American Association For The Surgery Of Trauma Grade Research Articles

Traumatismo renal secundario a accidente en patinete eléctrico

Introduction: the e-scooter has become a common transportation method which use has been rising in the last few years. Most lesions reported secondary to e-scooter accidents are traumatic brain injury (TBI), bone fractures and in a lower percentage abdominal visceral trauma. Methods: retrospective review of renal traumatisms cases secondary to e-scooter accidents presented to the emergency room (ER) of the Hospital Universitari Doctor Peset in Valencia, Spain since December 2021 to December 2022. A literature review on PubMed database was performed to investigate injuries caused by electric scooter use. Results: a total of five patients were included with a mean age of 34 years, being one woman and four men. A contrasted abdominopelvic computerized tomography (CT) scan was performed in all cases as a diagnosis method. The American Association for the Surgery of Trauma (AAST) renal injury scale was used to classify each case and determine the correct treatment. As a result, one case of AAST grade I, one case of AAST grade III, two cases of AAST grade IV and one AAST grade V were obtained; three of which were managed conservatively and two required invasive procedures. Conclusions: the rising use of the e-scooter as a transportation method has become a new cause and mechanism of renal traumatism to have in mind in polytraumatized patients in this context.

Machine Learning Detection and Characterization of Splenic Injuries on Abdominal Computed Tomography.

Multi-detector contrast-enhanced abdominal computed tomography (CT) allows for the accurate detection and classification of traumatic splenic injuries, leading to improved patient management. Their effective use requires rapid study interpretation, which can be a challenge on busy emergency radiology services. A machine learning system has the potential to automate the process, potentially leading to a faster clinical response. This study aimed to create such a system. Using the American Association for the Surgery of Trauma (AAST), spleen injuries were classified into 3 classes: normal, low-grade (AAST grade I-III) injuries, and high-grade (AAST grade IV and V) injuries. Employing a 2-stage machine learning strategy, spleens were initially segmented from input CT images and subsequently underwent classification via a 3D dense convolutional neural network (DenseNet). This single-centre retrospective study involved trauma protocol CT scans performed between January 1, 2005, and July 31, 2021, totaling 608 scans with splenic injuries and 608 without. Five board-certified fellowship-trained abdominal radiologists utilizing the AAST injury scoring scale established ground truth labels. The model achieved AUC values of 0.84, 0.69, and 0.90 for normal, low-grade injuries, and high-grade splenic injuries, respectively. Our findings demonstrate the feasibility of automating spleen injury detection using our method with potential applications in improving patient care through radiologist worklist prioritization and injury stratification. Future endeavours should concentrate on further enhancing and optimizing our approach and testing its use in a real-world clinical environment.

Survival Secrets: Unmasking the Factors Predicting Failure of Non-operative Management (NOM) in Splenic Injuries.

