American Association For The Surgery Of Trauma Research Articles

November 2022 Medical Image of the Month: COVID-19 Infection Presenting as Spontaneous Subcapsular Hematoma of the Kidney

No abstract available. Manuscript truncated after 150 words. A 57-year-old woman with pertinent medical history of hypertension presented to the emergency department with 3 days of right sided lower abdominal pain radiating to the flank, associated with nausea and nonbloody, nonbilious emesis. She reported recent travel to Florida where she visited amusement parks, but only rode small children’s rides with no experienced physical trauma. She experienced fatigue and chills 5 days prior to presentation and tested positive for SARS-CoV2 virus on admission. She had been vaccinated for COVID-19 x3 (Moderna). No other significant history nor medications were noted, and review of systems was otherwise unremarkable. Urinalysis demonstrated mild ketonuria (20), proteinuria (100) and moderate hematuria on urinalysis while BUN and creatinine remained stable at baseline throughout. Physical examination confirmed costovertebral angle tenderness to the right side. CT abdomen revealed an American Association for the Surgery of Trauma (AAST) grade 3 right renal subcapsular hematoma with 2.1 cm laceration …

Walk the line: An ethical framework for interactions with law enforcement in trauma care environments.

Comprehensive trauma services sit at the intersection of health care, law enforcement, ethics, and social work. Each domain has its own set of priorities around the patient and the community. While these priorities often overlap, the ultimate goal is to promote collaborative patient-centered care. The American Association for the Surgery of Trauma (AAST) Injury Prevention committee sought to provide recommendations for a framework that builds ethical interactions with law enforcement in the trauma bay. These are rooted in four prime bioethical principles: beneficence, nonmaleficence, honoring autonomy, and justice. In the presented work, cases are used to illustrate how common interactions can be ethically handled and suggestions on how to develop policies, create systems for patient advocates, and leverage infrastructure to reduce conflict and improve trauma care. By keeping the patient's best interest at the focus, acknowledging the importance of protecting community wellbeing, and acting within the bounds of ethical principles and local statutes, trauma care teams and law enforcement officers can work collaboratively to achieve respective goals.

Endovisual technologies in the diagnosis and treatment of closed injuries of the pancreas

