American Association For The Surgery Of Trauma Classification Research Articles

Single centre analysis of factors influencing surgical treatment of splenic trauma in children.

This study aims to investigate determinants impacting the surgical management of splenic trauma in paediatric patients by scrutinizing age distribution, etiological factors and concomitant injuries. The analysis seeks to establish a foundation for delineating optimal operative timing. A cohort of 262 paediatric cases presenting with splenic trauma at our institution from January 2011 to December 2021 underwent categorization into either the conservative or operative group. Significantly disparate attributes between the two groups included age, time of presentation, blood pressure, haemoglobin levels, blood transfusion requirements, thermal absorption, American Association for the Surgery of Trauma (AAST) classification and associated injuries. Logistic regression analysis revealed age, haemoglobin levels, AAST classification and blood transfusion as autonomous influencers of surgical intervention (OR = 1.024, 95% CI: 1.011-1.037; OR = 1.067, 95% CI: 1.01-1.127; OR = 0.2760, 95% CI: 0.087-0.875; OR = 7.873, 95% CI: 2.442-25.382; OR = 0.016, 95% CI: 0.002-0.153). The AAST type and age demonstrated areas under the receiver operating characteristic (ROC) curve of 0.782 and 0.618, respectively. Age, haemoglobin levels, AAST classification and blood transfusion independently influence the decision for surgical intervention in paediatric patients with splenic trauma. Age and AAST classification emerge as viable parameters for assessing and prognosticating the likelihood of surgical intervention in this patient cohort.

PD12-01 THE ROLE OF NON-OPERATIVE MANAGEMENT IN SEVERE RENAL INJURIES: DO ALL GRADE V INJURIES NECESSITATE INTERVENTION?

You have accessJournal of UrologyCME1 Apr 2023PD12-01 THE ROLE OF NON-OPERATIVE MANAGEMENT IN SEVERE RENAL INJURIES: DO ALL GRADE V INJURIES NECESSITATE INTERVENTION? Nizar Hakam, Sorena Keihani, Nathan Shaw, Douglas Rogers, Sherry Wang, Joel Gross, Ryan Joyce, Patrick Selph, Judith Hagedorn, Rachel Moses, Ian Schwartz, Shubham Gupta, Christopher Dodgion, Nima Baradaran, Bradley Erickson, Frank Burks, Richard Santucci, Joshua Broghammer, Jeremy Myers, and Benjamin Breyer Nizar HakamNizar Hakam More articles by this author , Sorena KeihaniSorena Keihani More articles by this author , Nathan ShawNathan Shaw More articles by this author , Douglas RogersDouglas Rogers More articles by this author , Sherry WangSherry Wang More articles by this author , Joel GrossJoel Gross More articles by this author , Ryan JoyceRyan Joyce More articles by this author , Patrick SelphPatrick Selph More articles by this author , Judith HagedornJudith Hagedorn More articles by this author , Rachel MosesRachel Moses More articles by this author , Ian SchwartzIan Schwartz More articles by this author , Shubham GuptaShubham Gupta More articles by this author , Christopher DodgionChristopher Dodgion More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Frank BurksFrank Burks More articles by this author , Richard SantucciRichard Santucci More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Jeremy MyersJeremy Myers More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Non-operative management has become standard for most renal trauma. Little data exists regarding conservative management of American Association for the Surgery of Trauma (AAST) grade V injuries. We aim to evaluate management of grade V renal trauma, focusing on feasibility and safety of non-operative management. METHODS: Grade V renal trauma cases submitted with available imaging from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We report management patterns categorized as expectant (observation with no interventions), conservative (performing kidney angioembolization, or stent / nephrostomy tube / perirenal drain placement), or operative (performing kidney related surgical interventions). RESULTS: 21 cases were independently radiologically verified as grade V cases by the 2018 AAST classification and were included in analysis. Most were males (15; 71%) with blunt trauma (20; 95%) and median age was 34 years (IQR 25-29). Most common management approach was operative (8, 38%), followed by conservative (7, 33%) and expectant (6, 29%). All those operatively management had nephrectomy, with 2 having a failed angioembolization attempt before nephrectomy. 4 out of 7 patients in the conservative group had angioembolization and the other 3 had a stent or drainage tube. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size, laceration size and proportion of cases with >50% and >95% devascularization (Table 1). Vascular contrast extravasation tended to be higher in operatively managed patients, but was not statistically significant. CONCLUSIONS: There is a significant role for non-operative management for grade V renal trauma, particularly in those with blunt trauma and are stable enough to undergo imaging. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e400 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nizar Hakam More articles by this author Sorena Keihani More articles by this author Nathan Shaw More articles by this author Douglas Rogers More articles by this author Sherry Wang More articles by this author Joel Gross More articles by this author Ryan Joyce More articles by this author Patrick Selph More articles by this author Judith Hagedorn More articles by this author Rachel Moses More articles by this author Ian Schwartz More articles by this author Shubham Gupta More articles by this author Christopher Dodgion More articles by this author Nima Baradaran More articles by this author Bradley Erickson More articles by this author Frank Burks More articles by this author Richard Santucci More articles by this author Joshua Broghammer More articles by this author Jeremy Myers More articles by this author Benjamin Breyer More articles by this author Expand All Advertisement PDF downloadLoading ...