Splenic injuries are common solid organ injuries resulting from blunt abdominal trauma in road traffic accidents. Very often, splenic injuries can be life-threatening. Earlier, splenic injuries were often dealt with surgical intervention, such as splenectomy. With the recognition of the immunological function of the spleen and possible complications of splenectomy surgery, such as overwhelming post-splenectomy infections (OPSI), there has been a recent trend for non-operative management (NOM). To study the variables predicting failure of NOM in blunt abdominal trauma patients with splenic injury. This is a retrospective study that includes 235 patients who presented to the Safdarjung Hospital emergency room (New Delhi, India) with blunt trauma abdomen and splenic injuries with or without associated injuries between January 2019 and December 2021. The data was entered in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Categorical variables were expressed as frequencies and percentages. Pearson's chi-square test of association was used to determine if there is a relationship between two variables. A p-value of <0.05 was considered statistically significant. Out of 235 patients with blunt abdominal trauma and splenic injuries, 82 were hemodynamically unstable despite resuscitation and were taken up for emergency laparotomy. The remaining 153 patients, who were either hemodynamically stable or stabilized after adequate resuscitation, were managed on the lines of NOM. The number of patients with splenic injury in AAST grades 1, 2, 3, 4, and 5 was 36, 50, 40, 24, and three, respectively. Out of 153 patients, 130 (85%) were successfully managed by NOM, while eight (5%) had to discontinue NOM as they required surgical intervention. The failure of NOM (fNOM) is seen mostly with grade 5 injuries (2/2, 100%, p<0.01), followed by grade 4 (4/20, 20%) and grade 3 (2/37, 5.7%). The mean age in fNOM was 58.3 years, as compared to 42.2 years in the success of NOM (sNOM). All eight patients had multiple concomitant injuries, with femur fracture being the most common association in up to six patients (p<0.01), followed by liver injury in four patients. There were 15 mortalities, irrespective of AAST severity grade. All of these patients had associated concomitant injuries, with intracranial bleeding (n = 10, 32%, p<0.01) being the most common association, followed by femur fracture (n = 6, 20%) and liver injury (n = 5, 16%). Also, the cause of death was unrelated to splenic trauma (p = 0.67), with pulmonary embolism (n = 6, 40%, p<0.01) being the most common cause, followed by brain stem herniation (n = 5, 34%). Non-operative management is a safe and efficient method for treating patients with splenic injuries who are hemodynamically stable or stabilized. The factors associated with fNOM include elderly age, a higher American Association for the Surgery of Trauma(AAST) grade of splenic injury, and associated concomitant injuries. Femur fracture was the most common concomitant injury present in cases where NOM failed, followed by liver injury. The presence of intracranial bleeds in these patients was a common association with mortality, irrespective of the grade of splenic injury.

Comparison of Pediatric Acute Appendicitis Before and During the COVID-19 Pandemic in New York City.

Background: Acute appendicitis (AA) is the most common abdominal surgical emergency in children and adolescents. In the year immediately following the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO), there was a precipitous decline in emergency department (ED) visits especially for surgical conditions and infectious diseases. Fear of exposure to severe acute respiratory coronavirus 2 infection resulted in delay in presentation and time to surgery, and a shift toward more conservative management. Objective: Our goal was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods: Patients aged 2-18years admitted with the diagnosis of AA to Flushing Hospital Medical Center or Jamaica Hospital Medical Center in Queens, New York, were selected for chart review. Data extracted from electronic health records included demographics, clinical findings, imaging studies, and operative and pathological findings. We calculated the Alvarado score (AS) for incidence and the American Association for the Surgery of Trauma (AAST) grade for severity. We compared patients admitted between March 1, 2018-February 29, 2020 (pre-pandemic) to patients admitted between March 1, 2020-February 28, 2021 (pandemic). We then compared pre-pandemic and pandemic groups to determine differences in pediatric AA incidence and severity. Results: Of 239 patients diagnosed with AA, 184 (77%) were in the pre-pandemic group and 55 (23%) in the pandemic group. Incidence (number per year) of AA declined by 40%. The pandemic group had significantly greater overall AS of ≥7, indicating increased likelihood to require surgery, (P = 0.04) and higher AAST grade demonstrating increased severity (P = 0.02). Conclusion: There was a decline in the number of AA cases seen in our pediatric EDs and admitted during the first year of the pandemic. Clinicians need to be aware of increased severity of AA at time of presentation during public health emergencies such as a pandemic, possibly due to modified patient behavior.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit.

The management of high-grade pancreatic trauma is controversial. To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries. A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified. Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies. We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.

