American Association For The Surgery Of Trauma Grading Research Articles

Utility of the American Association for the Surgery of Trauma Appendicitis Severity Grade in Predicting Prognosis in Children.

The American Association for the Surgery of Trauma (AAST) proposed a grade classification (I (mild) to V (severe)) to predict the risks and outcomes of acute appendicitis. However, its utility in children remains unknown. We investigated the relationship between the AAST grade and disease severity in children. We retrospectively evaluated 93 patients aged ≤16 years who underwent surgery for acute appendicitis between 2012 and 2020. The AAST computed tomography (CT), operative, and pathologic grades were analyzed. We collected data for demographics, length of stay (LOS), and complications. Trend tests were performed to compare the AAST grade and outcomes. Bland-Altman plots were used to evaluate the correlation between grades. Multiple regression analysis was performed to identify the factors related to LOS. AAST grades included CT (n=55), operative (n=93), and pathologic (n=93) grades. The number of complications and LOS increased significantly with the increase of every three-grade. Bland-Altman plots revealed that each of the three-grade correlated with each other. Multiple regression analysis identified AAST operative grades III-V as risk factors for prolonged LOS. Higher CT, operative, and pathologic grades were found to be significantly associated with an increased number of complications and prolonged LOS in pediatric patients. We further concluded that the AAST grading system could be useful in predicting the prognosis of acute appendicitis in children.

Out with the old, in with the new? The revised AAST grading schema better predicts splenic salvage but not splenectomy

BackgroundThe revised American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) for splenic injury incorporates radiologic features but the implications of this are unknown. We hypothesized that the revised AAST-OIS would better predict outcomes. MethodsPatients with a blunt splenic injury admitted to a Level I trauma center were reviewed from 2016 to 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for splenectomy were calculated for high-grade injuries (AAST-OIS grades IV-V) using both schemas. ResultsOf the 852 patients analyzed, 48.5% were observed, 24.6% were embolized, and the remaining underwent operative intervention. The median AAST-OIS increased from II to III (p ​< ​0.01). Sensitivity (38.0% vs. 73.7%) and NPV (80.9% vs. 88.2%) for splenectomy increased for high-grade injuries but specificity (93.5% vs 70.1%) and PPV (67.5% vs 46.7%) decreased. ConclusionThe revised AAST-OIS better predicted splenic salvage but is less accurate at predicting need for splenectomy.

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.

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.

A deep learning framework for automated detection and quantitative assessment of liver trauma

BackgroundBoth early detection and severity assessment of liver trauma are critical for optimal triage and management of trauma patients. Current trauma protocols utilize computed tomography (CT) assessment of injuries in a subjective and qualitative (v.s. quantitative) fashion, shortcomings which could both be addressed by automated computer-aided systems that are capable of generating real-time reproducible and quantitative information. This study outlines an end-to-end pipeline to calculate the percentage of the liver parenchyma disrupted by trauma, an important component of the American Association for the Surgery of Trauma (AAST) liver injury scale, the primary tool to assess liver trauma severity at CT.MethodsThis framework comprises deep convolutional neural networks that first generate initial masks of both liver parenchyma (including normal and affected liver) and regions affected by trauma using three dimensional contrast-enhanced CT scans. Next, during the post-processing step, human domain knowledge about the location and intensity distribution of liver trauma is integrated into the model to avoid false positive regions. After generating the liver parenchyma and trauma masks, the corresponding volumes are calculated. Liver parenchymal disruption is then computed as the volume of the liver parenchyma that is disrupted by trauma.ResultsThe proposed model was trained and validated on an internal dataset from the University of Michigan Health System (UMHS) including 77 CT scans (34 with and 43 without liver parenchymal trauma). The Dice/recall/precision coefficients of the proposed segmentation models are 96.13/96.00/96.35% and 51.21/53.20/56.76%, respectively, in segmenting liver parenchyma and liver trauma regions. In volume-based severity analysis, the proposed model yields a linear regression relation of 0.95 in estimating the percentage of liver parenchyma disrupted by trauma. The model shows an accurate performance in avoiding false positives for patients without any liver parenchymal trauma. These results indicate that the model is generalizable on patients with pre-existing liver conditions, including fatty livers and congestive hepatopathy.ConclusionThe proposed algorithms are able to accurately segment the liver and the regions affected by trauma. This pipeline demonstrates an accurate performance in estimating the percentage of liver parenchyma that is affected by trauma. Such a system can aid critical care medical personnel by providing a reproducible quantitative assessment of liver trauma as an alternative to the sometimes subjective AAST grading system that is used currently.

