Samer Schuman, MD; Gail Walker, PhD; Eli Avisar, MD
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Arch Surg. 2011;146(4):389-393. doi:10.1001/archsurg.2011.29
Megan Brenner, MD, MS; Grant Bochicchio, MD, MPH; Kelly Bochicchio, RN, MS; et al.
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Arch Surg. 2011;146(4):395-399. doi:10.1001/archsurg.2010.284
HypothesisDamage control laparotomy (DCL) has beneficial effects on the long-term morbidity and survival of trauma patients.DesignProspective study.SettingLevel I trauma center.PatientsEighty-eight trauma patients who were admitted during a 3-year period (January 1, 2000, through December 31, 2003) underwent damage control laparotomy and were subsequently followed up (January 1, 2001, through December 31, 2008).InterventionDamage control laparotomy.Main Outcome MeasuresMajor and long-term complications, lengths of stay, mortality, readmissions, subsequent surgical procedures, activities of daily living, and return to work.ResultsOn admission, the mean age and Injury Severity Score were 33 years and 34, respectively. Of the 88 patients, 66 (75%) were male; 46 patients had blunt injuries and 42 had penetrating injuries. Liver was the most common injury (63 patients), followed by bowel (34), spleen (33), major vessel (19), and pancreas (10). The mean admission pH and temperature were 7.19 and 34.4掳C, respectively, with 21.5 U of packed red blood cells transfused. The mean (SD) number of initial abdominal operations was 4.6 (2.5) per patient, with an overall mortality of 28% (25 patients). Intensive care unit and hospital lengths of stay were 18 (15) and 32 (20) days, respectively. Of the 63 patients who survived, 58 underwent intra-abdominal closure with polyglactin mesh. During the study, 44 intra-abdominal infections and 18 enterocutaneous fistulas were diagnosed. All 63 survivors were readmitted at least once. There were a total of 186 readmissions and 92 subsequent surgical procedures. Ventral hernia repair (66 readmissions) was the most common reason for readmission, followed by infection (41) and fistula management (29). There was 0% mortality for patients who survived the preliminary hospitalization. Of the 63 surviving patients, 51 (81%) reported that they had gone back to work and resumed normal daily activities.ConclusionAlthough damage control laparotomy is associated with a significant complication and readmission rate, its overall benefit is indisputable.
Hossein Masoomi, MD; Brian S. Buchberg, MD; Cheryl Magno, MPH; et al.
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Arch Surg. 2011;146(4):400-406. doi:10.1001/archsurg.2010.276
ObjectiveTo demonstrate the recent trends of admission and surgical management for diverticulitis in the United States.DesignRetrospective database analysis.SettingThe National Inpatient Sample database.PatientsPatients admitted to the hospital for diverticulitis from 2002 to 2007.Main Outcome MeasuresPatient characteristics, surgical approach, and mortality were evaluated for elective or emergent admission.ResultsA total of 1聽073聽397 patients were admitted with diverticulitis (emergent: 78.3%, elective: 21.7%). The emergent admission rate increased by 9.5% over the study period. For emergent patients, 12.2% underwent urgent surgical resection and 87.8% were treated with nonoperative methods (percutaneous abscess drainage: 1.88% and medical treatment: 85.92%). There was only a 4.3% increase in urgent surgical resections, while elective surgical resections increased by 38.7.%. The overall rate of elective laparoscopic colon resection was 10.5%. Elective laparoscopic surgery nearly doubled from 6.9% in 2002 to 13.5% in 2007 (P听&濒迟;听.001). Primary anastomosis rates increased for elective resections over time (92.1% in 2002 to 94.5% in 2007; P听&濒迟;听.001). For urgent open operation, use of colostomy decreased significantly from 61.2% in 2002 to 54.0% in 2007 (P听&濒迟;听.001). In-hospital mortality significantly decreased in both elective and urgent surgery (elective: 0.53% in 2002 to 0.44% in 2007; P聽=聽.001; urgent: 4.5% in 2002 to 2.5% in 2007; P听&濒迟;听.001).ConclusionDiverticulitis continues to be a source of significant morbidity in the United States. However, our data show a trend toward increased use of laparoscopic techniques for elective operations and primary anastomosis for urgent operations.
Athanasios Bramos, MD; George C. Velmahos, MD, PhD; Umar M. Butt, MD; et al.
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Arch Surg. 2011;146(4):407-411. doi:10.1001/archsurg.2010.277
HypothesisStable pelvic fractures (SPFs) that do not need operative fixation are only infrequently associated with significant bleeding (SigBleed). Our hypothesis is that simple indicators, easily detectable at the bedside, can alert the clinician about the likelihood of bleeding and the need for closer monitoring or early intervention in patients with SPFs.DesignRetrospective review of medical records.SettingAcademic level 1 trauma center.PatientsThe medical records of patients with SPFs admitted to our academic level 1 trauma center from January 1, 2002, to June 30, 2007, were reviewed. Stable pelvic fractures were defined as fractures not requiring external or internal fixation. SigBleed was defined as the need for blood transfusion and/or intervention for bleeding control within the first 24 hours after admission. The patients were divided into group A, which included patients without SigBleed; group B, which included patients with SigBleed of a nonpelvic cause; and group C, which included patients with SigBleed caused by the SPF. The 3 groups were compared by univariate and multivariate analysis.Main Outcome MeasureSignificant bleeding from SPFs.ResultsOf 391 patients with SPFs, 280 (72%) were in group A, 90 (23%) were in group B, and 21 (5%) were in group C. Compared with group A patients, those in group C were older and had a lower hematocrit and systolic blood pressure on admission. They also had longer hospital stays and a higher mortality. The following independent predictors of SigBleed from SPF were identified: hematocrit of 30% or lower (odds ratio [OR], 43.93; 95% confidence interval [CI], 9.78-197.32; P聽<聽.001); presence of pelvic hematoma on computed tomographic scan (OR, 39.37; 95% CI, 4.58-338.41; P聽<聽.001); and systolic blood pressure of 90 mm Hg or lower (OR, 18.352; 95% CI, 1.98-169.87; P聽=聽.01). When all independent predictors were present, 100% of the patients had SigBleed; when all were absent, no one had SigBleed.ConclusionsThe incidence of SigBleed due to SPFs is low (5% in this study) and independently predicted by an admission hematocrit of 30% or lower, the presence of a pelvic hematoma on computed tomographic scan, and systolic blood pressure of 90 mm Hg or lower.