MP02-06 FACTORS ASSOCIATED WITH INTERVENTIONS FOR RENAL TRAUMA

You have accessJournal of UrologyCME1 Apr 2023MP02-06 FACTORS ASSOCIATED WITH INTERVENTIONS FOR RENAL TRAUMA Nizar Hakam, Hiren Patel, Arnav Srivastava, Alain Kaldany, Charles Jones, and Benjamin Breyer Nizar HakamNizar Hakam More articles by this author , Hiren PatelHiren Patel More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Charles JonesCharles Jones More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: More conservative approaches have been utilized for renal trauma management over the last decade. However, certain clinical scenarios warrant further intervention. We sought to determine factors associated with interventions for renal trauma management using contemporary real-world data. METHODS: The National Trauma Data Bank (NTDB) was queried for renal trauma with an American Association for the Surgery of Trauma (AAST) grade for patients ≥18 years old. Patients without AAST grade or with no sign of life were excluded. A logistics regression model was used to determine factors associated with intervention, including nephrectomy, angioembolization, and renorrhaphy. Models were adjusted for patient, hospital, and clinical factors. RESULTS: Our cohort was comprised of 49,884 patients with renal trauma, of which 3,366 (6.8%), 995 (1.9%), and 691 (1.4%) underwent nephrectomy, renorrhaphy, and angioembolization, respectively. Among patients receiving a nephrectomy, patients were more likely to receive a transfusion (OR 3.8, p<0.001), have a penetrating trauma (OR 6.7, p<0.001), have a grade 4 (OR 7.9, p<0.001) or 5 renal trauma (OR 44.7, p<0.001). Patients who had renorrhaphy were more likely to receive a transfusion (OR 1.7, p<0.001) or have a penetrating trauma (OR 44.0, p<0.001). Patients who underwent angioembolization were less likely to be female (OR 0.78, p<0.05), Black (OR 0.71, p<0.01), or have a penetrating trauma (OR 0.31, p<0.001), and were more likely to receive a transfusion (OR 44.8, p<0.001) or have a grade 4 (OR 3.8, p<0.001) or 5 renal trauma (OR 4.2, p<0.001). We observed a complex association between age and probability of nephrectomy. In the unadjusted analysis, there was a peak in nephrectomy for young adults 30-40 years old (Figure 1A). However results of the multivariate model revealed a alternate association where the adjusted risk of nephrectomy was approximately linear and progressively increased with age (Figure 1B). CONCLUSIONS: Several patient, hospital, and clinical factors are associated with the use of nephrectomy, renorrhaphy, and angioembolization for the management of renal trauma. These data suggest that older age is an independent predictor of nephrectomy, warranting further research and efforts to improve renal salvage in the elderly population. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e12 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nizar Hakam More articles by this author Hiren Patel More articles by this author Arnav Srivastava More articles by this author Alain Kaldany More articles by this author Charles Jones More articles by this author Benjamin Breyer More articles by this author Expand All Advertisement PDF downloadLoading ...

Validating the American Association for the Surgery of Trauma Pancreas Injury Grade Using Trauma Quality Improvement Program Data.

The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the pancreas was created in 1990. Our aim was to validate the ability of the AAST-OIS pancreas grade to predict adjuncts to operative management, including endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drain placement. We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019, including all patients with a pancreas injury. Outcomes included the rates of mortality, laparotomy, ERCP, and peri-pancreatic or hepatobiliary percutaneous drain placement. Outcomes were analyzed by AAST-OIS, and odds ratios (ORs) and 95 confidence intervals (CIs) were calculated for each. 3571 patients were included in the analysis. The AAST grade was associated with increased rates of mortality and laparotomy at every level (P < .05). Endoscopic retrograde cholangiopancreatography rates increased from grade 2 to 3 (OR 4.685, 95% CI 3.254-6.745), were similar between grades 3 and 4 (P > .05), and decreased from grades 4 to 5 (OR .443, CI .250-.788). Likewise, rates of percutaneous drain placement increased from grade 2 to 3 (OR 1.999, CI 1.192-3.353), were similar between grades 3 and 4 (P > .05), and decreased from grades 4 to 5 (OR .266, .076-.934). Increasing pancreatic injury grade is associated with increased mortality and laparotomy rates at all levels. Endoscopic retrograde cholangiopancreatography and percutaneous drainage procedures are used most in mid-grade (3-4) pancreatic trauma. The decrease in nonsurgical procedures in grade 5 pancreatic trauma is likely secondary to increased rates of surgical management (resection and/or wide drainage). The AAST-OIS for pancreatic injury is associated with mortality and interventions.