Revision of the AAST grading scale for acute cholecystitis with comparison to physiologic measures of severity.

Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved. A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade. Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score. The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary. Diagnostic Test or Criteria, Level IV.

Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic Injuries.

Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic Injuries.

CT Imaging and Management of Blunt Splenic Trauma: Lessons for Today and Tomorrow

CT Imaging and Management of Blunt Splenic Trauma: Lessons for Today and Tomorrow

Accident-related hepatic trauma in a medical clinical center in eastern China: a cross-sectional study

BackgroundThe treatment of hepatic injury can be complex. Medical clinical centers are often the first line hospitals for the diagnosis and treatment of hepatic trauma in China. The aim of the study is to summarize the experience in the diagnosis and treatment of hepatic trauma in one medical clinical center in China.MethodsThis retrospective study included patients with hepatic trauma admitted between January 2002 and December 2019 at the Xishan People’s Hospital of Wuxi. The outcomes were cure rate and death within 14 days post-discharge.ResultsAmong the 318 patients with hepatic trauma, 146 patients underwent surgical treatment, and 172 received conservative treatment; three patients were transferred to other hospitals for further treatment; 283 patients were cured, and 35 died. Severe hepatic trauma occurred in 74 patients, with a mortality rate of 31.1% and accounting for 65.7% of total mortality. American Association for the Surgery of Trauma (AAST) grading ≥ III (OR = 3.51, 95%CI: 1.32–9.37, P = 0.012) and multiple organ injury (OR = 7.51, 95%CI: 2.51–22.46, P < 0.001) were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death (OR = 0.08, 95%CI: 0.01–0.45, P = 0.004). Among patients with ASST ≥ III and who underwent surgery, age (OR = 5.29, 95%CI: 1.37–20.33, P = 0.015) and peri-hepatic packing (PHP) (OR = 5.54, 95%CI: 1.43–21.487, P = 0.013) were independently associated with death.ConclusionsAAST grading ≥ III and multiple organ injury were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death. Among patients with ASST ≥ III and who underwent surgery, age and PHP were independently associated with death.

CT and MRI findings in pancreatic trauma in children and correlation with outcome.

There are limited published data on pancreatic trauma imaging in children. To present our experience using computed tomography (CT) and magnetic resonance (MR) imaging of pancreatic trauma in children and to correlate the imaging grade of pancreatic injury with management and outcome. A retrospective cohort study of children with pancreatic injury presenting between Jan. 1, 2000, and Dec. 31, 2016, was performed. Patient charts were reviewed to note demographics, the mechanism of injury, associated abdominal injuries, management and outcome. All imaging was rereviewed by two radiologists blinded to clinical and laboratory information, and pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST). Of 3,265 patients presented as trauma team activations during the study period, only 28 (0.86%) children (19 boys, 9 girls; mean age: 7.14years; age range: 1-15years) had pancreatic injury. Of the available 27 CTs of the abdomen, 26 were performed on the day of trauma. Associated injuries were seen in 25/27 children, most frequently in the liver and lung, 16 (59.2%) each. There were 5 (19%) Grade I, 9 (33%) Grade II, 8 (30%) Grade III and 3 (11%) Grade IV. No patients had Grade V injury. No pancreatic parenchymal injury was identified in 2 (7%) patients with isolated fluid around the pancreas and mesentery. The pancreatic duct was visible in all 10 children (days: 0-330, median days: 41 post-trauma) who had MRI. Eight of these children, who had Grade III/IV injuries on CT and confirmed pancreatic duct injury on endoscopic retrograde cholangiopancreatography (ERCP) or surgery, showed either signal intensity difference in pancreatic parenchyma and/or caliber difference in the pancreatic duct proximal and distal to the injury site. Two patients died because of multiorgan injuries, 9 patients (mainly with Grade III and IV injuries) underwent surgery and/or ERCP, and 16 patients were managed conservatively. AAST grading of pancreatic injury on CT correlated with type of management (P=0.0001) with most of the Grade III and IV injuries treated with intervention and/or surgery while all of the Grade I and II injuries were treated conservatively. Pancreatic injury is rare in children but often associated with other organ injuries most frequently involving the liver and lung. CT grading of injury correlates with management and guides intervention and/or surgery versus conservative treatment. MRI is useful for assessing pancreatic duct injury by demonstrating the pancreatic duct directly and/or secondary changes like signal intensity difference in pancreatic parenchyma and caliber difference in the pancreatic duct.

