in open adnexal surgery, to 0.1% after cesarean section. The technique of the procedure (open vs. laparoscopic) also played a major role in the development of adhesive SBO. The incidence was 7.1% in open cholecystectomies vs. 0.2% in laparoscopic; 15.6% in open total abdominal hysterectomies vs. 0.0% in laparoscopic; and 23.9% in open adnexal operations vs. 0.0% in laparoscopic. There was no difference in SBO following laparoscopic or open appendectomies (1.4% vs. 1.3%). Separate closure of the peritoneum, spillage and retention of gallstones during cholecystectomy, and the use of starched gloves all increase the risk for adhesion formation. There is not enough evidence regarding the role of age, gender, and presence of cancer in adhesion formation.ConclusionAdhesion-related morbidity comprises a significant burden on healthcare resources and prevention is of major importance, especially in high-risk patients. Preventive techniques and special barriers should be considered in high-risk cases.

The impact of platelets on the progression of traumatic intracranial hemorrhage.

BACKGROUND The purpose of this study was to analyze the association of the initial platelet count with mortality and progression of intracranial hemorrhage (ICH) in blunt traumatic brain injured (TBI) patients. METHODS All blunt trauma patients with severe TBI admitted from January 2006 to December 2007 were retrospectively identified. Patients with a chest, abdomen, or extremity AIS score >3 were excluded to minimize the impact of concomitant injuries on the outcomes of the patients. All brain computed tomography scans were reviewed to analyze ICH progression. Discrete platelet cutoff values were entered into a multiple regression model to detect critical thresholds associated with ICH progression and mortality. RESULTS Of 626 TBI patients, 310 (49.5%) had a minimum of two brain computed tomography scans and were able to have ICH progression evaluated. Patients with platelets <175,000/mm3 had a significantly increased risk for ICH progression (OR [95% CI]: 2.09 [1.07-4.37]; adjusted p = 0.043). ICH progression was associated with increased need for craniotomy (OR [95% CI]: 3.27 [1.28-8.33]; adjusted p = 0.013) and mortality (OR [95% CI]: 3.41 [1.11-10.53]; adjusted p = 0.033). A platelet count <100,000/m3 was an independent predictor for mortality (OR [95% CI]: 9.5 [1.3-71.4]; adjusted p = 0.029). CONCLUSION A platelet count <100,000/mm3 is associated with a ninefold adjusted risk of death, and a platelet count <175,000/mm3 is a significant predictor of ICH progression. The impact of early correction of the admission platelet count warrants further validation.

Blunt thoracic aortic injuries: an autopsy study.

OBJECTIVE The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries. METHODS All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries. RESULTS During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002). CONCLUSION Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.

Pediatric vs adult vascular trauma: a National Trauma Databank review

INTRODUCTION The purpose of this study was to examine nationwide data on vascular injuries in children and to compare pediatric and adult patients with respect to the incidence, injury mechanisms, and outcomes. METHODS This is a National Trauma Databank analysis based on dataset version 7.0 (spanning a 5-year period ending December 2006). Pediatric patients under the age of 16 with at least one reported diagnosis of a vascular injury were compared to the adult cohort aged 16 and greater with a vascular injury. RESULTS During the study period, of 251,787 injured patients younger than 16 years, 1138 (0.6%) had a vascular injury. The incidence in patients 16 years or older was significantly higher, at 1.6% (P < .01). Compared to the adult vascular patients, pediatric patients had a significantly lower Injury Severity Score (16.8 +/- 14.9 vs 26.3 +/- 16.7, P < .001) and encountered less frequently penetrating injuries (41.8% vs 51.2%, P < .001). The most commonly injured vessels in the pediatric population were vessels of the upper extremity (424 patients or 37.9%). The overall incidence of thoracic aortic injuries in children was seven-fold lower compared to the incidence in adults (0.03% vs 0.21%). After adjusting for confounding factors, pediatric patients demonstrated improved survival following vascular injuries (adjusted odds ratio, 0.60; 95% CI, 0.45-0.79; P < .001). No significant difference was identified in the rate of amputation between pediatric and adult patients who had sustained upper or lower extremity vascular injuries. CONCLUSION Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury. Vessels of the upper extremity were the most commonly injured and were associated with low mortality. Injuries of the thoracic aorta are rare. Overall, pediatric patients had an improved adjusted mortality when compared to adults.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the american association for the surgery of trauma

BACKGROUND Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Early coagulopathy after isolated severe traumatic brain injury: relationship with hypoperfusion challenged.

