L. D. Britt

Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fishers exact test, Students T test, and logistic regression analysis. RESULTS The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Multiinstitutional Experience With the Management of Superior Mesenteric Artery Injuries.

BACKGROUND Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullens classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullens zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullens ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullens zone I or II, and multisystem organ failure. CONCLUSION SMA injuries are highly lethal. Fullens anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullens zones I and II, Fullens maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship.

Objective: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship. Summary Background Data: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models. Methods: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale. Results: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows’ feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience “great -5” or “exceptional– 6.” Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship. Conclusion: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review.

Current Opinion on Catheter-based Hemorrhage Control in Trauma Patients

Abstract : Surgery has undergone several fundamental paradigm changes during the last 25 years. Laparoscopic and catheter-based interventions have become common, ultrasound is ubiquitous, and robotics and damage-control surgery are commonplace. When combined with ever-advancing imaging technology, all these tools will continue to change the face of trauma surgery. Accordingly, the University of Texas Health Science at Houston, the Memorial Hermann Texas Trauma Institute, and the Methodist Institute for Technology, Innovation, and Education held a 2-day meeting on February 26 to 27, 2013, to discuss developing new techniques and potential paradigm shifts for catheter-based hemorrhage control including the trauma hybrid operating room (THOR) concept. At this meeting, 60 North American physicians from more than 25 institutions including leaders from the American College of Surgeons and representatives from six specialties (trauma, vascular surgery, orthopedic surgery, critical care, general surgery) involved in caring for traumatically injured patients met and discussed relevant clinical problems, the technology needed to improve patient care, patient-centric flow patterns, new treatments, training, credentialing, and competency issues and participated in a catheter-based hemorrhage control skills laboratory for acute care surgeons. The following is a summary of the proceedings.

The role and value of surgical critical care, an essential component of Acute Care Surgery, in the Affordable Care Act: A report from the Critical Care Committee and Board of Managers of the American Association for the Surgery of Trauma

Heidi L. Frankel, MD, Karyn L. Butler, MD, Joseph Cuschieri, MD, Randall S. Friese, MD, Toan Huynh, MD, Alicia M. Mohr, MD, Miren A. Schinco, MD, Lena M. Napolitano, MD, L.D. Britt, MD, MPH, Raul Coimbra, MD, PhD, Martin A. Croce, MD, James W. Davis, MD, Gregory J. Jurkovich, MD, Ernest E. Moore, MD, John A. Morris, Jr., MD, Andrew B. Peitzman, MD, Basil A. Pruitt, MD, Grace S. Rozycki, MD, MBA, Thomas M. Scalea, MD, and J. Wayne Meredith, MD, Baltimore, Maryland

Defining the acute care surgery curriculum.

BACKGROUND This study was designed to define the gaps in essential and desirable (E/D) case volumes that may prompt reevaluation of the acute care surgery (ACS) curriculum or restructuring of the training provided. METHODS A review of the first 2 years of ACS case log entry (July 2011 to June 2013) was performed. Individual trainee logs were evaluated to determine how often they performed each case on the E/D list. Trainees described cases using current procedural terminology codes, which had been previously mapped to the E/D list. RESULTS There were 29 trainees from 15 programs (Year 1) and 30 trainees from 13 programs (Year 2) who participated in case log entry, with some overlap between the years. There were a total of 487 fellow-months of data with an average of 14.6 current procedural terminology codes per month and 175.5 per year for cases on the E/D list versus 12 and 143.5 for cases not on the E/D list, respectively. Overall, the most common essential cases were laparotomy for trauma (1,463; 705 in Year 1, 758 in Year 2), tracheostomy (665; 372 in Year 1, 293 in Year 2) and gastrostomy tubes (566; 289 in Year 1, 277 in Year 2). There are a total of 73 types of essential operations and 45 types of desirable operations in the current curriculum. There were 16 distinct codes (13.6%) never used, of which 6 overlapped with other codes. Based on body region, the 10 E/D codes never used by any fellow were as follows: one head/face, lateral canthotomy; five neck; elective neck dissections; one thoracic, vascular trauma to chest; three pediatrics, inguinal hernia repair and small bowel obstruction treatments. CONCLUSION The current ACS trainees lack adequate head/neck and pediatric experience as defined by the ACS curriculum. Restructuring rotations at individual institutions and a focus on novel educational modalities may be needed to augment the individual institutional exposure. Reevaluation of the curriculum may be warranted.