Automated quantitative assessment of pediatric blunt hepatic trauma by deep learning-based CT volumetry

BackgroundTo develop an end-to-end deep learning method for automated quantitative assessment of pediatric blunt hepatic trauma based on contrast-enhanced computed tomography (CT).MethodsThis retrospective study included 170 children with blunt hepatic trauma between May 1, 2015, and August 30, 2021, who had undergone contrast-enhanced CT. Both liver parenchyma and liver trauma regions were manually segmented from CT images. Two deep convolutional neural networks (CNNs) were trained on 118 cases between May 1, 2015, and December 31, 2019, for liver segmentation and liver trauma segmentation. Liver volume and trauma volume were automatically calculated based on the segmentation results, and the liver parenchymal disruption index (LPDI) was computed as the ratio of liver trauma volume to liver volume. The segmentation performance was tested on 52 cases between January 1, 2020, and August 30, 2021. Correlation analysis among the LPDI, trauma volume, and the American Association for the Surgery of Trauma (AAST) liver injury grade was performed using the Spearman rank correlation. The performance of severity assessment of pediatric blunt hepatic trauma based on the LPDI and trauma volume was evaluated using receiver operating characteristic (ROC) analysis.ResultsThe Dice, precision, and recall of the developed deep learning framework were 94.75, 94.11, and 95.46% in segmenting the liver and 72.91, 72.40, and 76.80% in segmenting the trauma regions. The LPDI and trauma volume were significantly correlated with AAST grade (rho = 0.823 and rho = 0.831, respectively; p < 0.001 for both). The area under the ROC curve (AUC) values for the LPDI and trauma volume to distinguish between high-grade and low-grade pediatric blunt hepatic trauma were 0.942 (95% CI, 0.882–1.000) and 0.952 (95% CI, 0.895–1.000), respectively.ConclusionsThe developed end-to-end deep learning method is able to automatically and accurately segment the liver and trauma regions from contrast-enhanced CT images. The automated LDPI and liver trauma volume can act as objective and quantitative indexes to supplement the current AAST grading of pediatric blunt hepatic trauma.

A case of blunt abdominal trauma resulting in significant bladder injury (AAST grade IV)

Introduction: Bladder injuries are uncommon and its diagnosis is often missed. However, in patients presenting with blunt abdominal trauma, bladder, and other lower urinary tract injuries must be ruled out using adequate investigations. Case Report: A 33-year-old male presented to the Emergency Department 24 hours after a fall, complaining of lower abdominal pain and inability to void. Examination revealed a mildly distended abdomen with no signs of peritonism. A random bladder scan showed a volume of 583 mL. Basic investigations showed the patient to be in acute kidney injury (AKI) stage III with a creatinine of 350 mmol/L. Clinical findings were suggestive of a bladder injury. However, due to the rarity of such cases, clinicians reviewing the patient did not think of a bladder injury as one of the differential diagnoses. Instead of also requesting for a computed tomography (CT) cystography, only a trauma CT abdomen and pelvis with contrast was requested which demonstrated an intraperitoneal bladder injury. The patient was taken to theater for an emergency laparotomy and repair of a 4 cm bladder laceration. According to the American Association for the Surgery of Trauma (AAST) classification, the patient had a Grade IV bladder injury. A cystogram performed 4 weeks after the surgery showed no urine leak and the urethral catheter was removed. Fortunately, no harm was brought to the patient. Conclusion: Intraperitoneal bladder injuries, if missed, can be associated with serious morbidities and even increase the risk of mortality.

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.

Severity of traumatic adrenal injury does not meaningfully affect clinical outcomes.

