Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail ...chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization.
Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis.
Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio OR, 1.59; 95% confidence interval CI, 1.50-1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57-1.71), south (OR, 1.48; 95% CI, 1.43-1.54), then midwest (OR, 1.4; 95% CI, 1.34-1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65-0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22-0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%).Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39-2.39; p < 0.0001), controlled by Injury Severity Score.
Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation.
Epidemiological study, level III.
The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with ...displaced rib fractures in the absence of flail chest.
Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared.
One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02).
In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest.
Therapeutic, level II.
The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that (1) demographic, radiologic, and clinical variables are associated with time to surgery and ...(2) shorter time to SSRF improves acute outcomes.
Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006-2016). The independent variable was days from hospital admission to SSRF (early <1 day, mid 1-2 days, and late 3-10 days). Outcomes included length of operation, number of ribs repaired, prolonged (>24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups.
Five hundred fifty-one patients were analyzed. The median time to SSRF was 1 day (range, 0-10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the midgroup, and 186 (31.9%) in the late group. There was a significant shift toward earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p < 0.01), year of surgery (p < 0.01), age (p = 0.02), mechanism of injury (p = 0.04), and body mass index (p = 0.02). Injury severity was not associated with time to surgery. Despite repairing the same median number of ribs (4; range, 1-13), median length of surgery was 68 minutes longer for the late as compared to the early group (p < 0.01). After controlling for the aforementioned significant covariates, each additional hospital day before SSRF was independently associated with a 31% increased likelihood of pneumonia (p < 0.01), a 27% increased likelihood of prolonged mechanical ventilation (p < 0.01), and a 26% increased likelihood of tracheostomy (p < 0.01).
Surgical stabilization of rib fractures within 1 day of admission is associated with certain demographic and physiologic variables. After controlling for confounding factors, early SSRF was accomplished using less operative time, and was associated with favorable outcomes. When indicated and feasible, SSRF should occur as early as possible.
Therapy, level III.
Surgical stabilization of rib fractures (SSRF) is now a common operation at most high-volume trauma centers. Increased experience with the procedure has spawned a variety of technical modifications ...to minimize incision length, muscle division, scapular retraction, and general tissue trauma. The ultimate example of such a minimally invasive approach is completely thoracoscopic SSRF, which refers to using a video-assisted thoracoscopic surgery (VATS) technique to both reduce and fixate rib fractures in an intra-thoracic fashion. The benefits of thoracoscopic SSRF may be divided broadly into those that relate to the repair of the rib fractures themselves, and those that relate to adjuncts to rib fracture repair. With respect to the former, theoretical benefits include improved visualization of rib fractures (particularly in posterior and sub-scapular locations), minimization of trauma to overlying muscles and nerves, minimization of trauma to intra-thoracic structures, and elimination of palpable plates. With respect to the latter, theoretical advantages include evacuation of retained hemothorax, guided placement of loco-regional anesthesia and chest tubes, and identification and repair of associated, intra-thoracic injuries. A VATS may also aid in trainee education. Despite these theoretical benefits, early attempts at thoracoscopic SSRF have been limited by both user inexperience and inadequate instrumentation. Furthermore, there are currently no data comparing the efficacy of completely thoracoscopic SSRF to either contemporary, minimally-invasive, extra-thoracic SSRF or non-operative management.
A typical pathway for treatment of choledocholithiasis (CD) in emergency general surgery patients involves same admission laparoscopic cholecystectomy (LC) with either preoperative or postoperative ...endoscopic retrograde cholangiopancreatography (ERCP). The goal of this study was to describe our initial experience at a safety net hospital with acute care surgeon-performed laparoscopic common bile duct exploration (LCBDE) when CD is confirmed at the time of LC. We hypothesized that this strategy would result in reduced length of stay, and lower charges compared to ERCP.
This was a retrospective case control study over a 2 year period matching LCBDE to ERCP (1:3) among a cohort of patients with CD confirmed at first procedure. Data is reported as median (interquartile range). Statistical analysis used the Kruskal-Wallis and Chi-squared tests with 95% confidence interval.
Demographics, preoperative WBC, and bilirubin were similar between the LCBDE (n = 14) and ERCP (n = 37) groups. Success rate for LCBDE was 11/14 (79%), and the remaining three subjects successfully underwent post-operative ERCP. Overall complication rate for the LCBDE group was 1/14 (7%) and the readmission rate was 0/14 (0%). Length of stay for LCBDE vs ERCP was 2.5 (1–3) vs 5 (3–5) days (p < 0.01). Charges during initial hospitalization was $35858 ($26587-$49570) vs $48662 ($36018-$57106) (p = 0.05).
LCBDE by acute care surgeons at the time of LC was associated with lower charges, reduced hospital length of stay, low rates of post-operative complications, and no readmissions.
•At a safety net hospital LCBDE at the time of LC is associated with reduced length of stay and charges compared to ERCP.•LCBDE at the time of laparoscopic cholecystectomy is a safe and effective procedure.•Common bile duct exploration at the time of LC is within the skill set of ACS and General Surgeons.
Abstract Background We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with ...earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified. Methods Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria. Results BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms. Conclusions There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.
BACKGROUND:Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, ...randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA).
METHODS:This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival.
RESULTS:One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients CCA5.0 (2–11), TEG4.5 (2–8) (P = 0.317), but more plasma units CCA2.0 (0–4), TEG0.0 (0–3) (P = 0.022), and more platelets units CCA0.0 (0–1), TEG0.0 (0–0) (P = 0.041) in the first 2 hours of resuscitation.
CONCLUSIONS:Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.
PDF