Tim K. Timmers, MD; Michiel H. J. Verhofstad, MD, PhD; Karl G. M. Moons, MSc, PhD; et al.
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Arch Surg. 2011;146(4):412-418. doi:10.1001/archsurg.2010.279
ObjectivesTo quantify the long-term (>6 years) health-related quality of life (HRQOL) of a large cohort of patients admitted to a surgical intensive care unit (ICU). In addition, we aimed to explore the influence of different surgical classifications on long-term health status and to make comparisons with general population norms.DesignProspective observational cohort study.SettingA Dutch teaching hospital.PatientsAll surviving surgical ICU patients admitted to the Dutch teaching hospital between 1995 and 2000.Main Outcome MeasuresPatient-reported data on HRQOL were collected with the EuroQol-6D (EQ-6D) after a mean follow-up of 8 years (range, 6-11 years). Patient characteristics, surgical classification, length of ICU stay, and survival were prospectively registered. The EQ utility scores (measured with the EQ-5D US index tariff), EQ visual analog scale scores, and prevalences of domain-specific health problems were calculated. The effect of surgical classification on EQ utility scores and EQ visual analog scale scores was assessed by multivariable generalized linear regression analysis. Logistic regression was used to explore the influence of surgical classification on domain-specific health problems. Long-term HRQOL of surgical ICU patients was compared with an age- and sex-matched general Dutch population using t test analysis.ResultsEight hundred thirty-four patients survived the ICU and were available for follow-up. In 575 patients (69%), the HRQOL was measured. For all surgical classifications combined, after 6 to 11 years, nearly half of all patients still had problems with mobility (52%), usual activity (52%), pain/discomfort (57%), and cognition (43%). Compared with the age- and sex-matched general population, HRQOL was worse, with a difference of 0.11 on the EQ utility score (range, 0-1). Oncological surgery patients had the best (EQ utility score, 0.83) and vascular patients had the worst (EQ utility score, 0.72) HRQOL. Trauma (odds ratio between 2.47-3.47) and vascular surgery (odds ratio between 2.27-5.37) patients showed significantly increased prevalences of problems in mobility, self-care, usual activities, and cognition.ConclusionsMore than 6 years after a surgical ICU admission, HRQOL of this patient population is largely reduced. Many patients still have a variety of health problems, including decreased cognitive functioning. Treatment advances should be made to reduce the current health deficit of surgical ICU survivors compared with the general population.
Anthony G. Gallagher, PhD; Emily Boyle, MRCS; Paul Toner, PhD; et al.
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Arch Surg. 2011;146(4):419-426. doi:10.1001/archsurg.2011.67
Matthew C. Koopmann, MD; Brett H. Yamane, MD; James R. Starling, MD
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Arch Surg. 2011;146(4):427-431. doi:10.1001/archsurg.2011.49
Brian J. Wheatley, MD; M. Ashraf Mansour, MD; P. Michael Grossman, MD; et al.
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Arch Surg. 2011;146(4):432-435. doi:10.1001/archsurg.2011.47
Janice H. H. Yeung, PhD; Antonina A. Mikocka-Walus, PhD; Peter A. Cameron, MD; et al.
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Arch Surg. 2011;146(4):436-442. doi:10.1001/archsurg.2011.46
Patrizio Petrone, MD; Grant Sarkisyan, MD; Eileen Coloma, NP; et al.
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Arch Surg. 2011;146(4):444-447. doi:10.1001/archsurg.2011.55
Shirin Towfigh, MD; Tatyan Clarke, MD; Wael Yacoub, MD; et al.
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Arch Surg. 2011;146(4):448-452. doi:10.1001/archsurg.2011.61
Gerald S. Lipshutz, MD; Suzanne McGuire, RN; Qing Zhu, RN; et al.
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Arch Surg. 2011;146(4):453-458. doi:10.1001/archsurg.2011.40
Meghann L. Kaiser, MD; Matthew D. Whealon, BS; Cristobal Barrios Jr, MD; et al.
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Arch Surg. 2011;146(4):459-463. doi:10.1001/archsurg.2011.56
Amitai Bickel, MD; Michael Gurevits, MD; Ronny Vamos, MD; et al.
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Arch Surg. 2011;146(4):464-470. doi:10.1001/archsurg.2011.65
Christopher P. Neal, MRCS, PhD; Christopher D. Mann, MRCS; Giuseppe Garcea, MD, MRCS; et al.
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Arch Surg. 2011;146(4):471-478. doi:10.1001/archsurg.2011.50