Splenic trauma, the way forward in reducing splenectomy: our 15-year experience.

The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.

The American Association for the Surgery of Trauma renal injury grading scale: Implications of the 2018 revisions for injury reclassification and predicting bleeding interventions.

In 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions. Data on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared. Of the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34). About one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions. Prognostic and Epidemiological Study, level III.

MSCT IN NON-OPERATIVE MANAGEMENT OF HIGH GRADE BLUNT RENAL TRAUMA, A PROSPECTIVE STUDY

Aim: To highlight the validity of MSCT in predicting the efficacy of non-operative management in patients with high grade blunt renal trauma using American Association for the Surgery of Trauma (AAST) renal injury scale Patients and methods: Through a prospective study included 39 patients with high grades blunt renal traumas (grade III, IV and V), MSCT was done for all included cases and correlated to AAST grading system then we followed up non-operated cases by clinical, laboratory and US for all cases and CT in 12 cases along two weeks period. Statistical analysis was done for planed management immediately after CT and proper management done through two weeks of follow up. Results: MSCT graded the injury into grade III, IV and V according to AAST grading system presented in 48.7%, 33.3% and 17.9 % respectively. 74.4% of cases underwent conservative management, 5.1% underwent immediate surgical nephrectomy, 7.7 % underwent intervention embolization and double J fixation was done in 7.7%. Within 2 weeks of follow up conservative management was sufficient in only 64.1% as some patients developed other predisposing factors demanded further interventions and a total percentage of 17.9% of our cases underwent surgical laparotomy (6 cases nephrectomy and one case renorrhaphy), surgical percutaneous drainage of urinoma in one case and renal artery embolization raised to 10.3% of our cases. Conclusion: MSCT can determine the exact criteria for selecting patients for conservative management in hemodynamic stable patients. Non-operative management strategy in line with repeated imaging and close clinical follow up salvaged the affected kidney in most of the cases.

Management of renal injury in a UK major trauma centre

Introduction This study reviews the type, severity, management and follow-up of renal trauma presenting to a major trauma centre in the northwest of England in the four years following inception of the major trauma centre. Given the recent introduction of major trauma centres nationally, research is needed within every specialty to ensure that the centralisation of services benefits all patients affected by these changes. Methods Patients presenting to Aintree University Hospital with renal trauma between June 2012 and June 2016 were identified using the Trauma Audit and Research Network (TARN) database. The data gathered retrospectively for each patient included mechanism of injury, injury severity score, American Association for the Surgery of Trauma (AAST) grading, management of injury, and follow-up. Results Out of a total of 2595 trauma patients, 33 renal injuries were identified. The 31 patients who received imaging were classified according to AAST grading, with 8 Grade I (25.8%), 4 Grade II (12.9%), 8 Grade III (25.8%), 4 Grade IV (12.9%), and 7 Grade V (22.6%) injuries. Twenty-five out of the 30 surviving patients received conservative treatment, three patients received angioembolisation (AE), one patient received a laparotomy with renal suturing, and one patient required a nephrectomy. Of these 30 surviving patients, seven received urology follow-up in clinic (23%). Conclusion The findings appear to support the growing trend towards the conservative management of high-grade renal injuries, and provide further evidence for the value of AE in renal trauma. The success of AE in this study appears to support the centralisation of services in renal trauma; however, the low nephrectomy rate could be interpreted as suggestive of the opposite. The study revealed that improvements to follow-up are needed, and that further research should seek to inform the optimal radiological follow-up of high-grade renal injury.

