Loek P. H. Leenen

The registration of complications in surgery: a learning curve.

Registration of complications in surgery is an important method used for quality improvement. Unfortunately many different definitions and classification systems have been used, which influences the interpretation and the outcome of complication registration. Since 1986 complications have been registered on a daily basis in our surgical department. We focus in this article on the influence of changes in interpretation of the definition and registration methods used on the incidence of registered complications. Between 1986 and 1993 complications registered were strictly related to surgical procedures. In the second period, between 1993 and 2001, the interpretation of the definition changed and all adverse events were registered in a patient-centred way, not only related to the surgical procedure. The definition used in both periods did not change. In 1993 we started with the implementation of a fully automated registration system in our surgical department. In the first period 1699 (7%) complications in 24,201 surgical procedures were registered and in the second period 8335 (27%) complications were registered in 31,161 surgical procedures. A dramatic increase in the total number of registered complications was seen with the implementation of a fully automated registration system and a patient-centred way of registering complications. In the context of the evolving discussion of quality of care, a uniform definition and registration system has to be used to assure reliable outcome data in surgery and to form a basis for comparison.

Feasibility of using head and neck CT imaging to assess skeletal muscle mass in head and neck cancer patients

OBJECTIVES Patients with head and neck cancer (HNC) have a higher risk of malnutrition and sarcopenia, which is associated with adverse clinical outcome. As abdominal CT-imaging is often used to detect sarcopenia, such scans are rarely available in HNC patients, possibly explaining why no studies investigate the effect of sarcopenia in this population. We correlated skeletal muscle mass assessed on head and neck CT-scans with abdominal CT-imaging. METHODS Head and neck, and abdominal CT-scans of trauma (n=51) and HNC-patients (n=52) were retrospectively analyzed. On the head and neck CT-scans, the paravertebral and sternocleidomastoid muscles were delineated. On the abdominal CT-scans, all muscles were delineated. Cross-sectional area (CSA) of the muscles at the level of the C3 vertebra was compared to CSA at the L3 level using linear regression. A multivariate linear regression model was established. RESULTS HNC-patients had significantly lower muscle CSA than trauma patients (37.9 vs. 45.1cm2, p<0.001, corrected for sex and age). C3 muscle CSA strongly predicted L3 muscle CSA (r=0.785, p<0.001). This correlation was stronger in a multivariate model including sex, age and weight (r=0.891, p<0.001). DISCUSSION Assessment of skeletal muscle mass on head and neck CT-scans is feasible and may be an alternative to abdominal CT-imaging. This method allows assessment of sarcopenia using routinely performed scans without additional imaging or additional patient burden. Identifying sarcopenic patients may help in treatment selection, or to select HNC patients for physiotherapeutic or nutritional interventions to improve their outcome.

Variation in treatment of blunt splenic injury in Dutch academic trauma centers

BACKGROUND The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality. METHODS Consecutive adult patients who were admitted between January 2009 and December 2012 to five academic level 1 trauma centers were identified. Multinomial logistic regression was used to measure the influence of hospital on treatment strategy, controlling for hemodynamic instability on admission, high grade (American Association for the Surgery of Trauma 3-5) splenic injury, and injury severity score. Binary logistic regression was used to quantify differences among hospitals in splenic salvage rate. RESULTS A total of 253 patients were included: 149 (59%) were observed, 57 (23%) were treated with splenic artery embolization and 47 (19%) were operated. The observation rate was comparable in all hospitals. Splenic artery embolization and surgery rates varied from 9%-32% and 8%-28%, respectively. After adjustment, the odds of operative management were significantly higher in one hospital compared with the reference hospital (adjusted odds ratio 4.98 [1.02-24.44]). The odds of splenic salvage were significantly lower in another hospital compared with the reference hospital (adjusted odds ratio 0.20 [0.03-1.32]). CONCLUSIONS Although observation rates were comparable among the academic trauma centers, embolization and surgery rates varied. A nearly 5-fold increase in the odds of operative management was observed in one hospital, and another hospital had significantly lower odds of splenic salvage. The development of a national guideline is recommended to minimalize splenectomy after trauma.

The Hospital Trauma Index

Background and Purpose:The Injury Severity Score (ISS) is a widely used trauma scoring system which, based on the Hospital Trauma Index (HTI), categorizes injury into six different organ systems. A possible limitation is the equal weight given to each body region, although this equal qualification is not appropriate when predicting mortality. This study was undertaken to determine the impact on mortality of equal injury severity in different body regions.Patients and Methods:All consecutive multiply injured patients (HTI-ISS ≥ 18) treated over a 4-year period in the University Medical Center Utrecht, the Netherlands, were reviewed. The prognostic value of the HTIISS concerning mortality was assessed, before and after incorporating the presence of relevant injury (HTI ≥ 3) in each separate organ system, with receiver operating characteristics and logistic regression modeling.Results:The HTI-ISS proved to be a good predictor of mortality. In the highest quintile, 55% of the patients died. The area under the curve (AUC) was 0.83 (95% confidence interval [CI] 0.79–0.87). The risk of dying increased 13 times (hazard ratio [HR] 13.2 [6.5–26.8]) once relevant head injury was present. After incorporation of head injury, the prognostic value of the HTI-ISS increased to 0.87 (95% CI 0.84–0.91). Injury in any of the other organ systems did not significantly increase the prognostic value of the HTI-ISS for mortality.Conclusion:The prognostic value of the HTI-ISS for mortality is fairly good. If the weight of head injury in the HTI-ISS is doubled, the predicted probability rises significantly to an AUC of 0.87. It is too far-fetched to change the calculation of the HTI-ISS based on one study, but one should be aware of the impact of relevant injuries to the head. This study confirms the expert opinion that relevant to severe head injury is a special and dominant predictor of mortality in multiply injured patients.