There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury. After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded. A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p < 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10days vs. 16days, p = 0.03). The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

Expectant Management of Blunt Grade III Renal Injuries: Early Discharge Outcomes From a Level I Trauma Center

ObjectivesTo determine whether patients with American Association for the Surgery of Trauma (AAST) grade III blunt renal injuries discharged within 48 hours of admission have increased rates of readmission for renal-related complications compared to patients observed for over 48 hours. MethodsRenal trauma patients from 2005 through 2020 were identified from our institutional trauma registry. Patients with AAST III blunt renal injuries who survived beyond 48 hours of admission were included. Univariable analysis was used to identify variables associated with discharge within 48 hours. Reasons for readmission were compared between patients discharged before and after 48 hours of admission. ResultsOf the 1751 renal trauma patients, 377 (21.5%) met inclusion criteria. Sixty-five of 377 (17.2%) AAST III injuries were discharged within 48 hours of admission. Forty (10.6%) patients required readmission, 3 in the early discharge group and 37 in the standard discharge group. No patient required readmission for renal-related complications. ConclusionPatients with AAST grade III blunt renal injuries are not at increased risk for early renal-related complications if discharged within 48 hours of admission and should be considered for early discharge. The very low rate of renal-related complications for AAST III blunt renal injuries supports their categorization as “low-grade” renal trauma.

Validity of the American Association for the Surgery of Trauma Intestinal Obstruction Grading System

• Severity of intestinal obstruction (AAST grade) is associated with complications. • AAST intestinal obstruction grades have near-perfect inter-rater reliability. • AAST grades can be applied to both large and small intestinal obstruction. The American Association for the Surgery of Trauma (AAST) grading system for intestinal obstruction may be a useful measure of anatomic severity, but its construct validity has not yet been evaluated in patients with either large or small bowel obstruction, using the grade applicable at initial presentation (rather than after definitive management). We conducted a retrospective case series of adult inpatients presenting with intestinal obstruction at our center during 2008-2014. We excluded patients without confirmed intestinal obstruction, those with obstruction secondary to a hernia, those who were treated for >24 hours at another hospital, and those with a previous encounter already included in the study. We measured inter-rater reliability using a weighted kappa coefficient. We used multivariable logistic regression, accounting for sampling weights, to assess the relationship of grades with complications, 30-day mortality, and 30-day readmission. Of 287 patients, 165 (58%) had grade I anatomic severity, 75 (26%) grade II, 23 (8%) grade III, 15 (5%) grade IV, and 9 (3%) grade V. Forty-six (16%) patients had a large bowel obstruction. There was substantial inter-rater agreement in grades [weighted kappa 0.69 (95% CI 0.47-0.91)]. Compared to grade I, grades III-V [OR 12.2 (95% CI 2.26-66.2)] but not grade II [OR 2.04 (95% CI 0.79-5.28)] were associated with increased risk of a complication. grade II [OR 7.92 (95% CI 3.27-19.2)], but not grades III-V [OR 3.56 (95% CI 0.30-42.5)] was associated with increased 30-day mortality. Grades were not associated with increased 30-day readmission. AAST intestinal obstruction grades have predictive validity for some but not all outcomes, and may serve a useful role in the measurement of anatomic disease severity.

The American Association for the Surgery of Trauma (AAST) Liver Injury Grade Does Not Equally Predict Interventions in Blunt and Penetrating Trauma

The AAST liver injury grade has a validated association with mortality and need for operation. AAST liver injury grade is the same regardless of the mechanism of trauma. A 5-year retrospective review of all liver injuries at an urban, level-one trauma center was performed. Totally, 315 patients were included (29% blunt, 71% penetrating). In blunt trauma, AAST grade was associated with need for laparotomy (0%, 7%, 5%, 33%, 29%, Grade 1-5, p = 0.01), angiography (0%, 7%, 25%, 40%, 57%, p < 0.001), embolization (0%, 7%, 15%, 33%, 43%, p = 0.01), and percutaneous drainage procedures (13% use in Grade 4, otherwise 0%, p = 0.04), but not ERCP (0% for all grades). In penetrating trauma, AAST grade was associated with need for angiography (7%, 4%, 15%, 24%, 30%, p < 0.01) and percutaneous drainage (7%, 2%, 14%, 18%, 26%, p = 0.03) and had a marginal association with embolization (0%, 4%, 11%, 13%, 22%, p = 0.06). Laparotomy, ERCP, sphincterotomy, and stenting rates increased with AAST grade, but this was not statistically significant. AAST grade is associated with the need for surgical hemostasis, angioembolization, and percutaneous drainage in both penetrating and blunt trauma. Operative, endoscopic, and percutaneous procedures are utilized more in penetrating trauma. Angioembolization was used more in blunt trauma. Mechanism should be considered when using AAST grade to guide management of liver injuries.