Pediatric Appendicitis Severity in KwaZulu‐Natal, South Africa: A Retrospective Cohort Analysis

Acute appendicitis is a common pediatric surgical emergency; however, there are few grading systems to assign disease severity. The American Association for the Surgery of Trauma (AAST) recently developed a grading system for a variety of emergency surgical conditions, including appendicitis. The severity of acute appendicitis in younger patients in KwaZulu-Natal (South Africa) is unknown. We aimed to describe the disease severity in this patient population using the AAST grading system hypothesizing that the AAST grade would correlate with morbidity, management type, and duration of stay. Single institutional review of patients <18years old with a final diagnosis of acute appendicitis during 2010-2016 in KwaZulu-Natal, South Africa, was performed. Demographics, physiologic and symptom data, procedural details, postoperative complications, and Clavien-Dindo classification were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and nominal logistic regression analyses were performed to compare AAST grade and outcomes. A total of 401 patients were identified with median [IQR] age of 11 [5-13], 65% male. Appendectomy was performed in all patients; 2.4% laparoscopic, 37.6% limited incision, and 60% midline laparotomy. Complications occurred in 41.6%, most commonly unplanned relaparotomy (22.4%), surgical site infection (8.9%), pneumonia (7.2%), and acute renal failure (2.9%). Complication rate and median length of stay increased with greater AAST grade (all p < 0.001). AAST grade was independently associated with increased risk of complications. Pediatric appendicitis is a morbid disease in a developing middle-income country. The AAST grading system is generalizable and accurately corresponds with management strategies as well as key clinical outcomes. Retrospective study, Level IV. Retrospective single institutional study.

Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study.

To determine the relationship between multidetector computed tomography (MDCT) findings, management strategies, and ultimate clinical outcomes in patients with splenic injuries secondary to blunt trauma. This Institutional Review Board-approved study collected 351 consecutive patients admitted at the Emergency Department (ED) of a Level I Trauma Center with blunt splenic trauma between October 2002 and November 2015. Their MDCT studies were retrospectively and independently reviewed by two radiologists to grade splenic injuries according to the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) and to detect intraparenchymal (type A) or extraparenchymal (type B) active bleeding and/or contained vascular injuries (CVI). Clinical data, information on management, and outcome were retrieved from the hospital database. Statistical analysis relied on Student's t, chi-squared, and Cohen's kappa tests. Emergency multiphase MDCT was obtained in 263 hemodynamically stable patients. Interobserver agreement for both AAST grading of injuries and vascular lesions was excellent (k= 0.77). Operative management (OM) was performed in 160 patients (45.58% of the whole cohort), and high-grade (IV and V) OIS injuries and type B bleeding were statistically significant (p< 0.05) predictors of OM. Nonoperative management (NOM) failed in 23 patients out of 191 (12.04%). In 75% of them, NOM failure occurred within 30h from the trauma event, without significant increase of mortality. Both intraparenchymal and extraparenchymal active bleeding were predictive of NOM failure (p< 0.05). Providing detection and characterization of parenchymal and vascular traumatic lesions, MDCT plays a crucial role for safe and appropriate guidance of ED management of splenic traumas and contributes to the shift toward NOM in hemodynamically stable patients.

Management of paediatric high-grade blunt renal trauma: a 10-year single-centre UK experience.

To report the management and outcome of paediatric patients sustaining high-grade blunt renal trauma. Medical records were examined for all American Association for the Surgery of Trauma (AAST) grade III-V blunt renal trauma cases admitted to a paediatric trauma centre from 2005 to 2015. Data collected and analysed included: demographics, imaging modalities, management, length of hospital stay (LOS), complications, and follow-up outcomes. In all, 18 children (12 boys, six girls) with mean (range) age 11 (4-15) years were included. According to the AAST grading criteria, 39% (seven of 18) of the patients had grade III, 50% (nine of 18) grade IV, and 11% (two of 18) grade V injuries; 44% (eight of 18) had concomitant injuries. Most of the patients were managed conservatively (89%, 16 of 18), although two of the 16 subsequently needed JJ-stent insertion during inpatient stay for symptomatic urinoma(s). In all, 11% (two of 18) of the patients required interventional radiology service(s), involving selective embolisation for life-threatening renal tract haemorrhage. Blood transfusion for renal injury exclusively was required in 11% (two of 18) of the patients. In all, 89% (16 of 18) of the patients had at least one follow-up imaging study before hospital discharge; most (13 of 16) had ultrasonography and three required computed tomography. The median (range) LOS was 11 (4-31) days. In all, 17% (three of 18) of the patients required hospital re-admission within 30 days for complications and all required interventional procedures: JJ stent for urinoma (one), embolisation of renal arterio-venous fistula (one), and embolisation for a post-traumatic pseudoaneurysm (one). Overall, the median (range) follow-up was 6 (2-60) months. In all, 78% (14 of 18) of the patients had dimercaptosuccinic acid studies, with 11 showing reductions in renal function (range 3-44%). This study supports a care pathway strategy advocating conservative management of high-grade renal injuries in children. However, patients may experience a relative decline in renal function with higher grade injuries indicating the need for monitoring and follow-up.