Toward automated interpretable AAST grading for blunt splenic injury.

The American Association for the Surgery of Trauma (AAST) splenic organ injury scale (OIS) is the most frequently used CT-based grading system for blunt splenic trauma. However, reported inter-rater agreement is modest, and an algorithm that objectively automates grading based on transparent and verifiable criteria could serve as a high-trust diagnostic aid. To pilot the development of an automated interpretable multi-stage deep learning-based system to predict AAST grade from admission trauma CT. Our pipeline includes 4 parts: (1) automated splenic localization, (2) Faster R-CNN-based detection of pseudoaneurysms (PSA) and active bleeds (AB), (3) nnU-Net segmentation and quantification of splenic parenchymal disruption (SPD), and (4) a directed graph that infers AAST grades from detection and segmentation results. Training and validation is performed on a dataset of adult patients (age ≥ 18) with voxelwise labeling, consensus AAST grading, and hemorrhage-related outcome data (n = 174). AAST classification agreement (weighted κ) between automated and consensus AAST grades was substantial (0.79). High-grade (IV and V) injuries were predicted with accuracy, positive predictive value, and negative predictive value of 92%, 95%, and 89%. The area under the curve for predicting hemorrhage control intervention was comparable between expert consensus and automated AAST grading (0.83 vs 0.88). The mean combined inference time for the pipeline was 96.9s. The results of our method were rapid and verifiable, with high agreement between automated and expert consensus grades. Diagnosis of high-grade lesions and prediction of hemorrhage control intervention produced accurate results in adult patients.

Re-interventions following appendectomy in children: a multicenter study.

Acute appendicitis is the most frequent cause of acute abdomen in children. The objective of this study was to analyze the causes, approach, and results of complications requiring surgery following appendectomy. A retrospective study of the appendectomies conducted in three third-level institutions from 2015 to 2019 was carried out. Complications, causes, and number of re-interventions, time from one surgery to another, surgical technique used, operative findings at baseline appendectomy according to the American Association for the Surgery of Trauma (AAST) classification, and hospital stay were collected. 3,698 appendicitis cases underwent surgery, 76.7% of which laparoscopically, with 37.2% being advanced (grades II-V of the AAST classification). Mean operating time was 50.4 minutes (49.8 ± 20.1 for laparoscopy vs. 49.9 ± 20.1 for open surgery, p>0.05), and longer in patients requiring re-intervention (68.6±27.2 vs. 49.1 ± 19.3, p < 0.001). 76 re-interventions (2.05%) were carried out. The causes included postoperative infection (n = 46), intestinal obstruction (n=20), dehiscence (n = 4), and others (n = 6). Re-intervention risk was not impacted by the baseline approach used (open surgery or laparoscopy, OR: 1.044, 95% CI: 0.57-1.9), but it was by appendicitis progression (7.8% advanced vs. 0.7% incipient, OR: 12.52, 95% CI: 6.18-25.3). There was a tendency to use the same approach both at baseline appendectomy and re-intervention. This occurred in 72.2% of laparoscopic appendectomies, and in 67.7% of open appendectomies. The minimally invasive approach (50/76) was more frequent than the open one (27 laparoscopies and 23 ultrasound-guided drainages vs. 26 open surgeries) (p < 0.05). 55% of obstruction patients underwent re-intervention through open surgery (p > 0.05). Re-intervention rate was higher in advanced appendicitis cases. In this series, the minimally invasive approach (laparoscopic or ultrasound-guided drainage) was the technique of choice for re-interventions.

Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes

BackgroundThe American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record. MethodsOur institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine—a machine learning algorithm attuned for small sample sizes—was used to compare the associations between the two classification systems and decision to operate and incidence of complications. Results67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%). ConclusionsThis study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.

Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma

IntroductionPancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures. Patients and MethodsWe retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003–2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification. ResultsThe median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety. ConclusionsOften extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.

Management of Splenic Injuries Utilizing a Multidisciplinary Protocol in 110 Consecutive Patients at a Level II Hospital

IntroductionNon-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. Aim of the present study was to assess the failure rate of the NOM after implantation of a multidisciplinary protocol for splenic injuries comparing the results with the literature. Methods16-year retrospective study. Management of these lesions was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), grades of injuries according to the American Association for the Surgery of Trauma(AAST), failure of the NOM, morbidity and mortality. Results110 patients were included, 90 (81.8%) men, 20 (18.2%) women; mean age 37 years; 106 (96.5%) cases were blunt and four (3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14 (13%) patients were grade I; 24 (22%) grade II; 34 (31%) grade III; 37 (34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was established in 56, conservative surgery in 16 and splenectomy in 38. Ten patients presented postoperative complications: seven in the splenectomy group, two in the conservative surgery group and one in non-operative group. One patient died. Average hospital stay: 22.8 days- TNO 17.6 days, conservative surgery 29, splenectomy 22.4 days. ConclusionsAlthough we continue with a high hospital stay, our results are comparable to the literature. The implementation of the protocol by consensus contributed to the change towards NOM.

Resultados en el tratamiento de traumatismos esplénicos utilizando un protocolo multidisciplinar en 110 pacientes consecutivos en un hospital de nivel II

IntroductionNon-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. The aim of the present study was to assess the failure rate of NOM after implementation of a multidisciplinary protocol for splenic injuries compared to literature results. MethodsA retrospective study was performed over a 16-year period. Patient data and management of splenic trauma was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), injury grade according to the American Association for the Surgery of Trauma(AAST), failure of NOM, morbidity and mortality. ResultsOne hundred ten patients were included: 90(81.8%) men, 20(18.2%) women; mean age 37 years; 106(96.5%) cases were blunt and four(3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14(13%) grade I; 24(22%) grade II; 34(31%) grade III; 37(34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was utilized in 56 patients, spleen-preserving surgery in 16, and splenectomy in 38. Ten patients had postoperative complications: seven in the splenectomy group, two in the spleen-preserving surgery group, and one in the NOM group. One patient died. Average hospital stay: 22.8 days- NOM 17.6 days, conservative surgery 29 days, splenectomy 22.4 days. ConclusionsAlthough we continue with a high hospital stay, the literature reports support our results. The implementation of the protocol by consensus contributed to the change towards NOM.

Can we refine the management of blunt liver trauma?