A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center.

IntroductionPancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic.MethodsOurs is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form.ResultsOne patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura’s splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively.ConclusionThe pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.

MP20-07 UROLOGY CONSULTATION IS ASSOCIATED WITH ADHERENCE TO IMAGING GUIDELINES AND DECREASED NEPHRECTOMY IN HIGH GRADE RENAL TRAUMA

You have accessJournal of UrologyCME1 May 2022MP20-07 UROLOGY CONSULTATION IS ASSOCIATED WITH ADHERENCE TO IMAGING GUIDELINES AND DECREASED NEPHRECTOMY IN HIGH GRADE RENAL TRAUMA Shirley Wang, Pranjal Agrawal, Mary Rostom, Nikita Gupta, Albert Holler, Isabelle Pan, Kent Stevens, Raymond Fang, Elliott Haut, Ryan Fransman, Renu Berry, and Andrew Cohen Shirley WangShirley Wang More articles by this author , Pranjal AgrawalPranjal Agrawal More articles by this author , Mary RostomMary Rostom More articles by this author , Nikita GuptaNikita Gupta More articles by this author , Albert HollerAlbert Holler More articles by this author , Isabelle PanIsabelle Pan More articles by this author , Kent StevensKent Stevens More articles by this author , Raymond FangRaymond Fang More articles by this author , Elliott HautElliott Haut More articles by this author , Ryan FransmanRyan Fransman More articles by this author , Renu BerryRenu Berry More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal trauma is unique in that acute management involves the trauma team, primarily urology, or joint management. The ideal management pathway has yet to be established. We aim to describe rates of urology consultation following renal trauma and assess subsequent impact on imaging and intervention. METHODS: We conducted an IRB-approved retrospective review of patients at a Level I trauma center sustaining renal trauma between 2014 and 2021. Demographic, injury, radiologic, and intervention variables were extracted and compared by urology and trauma surgery management using chi-squared, Fischer’s exact tests, and Mann-Whitney U tests. All available images were ultimately graded using American Association for the Surgery of Trauma (AAST) scoring. Analyses were performed using STATA with p <0.05 considered significant. RESULTS: From 2014-2021, 118 patients with median age 29 (IQR 22-41) incurred renal trauma. Urology was consulted in 18 (15.3%) cases. Demographic and injury characteristics were similar between the two groups. AAST renal injury grade was transcribed in the initial radiologic reports for 49 (41.5%) of patients. Among the full cohort including AAST grade I through V injuries, urology consult was associated with greater likelihood of receiving delayed contrast imaging (50.0% vs. 17.0%, p=0.002); however, there was no significant difference in rate of follow-up imaging within 48 hours among patients with grade IV and V injuries (Table 1). In this sub-group, there was no significant difference in rates of penetrating injury or whether an initial exploratory laparotomy was conducted. Of patients with high-grade injuries, those with urology consult were less likely to undergo nephrectomy (36% vs. 79%, p=0.018). CONCLUSIONS: We observed differences in imaging patterns between renal trauma patients who are managed primarily by trauma surgery versus urology. However, the further downstream impact of these differences in imaging remains to be elucidated. Among patients with high-grade renal trauma, urology consult was associated with decreased rate of nephrectomy, highlighting the feasibility of renal salvage in a multidisciplinary trauma setting. In our center, future quality improvement may involve improved compliance with AAST Renal Trauma Grading. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e319 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shirley Wang More articles by this author Pranjal Agrawal More articles by this author Mary Rostom More articles by this author Nikita Gupta More articles by this author Albert Holler More articles by this author Isabelle Pan More articles by this author Kent Stevens More articles by this author Raymond Fang More articles by this author Elliott Haut More articles by this author Ryan Fransman More articles by this author Renu Berry More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF DownloadLoading ...