Appendicitis Grade, Operative Duration, and Hospital Cost

The American Association for the Surgery of Trauma (AAST) established a grading system for appendicitis to allow prediction of risk and outcomes, to assist in quality improvement and resource management, and to provide a framework for research. Grading is determined in clinical, imaging, operative, and pathologic categories, but has not been completely validated. Our aim was to validate appendicitis grade with respect to duration of symptoms, operative duration, and hospital costs. We performed a retrospective medical record review, working backward until at least 40 of each grade of appendicitis were reviewed. Patients 8 years old and younger and those treated nonoperatively were excluded. Appendicitis severity was determined using the AAST grading scale (I to V), with V being the most severe. Statistical comparisons were made between increased grade and duration of symptoms, operative duration, hospital costs, and revenue. Data were analyzed using ANOVA or chi-square tests as appropriate. A total of 1,099 appendectomies performed between August 2013 and December 2016 were analyzed. Most were low grade. Median age was 18 years old, and 44.4% were female. Patients with increasing AAST grade had a longer symptom duration (p < 0.001), longer operative duration (p < 0.001), increased direct costs (p < 0.001) in every category measured (operating room, pharmacy, imaging, lab), and contribution margin (p < 0.001). The AAST appendicitis grade is a valid predictor of disease severity as defined by operative duration, hospital cost, and revenue. Duration of symptoms predicts severity. Appendicitis grade can be used in clinical care, residency training, and resource allocation.

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines

BackgroundAcute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes. MethodsAdults (≥18 years) with acute cholecystitis during 2013–2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30-day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics. ResultsThere were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0–6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68). ConclusionEmergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.

Assessment of blunt splenic trauma: Which imaging scoring system is superior?

Background:Spleen is the most common viscera that may be hurt in blunt abdominal trauma. Operative or nonoperative management of splenic injury is a dilemma. The American Association for the Surgery of Trauma (AAST) is the most common grading system which has been used for the management of blunt splenic injuries. The new recommended grading system assesses other aspects of splenic injury such as contrast extravasation, pseudoaneurysm, arteriovenous fistula, and severity of hemoperitoneum, as well. The aim of this study is to compare and prioritize the cutoff of AAST grading system with the new recommended one.Materials and Methods:This is a cross-sectional study on patients with splenic injury caused by abdominal blunt trauma referred to Isfahan University of Medical Sciences affiliated Hospitals, Iran, in 2013–2016. All patients underwent abdominopelvic computed tomography scanning with intravenous (IV) contrast. All images were reported by a single expert radiologist, and splenic injury grading was reported based on AAST and the new recommended system. Then, all patients were followed to see if they needed surgical or nonsurgical management.Results:Based on the findings of this study conducted on 68 patients, cutoff point of Grade 2, in AAST system, had 90.3% (95% confidence interval [CI]: 0.73–0.97) specificity, 51.4% (95% CI: 0.34–0.67) sensitivity, 86.4% (95% CI: 0.64–0.95) positive predictive value (PPV), and 60.9% (95% CI: 0.45–0.74) negative predictive value (NPV) for prediction of surgical management requirement, while it was 90.3% (95% CI: 0.73–0.97) specificity, 45.9% (95% CI: 0.29–0.63) sensitivity, 85% (95% CI: 0.61–0.96) PPV, and 58.3% (95% CI: 0.43–0.72) NPV for the new system (P = 0.816).Conclusion:In contrast to the previous studies, the new splenic injury grading method was not superior to AAST. Further studies with larger populations are recommended.