A research agenda for emergency general surgery: health policy and basic science.

A care surgery encompasses the fields of trauma, burn and surgical critical care, and now emergency general surgery (EGS). The EGS patient is defined by the American Association for the Surgery of Trauma (AAST) Severity Assessment Committee as any patient (inpatient or emergency department) requiring an emergency surgical evaluation (operative or nonoperative) for a disease generally considered within the realm of general surgery. In an accompanying article, Shafi present the technical definition of EGS using DRG International Classification of DiseasesV9th Rev. codes and identified 260 conditions as primary EGS diagnosis codes. Eachyear in theUnitedStates,more than3million patients present with acute conditions requiring timely surgical interventions. The acuity spectrum ranges from appendectomy to necrotizing fasciitis. In fact, more patients present with general surgical emergencies than are diagnosed with diabetes each year. Today, health care is in a period of great changemanifested by the following: 1. The creation of integrated health care networks; 2. The consolidation of hospitals and physician practices; 3. An explosion in information technology; and 4. The development of accountable care organizations.

A research agenda for emergency general surgery: clinical trials.

A care surgery encompasses the fields of trauma, burn, and surgical critical care and now emergency general surgery (EGS). The EGS patient is defined by the American Association for the Surgery of Trauma (AAST) Severity Assessment Committee as any patient (inpatient or emergency department) requiring an emergency surgical evaluation (operative or nonoperative) for a disease generally considered within the realm of general surgery. Today, health care is in a period of great change manifested by the following:

β-Blockade therapy in the perioperative period: is there convincing evidence?

Notwithstanding the several inherent limitations of any retrospective review (including omissions, miscodings or other inaccuracies, potential for selection bias), the study by Richman et al1 in this issue of JAMA Surgery reflects an enormous effort by the authors to analyze a large patient database to assess and measure the adherence and outcomes of β-blockade continuation according to the Surgical Care Improvement Project (SCIP) and the revised SCIP criteria. Since the initiation of the SCIP, specific best-practice metrics have become measurable standards of care. Despite its widespread acceptance and use, the merits of β-blockade in the perioperative setting have been inconsistent based on multiple investigations. Unfortunately, the article “Improved Outcomes Associated With a Revised Quality Measure for Continuing Perioperative β-Blockade” demonstrates, again, the lack of understanding with respect to β-blockade therapy and the associated risks and benefits when use occurs during the perioperative time line. The authors’ primary aim was to examine the relationship between the original SCIP β-blockade (SCIP-BB) measure and cardiovascular events. The most interesting aspect of the article is the secondary analysis that compares the cardiovascular events and mortality between the original and revised SCIP-BB measures. The authors concluded that the revised SCIP-BB measure was associated with decreased cardiovascular events and mortality, whereas the original SCIP-BB measure showed no effect on cardiac events and an actual increase in cerebrovascular accidents. These data call into question the original SCIP-BB criteria, underscoring a concern regarding a lack of benefit and potential harm. Although a significant benefit was able to be demonstrated with the revised criteria, the authors question the appropriateness of large-scale quality measures without adequate research. The Veterans Affairs Surgical Quality Improvement Program serves as an excellent study population, with a large amount of consistent data. The database was able to serve as its own control population, effectively comparing patients who adhered to the original SCIP-BB measure with those who received the prolonged β-blockade described in the revised SCIP-BB measure. The concern inherent in this comparison is that the patients who received the extended β-blockade did not do so as a prescribed quality measure but for reasons unknown. During the study period, all patients were expected to receive the original abbreviated duration of β-blockers. It is impossible to know why certain patients received the prolonged course of β-blockers recommended by the revised SCIP protocol. Although the significantly different rate of cardiovascular and cerebrovascular events between the 2 protocols is alarming, it is difficult to draw any broad conclusions when the 2 patient populations are fundamentally different! While the original SCIP-BB patient group was protocol driven, the revised SCIP-BB group was driven by individual patient and physician treatment plans. An additional concern, which the authors point out, is that the Veterans Affairs patient population is a specific patient population and any conclusions cannot necessarily be applied to the general surgical population. This study raises interesting questions regarding the ideal duration of perioperative β-blockade in surgical patients. Although it is unable to definitively answer those questions, the results of the study serve to demonstrate how little is actually understood regarding the subject, which clearly emphasizes the need for more comprehensive and reproducible research before the enactment of large-scale national quality measures.