Injuries related to bicycle accidents: an epidemiological study in The Netherlands

Background This study aims to analyze the incidence and outcomes of bicycle-related injuries in hospitalized patients in The Netherlands. Methods Bicycle accidents resulting in hospitalization in a level-I trauma center in The Netherlands between 2007 and 2017 were retrospectively identified. We subcategorized data of patients involved in a regular bicycle, race bike, off-road bike or e-bike accident. The primary outcomes were mortality rate and incidence of multitrauma. Secondary outcomes were differences between bicycle subcategories. Independent risk factors were identified using multivariable logistic regression. All variables with a p value < 0.20 in univariable analysis were entered in multivariable analysis. Results We identified 1986 patients. The mortality rate after emergency room admission was 5.7%, and 41.0% were multitraumas. A higher age, multitrauma and cerebral haemorrhages were independent risk factors for in hospital mortality. Independent risk factors found for multitrauma were a higher age, two-sided trauma, e-bike accidents and cerebral haemorrhage. Conclusion Bicycle accidents resulting in hospitalization have a high mortality rate. Furthermore, a high incidence of multitrauma, fractures and cerebral haemorrhages were found. Considering the increasing incidence of bicycle accident victims needing hospital admission, new and more efficient prevention strategies are essential.

Introducing the Surgical Therapeutic Index in trauma surgery: an assessment tool for the benefits and risks of operative fracture treatment strategies

BACKGROUND The Surgical Therapeutic Index (STI) has been described as an indicator of the benefits and risks of surgical treatment. The index is calculated by dividing the cure rate of an operative treatment by the complication rate. This study introduces the STI in trauma surgery by comparing the indices for surgical plate fixation (PF) and intramedullary fixation (IMF) of displaced midshaft clavicular fractures. METHODS In a previously reported, randomized controlled fashion, 120 patients were assigned to PF or IMF. Cure was defined by a Disabilities of the Arm, Shoulder and Hand score of 8 or less. Complications were noted as present or not present for each follow-up assessment, and a panel of experts provided weights to the severity of complications. STIs were reported along with their 95% confidence intervals. The higher a procedures STI, the higher the benefit/risk balance of that procedure. RESULTS The nonweighted STI after 6 weeks was significantly higher in the PF group. During further follow- up, the differences leveled out and became nonsignificant. When weighting the STI for severity, the indices decrease but are significantly in favor of the PF group at 6 weeks and 6 months after surgery. At 1 year postoperatively, differences are not significant. CONCLUSION The STI may be a reliable tool to assess the benefits and risks of operative fracture treatment. Further studies with consistent results of this new scoring system are needed before conclusions can be generalized. When determining the indices of PF and IMF, a significant difference in favor of PF was observed during the early phase of recovery.

Pneumocephalus Following Severe Head Trauma

It is important to be alert to the possibility of pneumocephalus in patients with head injury. Pneumocephalus is a potentially lethal complication in patients with craniofacial fractures following severe head trauma. A patient presented with intracranial air after he fell down from a height of 4 m. The patient recovered without any neurological deficits after conservative treatment. A time sequence of cerebral CT scans shows how the pneumocephalus developed and finally resolved without surgical intervention. The etiology, diagnosis, treatment and possible complications of this injury are discussed briefly.

The Influence of Blood Transfusion on Mortality in Multiply Injured Patients

Background and Purpose:Severely injured patients often need large amounts of blood transfusion. Besides the life-saving effect, it is known to have negative side effects as well, affecting multiple organ systems. These side effects may add significantly to the already high mortality rate of these patients. This study was undertaken to determine the independent influence of the speed (= relative) as well as the total (= absolute) amount of blood transfusion given to multiply injured patients on mortality.Patients and Methods:All consecutive multiply injured patients with an Injury Severity Score (ISS) ≥ 18, based on the Hospital Trauma Index (HTI), treated over a 4-year period in the University Medical Center Utrecht, The Netherlands, were reviewed. Using cross tabulation analysis, the relation between relative and absolute blood transfusion and mortality was described. Potential transfusion-influencing factors were selected on the basis of literature and common knowledge. The independent effect of blood transfusion on mortality was calculated by means of nonparametric tests and binary logistic regression analysis.Results:The mean age of the 668 included patients was 36.8 years (standard deviation [SD] ± 18.5 years) and the median HTI-ISS 30 (range 18–75). 360 patients needed blood transfusion. Their mean relative blood transfusion was 8.5 PRBCrel (SD ± 11) (and their mean absolute blood transfusion 12.7 PRBCabs (SD ± 17). The overall mortality was 18.4%. The patients without blood transfusion (n = 308) had a mortality rate of 14%. The mortality rate of the patients with > 30 PRBCrel relative transfusion (n = 14) was highest with 50%. Both relative as well as absolute transfusion displayed no significant influence on mortality. The HTI-ISS, hemothorax, splenic and hepatic injury, laparotomy, vascular or retroperitoneal injury, and fractures of the pelvis and/or femur were exhibited as having significant influence on blood transfusion.Conclusion:The seemingly significant influence of both relative and absolute blood transfusion on mortality, even in high amounts, disappeared after correction for the significant determinants mentioned above. Blood transfusion itself does not turn the scale in decision-making for treatment of severely injured patients.