To describe the management of blunt liver injury and to study the potential relation between delayed complications, type of trauma mechanisms and liver lesions. This is a retrospective single center study including 116 consecutive patients admitted with blunt liver injury between 2007 and 2015. Initial CT-scan identified an active bleeding in 33 (28%) patients. AAST (American Association for the Surgery of Trauma) grade was 1 to 3 in 82 (71%) patients and equal to 5 in 15 (13%) patients. Eighty (69%) patients had NOM, with a success rate of 96%. Other abdominal organ lesions were associated to invasive initial management. A follow-up CT-scan was useful to detect hepatic and extra-hepatic complications (46 complications in 80 patients), even without clinical or biological abnormalities. Subsequent hepatic complications such as bleeding, pseudo aneurysms, biloma and biliary peritonitis developed in 15 patients and were associated with the severity of blunt liver injury according to AAST classification (3.7±1.0 vs. 3.0±1.1, P=0.010). Total biliary complications occurred in 13 patients and were significantly more frequently observed in patients with injury of central segments 1, 4 and 9 (69% vs. 36%, P=0.033). Non-operative management is possible in most blunt liver injury with a success rate of 96%. A systematic CT-scan should be advocated during follow-up, especially when AAST grade is equal or superior to 3. Biliary complications should be suspected when lesions involve segments 1, 4 and 9.

MDCT of blunt renal trauma: imaging findings and therapeutic implications.

ObjectivesTo show the wide spectrum of computed tomography (CT) findings in blunt renal trauma and to correlate them with consequent therapeutic implications.MethodsThis article is the result of a literature review and our personal experience in a level II trauma centre. Here we describe, discuss and illustrate the possible CT findings in blunt renal trauma, and we correlate them with the American Association for the Surgery of Trauma (AAST) classification and their therapeutic implications.ResultsCT findings following blunt renal trauma can be grouped into 15 main categories, 12 of them directly correlated with the AAST classification and 3 of them not mentioned in it. Non-operative management, which includes the “watchful waiting” approach, endourological treatments and endovascular treatments, is nowadays widely adopted in blunt renal trauma, and surgery is limited to haemodynamically unstable patients and a minority of haemodynamically stable patients.ConclusionsThe interpretation of CT findings in blunt renal trauma may be improved and made faster by the knowledge of their therapeutic consequences.Teaching Points• The majority of blunt renal injuries do not require surgical treatment.• CT findings in blunt renal injury must be evaluated considering their therapeutic consequences.• Some CT findings in blunt renal trauma are not included in the AAST classification.

OWN EXPERIENCE OF SURGICAL TREATMENT OF BLUNT RENAL TRAUMA

37 patients with blunt renal trauma were surgery at our clinic between1989 and 2013 yrs. Basing on our own experience as well as generally accepted standards of treatment, we developed a tactic of treatment of this pathology. In daily work we used two classifications: proposed by the American Association for the Surgery of Trauma (AAST) in 1989 and proposed by prof. S.A. Vozianov and prof. A.V. Shulyak in 2003. An analysis of the research was carried out; it demonstrates the efficacy of conservative treatment in patients with blunt renal trauma III-V grades according to AAST classification.

Reliability of injury grading systems for patients with blunt splenic trauma

ObjectivesThe most widely used grading system for blunt splenic injury is the American Association for the Surgery of Trauma (AAST) organ injury scale. In 2007 a new grading system was developed. This ‘Baltimore CT grading system’ is superior to the AAST classification system in predicting the need for angiography and embolization or surgery. The objective of this study was to assess inter- and intraobserver reliability between radiologists in classifying splenic injury according to both grading systems. MethodsCT scans of 83 patients with blunt splenic injury admitted between 1998 and 2008 to an academic Level 1 trauma centre were retrospectively reviewed. Inter and intrarater reliability were expressed in Cohen's or weighted Kappa values. ResultsOverall weighted interobserver Kappa coefficients for the AAST and ‘Baltimore CT grading system’ were respectively substantial (kappa=0.80) and almost perfect (kappa=0.85). Average weighted intraobserver Kappa's values were in the ‘almost perfect’ range (AAST: kappa=0.91, ‘Baltimore CT grading system’: kappa=0.81). ConclusionThe present study shows that overall the inter- and intraobserver reliability for grading splenic injury according to the AAST grading system and ‘Baltimore CT grading system’ are equally high. Because of the integration of vascular injury, the ‘Baltimore CT grading system’ supports clinical decision making. We therefore recommend use of this system in the classification of splenic injury.