INTRODUCTION The purpose of this study was to examine the incidence of tissue hypoperfusion in victims of severe traumatic brain injury (sTBI) and to determine the associations between hypoperfusion and TBI coagulopathy. METHODS This is a retrospective analysis of a prospectively collected cohort admitted to the surgical intensive care unit from June 2005 to December 2007 sustaining isolated sTBI, defined as sTBI [head Abbreviated Injury Scale (AIS) ≥ 3] with chest, abdomen, and extremity AIS < 3. Criteria for TBI-associated early coagulopathy included isolated sTBI in conjunction with thrombocytopenia (platelet count < 100,000 per mm³) or elevated international normalized ratio > 1.2 or prolonged activated partial thromboplastin time > 36 seconds at admission. Hypoperfusion was defined by the presence of an arterial base deficit (BD) > 6 mmol/L. Univariate and multivariate analysis was performed to identify associations among hypoperfusion, coagulopathy, and mortality. RESULTS A total of 132 patients met the study criteria. TBI-associated early coagulopathy occurred in 48 patients (36.4%). With increasing head injury severity, the incidence of coagulopathy increased in a stepwise fashion. Mean BD values and mean lactate values were significantly higher among patients with coagulopathy compared with their noncoagulopathic counterparts at hospital admission. The coagulopathic cohort presented more frequently with a BD > 6 mmol/L at admission (39.6% vs. 20.2%, p = 0.016). In the stepwise logistic regression analysis, head AIS = 5 and an admission BD > 6 mmol/L were independently associated with early coagulopathy. Coagulopathy was associated with increased mortality in patients after blunt head trauma, adjusted odds ratio (95% confidence interval): 3.79 (1.06-13.51); adjusted p = 0.04. CONCLUSION Hypoperfusion is an independent risk factor for the development of early coagulopathy in patients with isolated sTBI. Nevertheless, early coagulopathy after sTBI does not occur exclusively in patients experiencing tissue hypoperfusion.

Isolated severe traumatic brain injuries: association of blood alcohol levels with the severity of injuries and outcomes

BACKGROUND Traumatic brain injury is a common cause of death after traumatic insults. Alcohol intoxication is a recognized contributor to the occurrence of these injuries. The specific effects of alcohol exposure on injury severity and subsequent outcomes, however, remain controversial. The aim of this study was to investigate the relationship between blood alcohol levels (BAL) and outcomes in patients with isolated severe traumatic brain injuries (sTBI). METHODS During the calendar year 2003, as part of a pilot project, the Los Angeles County Department of Health Services obtained routine BAL on all patients transported to any of its 13 trauma centers. This study analyzes the effect of BAL on outcomes in patients with isolated sTBI (head Abbreviated Injury Scale (AIS) score >or=3; extracranial AIS score <3). The Low/No ethanol (ETOH) group included patients with negative or low (<0.08 mg/dL) BAL. Patients with BAL >or=0.08 mg/dL constituted the high ETOH group. Logistic regression was performed to determine whether alcohol levels had an independent association with outcomes. RESULTS There were 815 patients with isolated severe head injuries. Overall, 468 patients (57%) constituted the Low/No ETOH group, and 347 (43%) the high ETOH group. Alcohol levels were not significantly associated with severity of injury, hypotension at admission, Glasgow Coma Scale score, incidence of major complications, and intensive care unit or hospital length of stay. However, adjusted mortality was significantly lower in the high ETOH group when compared with the Low/No ETOH (8.9% vs. 17.1%; adjusted odds ratio: 0.60, 95% confidence interval: 0.37-0.96, p = 0.037). In the subgroup of patients with Injury Severity Score >15 the relative risk for mortality in the high ETOH group was significantly lower than in patients with Low/No ETOH. There was also an increased survival with high ETOH in patients with Injury Severity Score >25, but this was not statistically significant. CONCLUSIONS Among patients with isolated sTBI, BAL do not seem to be associated with overall injury severity, head injury severity, or the occurrence of major morbidities. Similarly, hospital and intensive care unit lengths are not affected by high admission BAL level. The adjusted overall in-hospital mortality, however, is significantly lower in patients presenting with the high BAL (>or=0.08 g/dL) after isolated sTBI.

The changing epidemiology of spinal trauma: A 13-year review from a Level I trauma centre

INTRODUCTION Spinal injuries secondary to trauma are a major cause of patient morbidity and a source of significant health care expenditure. Increases in traffic safety standards and improved health care resources may have changed the characteristics and incidence of spinal injury. The purpose of this study was to review a single metropolitan Level I trauma centres experience to assess the changing characteristics and incidence of traumatic spinal injuries and spinal cord injuries (SCI) over a 13-year period. PATIENTS AND METHODS A retrospective review of patients admitted to a Level I trauma centre between 1996 and 2008 was performed. Patients with spinal fractures and SCI were identified. Demographics, mechanism of injury, level of spinal injury and Injury Severity Score (ISS) were extracted. The outcomes assessed were the incidence rate of SCI and in-hospital mortality. RESULTS Over the 13-year period, 5.8% of all trauma patients suffered spinal fractures, with 21.7% of patients with spinal injuries having SCI. Motor vehicle accidents (MVAs) were responsible for the majority of spinal injuries (32.6%). The mortality rate due to spinal injury decreased significantly over the study period despite a constant mean ISS. The incidence rate of SCI also decreased over the years, which was paralleled by a significant reduction in MVA associated SCI (from 23.5% in 1996 to 14.3% in 2001 to 6.7% in 2008). With increasing age there was an increase in spinal injuries; frequency of blunt SCI; and injuries at multiple spinal levels. CONCLUSION This study demonstrated a reduction in mortality attributable to spinal injury. There has been a marked reduction in SCI due to MVAs, which may be related to improvements in motor vehicle safety and traffic regulations. The elderly population was more likely to suffer SCI, especially by blunt injury, and at multiple levels. Underlying reasons may be anatomical, physiological or mechanism related.