An analysis of 77 cases of pancreatic injuries at a level one trauma center: Outcomes of conservative and surgical treatments.

Backgrounds/AimsTraumatic pancreatic injury (TPI) is rare as an isolated injury. There is a trend to perform conservative treatment even in patients with complete duct dissection and successful treatment. This study reviewed our 20 years of experience in the management of TPI and assessed patient outcomes according to age group and treatment strategy.MethodsA retrospective analysis of patients diagnosed and treated with TPI at a level-I trauma center from 2000-2019. Patients were divided into two groups: adults and pediatrics. Conservative treatment cases were subjected to subgroup analysis. Level of evidence: IV.ResultsOf a total of 77 patients, the mean age was 24.89 ± 15.88 years. Fifty-six (72.7%) patients had blunt trauma with motor vehicle accident. Blunt trauma was the predominant mechanism in 42 (54.5%) patients. Overall, 38 (49.4%) cases had grade I or II injury, 24 (31.2%) had grade III injury, and 15 (19.5%) had grade IV injury. A total of 30 cases had non-operative management (NOM). Successful NOM was observed in 16 (20.8%) cases, including eight (32.0%) pediatric cases and eight (15.4%) adult cases. Higher American association for the surgery of trauma (AAST) grade of injury was associated with NOM failure (16.7% for grade I/II, 100% for grade III, and 66.7% for grade IV injury; p = 0.001). An independent factor for NOM failure was female sex (69.2% in females vs. 29.4% in males; p = 0.03).ConclusionsHigh AAST grade TPI is associated with a high rate of NOM failure in both pediatric and adults.

The necessity of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy: a retrospective cohort study

BackgroundThis study aimed to evaluate the necessity of abdominal drainage after laparoscopic appendectomy in patients with complicated appendicitis.MethodsPatients with acute appendicitis undergoing laparoscopic appendectomy at two hospitals between January 2014 and December 2018 were retrospectively included. Complicated appendicitis was defined as the American Association for the Surgery of Trauma (AAST) grade ≥ II. The patients were classified according to the AAST grade and the indwelling of abdominal drainage. The postoperative surgical outcomes and recovery were compared among patient groups to evaluate the impact of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy.ResultsA total of 1241 patients was retrospectively included. Among them, there were 820 patients with simple appendicitis (AAST grade I) and 421 patients with complicated appendicitis (AAST grade ≥ II). For complicated appendicitis, the drainage group (N = 192) tended to harbor more overall complications, intra-abdominal abscess formation, time to resume a soft diet, and the postoperative length of hospitalization (P = 0.0000 for all). Multivariate logistic regression confirmed that abdominal drainage increased the risk of overall complications [Odds ratio (OR) 2.439; 95% confidence interval (CI) 1.597–3.726; P ≤ 0.0001] and failed to decrease the risk of intra-abdominal abscess formation (OR 1.655; 95% CI 0.487–5.616; P = 0.4193). Multivariate linear regression analysis also showed that the drainage group harbored longer postoperative length of hospitalization (Coefficients: 20.697; 95% CI 15.251–26.143; P < 0.0001) and time to resume a soft diet (Coefficients: 45.899; 95% CI 34.502–57.297; P < 0.0001).ConclusionsAbdominal drainage did not prevent overall complications in patients with complicated appendicitis; paradoxically, it delayed the convalescence. Our results discourage the routine use of abdominal drainage and suggest that abdominal drainage should be performed sparingly.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study.

The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. There were 367 patients, with a mean (± SD) age of 62 ± 15years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.