BACKGROUND: To date, there is no consensus on the optimal treatment and diagnostic algorithm for patients with closed pancreatic injury in cases where emergency surgery is not required. Patients with suspected pancreatic injury require the closest attention and maximum efforts aimed at establishing an accurate diagnosis.
 AIM: To optimize the method of diagnosis and surgical intervention for closed abdominal trauma with damage to the pancreas.
 MATERIALS AND METHODS: We have analyzed the results of treatment of 125 patients with pancreatic injuries who were treated in the surgical department of the Republican Scientific Center for Emergency Medical Aid and its branches from 20112021 among the victims, men predominated 104 (83.2%) patients, women 21 (16.8%), age ranged from 20 to 60 years. For the study, two groups of patients with damage to the pancreas with a closed abdominal injury have been formed. Group I included 84 victims in the period from 2011 to 2016 using traditional surgical interventions. Group II included 41 patients in the period from 2016 to 2021 using endovideosurgical technologies for the diagnosis and treatment of patients with a closed injury of the pancreas.
 Isolated trauma of the pancreas was diagnosed in 22 (26.1%) patients, combined in 103 (82.4%). Injuries of the pancreas in case of a closed injury were localized mainly in the tail of the pancreas, less often in the head, body and isthmus.
 RESULTS: Resection of the pancreas was performed in the predominant number of cases with III degree of damage, when there was damage to the tail of the gland with a violation of the integrity of the MP. In group I, this volume of operation was performed in 1 out of 4 cases of distal damage to the gland, in group II, resection was also performed in 1 out of 3 cases of damage to the pancreas with degree of damage. Suturing was carried out with a hemostatic purpose in case of damage to the integrity of the blood vessel in the projection of the pancreas. It was used in 9 (10.7%) cases in group I and also in 3 (7.3%) cases in group , in both cases II and III degree of damage to the pancreas occurred. Opening of the hematoma of the pancreas was performed in 6 (7.1%) cases in group I, in 4 of which with the I degree of damage to the gland, in the II group it was performed in 3 (7.3%) cases also with I and II degrees of damage. Among our patients in group II there were 12 patients with degree I damage to the pancreas. 6 patients underwent diagnostic videolaparoscopy, bursoscopy (pancreatoscopy), drainage of the omental sac. There were no significant differences in the number of complications in patients undergoing laparotomy and laparoscopy. This indicates that both methods can adequately inspect the abdominal cavity and establish a diagnosis.
 Of the 125 victims with dominant damage to the pancreas, 17 (13.6%) died. According to our data on the Pancreatic Injury Mortality Scale, there were no lethal outcomes with mild severity. In the group with moderate severity, 4 (8.6) patients died in group I and in group II, 1 (2.1%) patient, with a severe case, 9 (52.9%) patients died in group I and in group II 3 (17.6%) patients. The main causes of death in 9 patients were severe destructive post-traumatic pancreatitis, 6 victims had injuries with severe traumatic and hemorrhagic shock, 2 had multiple complications of combined injuries, chest, brain.
 CONCLUSIONS: In our opinion, therapeutic laparoscopy can be used for isolated injuries of the pancreas and only for injuries according to American Association for the Surgery of Trauma (AAST) I degree. With II degree of damage, it is better to end the operation with precision hemastosis with drainage of the stuffing bag. At the III degree of damage to the pancreas, it is possible to perform a distal resection. Indications for tamponing rarely arise exclusively within the framework of the treatment tactics Damage control and when it is impossible to stop bleeding from the pancreas.

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.

Developing and leading a sustainable organization for early career acute care surgeons: Lessons from the inaugural American Association for the Surgery of Trauma Associate Member Council

The associate membership of the American Association for the Surgery of Trauma (AAST) was established in 2019 to create a defined but incorporated entity within the larger AAST for the next generation of acute care surgeons. The Associate Member Council (AMC) was subsequently established in 2020 to provide the new AM with an elected group of leaders who would represent them within the AAST. In its inaugural year, this cohort of junior faculty and surgical trainees had developed for the AM a set of bylaws, a mission statement, a strategic vision, and a succession plan. The experience of the AAST AMC is exemplary of what can be accomplished with collaboration, mentorship, innovation, and tenacity. It has the potential to serve as a template for the creation and vitalization of future professional groups. In this piece, the AMC proposes a blueprint for the successful conception of a new organization.

#38 The Impact of the COVID-19 Pandemic on Acute Appendicitis Presentation in Two Urban Multiethnic Community Hospitals

BackgroundAcute appendicitis (AA) is the most common abdominal surgical emergency in pediatrics. There was a precipitous drop in pediatric visits to hospitals, including the emergency department, since the United States declared COVID-19 a national emergency. Managing AA during the pandemic remains a challenge as fear of COVID exposure can lead to delays in presentation and surgery, as well as a shift to conservative management. Alvarado score (AS) is a ten-point clinical scoring system to identify AA and the American Association for the Surgery of Trauma (AAST) grading system (I-V) is a validated tool for AA diagnosis and severity. There are no studies on prevalence and severity of AA during the COVID-19 pandemic in an urban multiethnic community.MethodThis is a retrospective chart review of patients admitted to Flushing Hospital Medical Center and Jamaica Hospital Medical Center with the diagnosis of AA from March 2018 to March 2021. Charts were reviewed for demographics, clinical, imaging and surgical data to determine AS and AAST. AS grouped from 1-6 (less likely to require surgery) and 7-10 (more likely to require surgery). AAST scoring was based on most severe criteria if grading discrepancies were found between pathology, surgical and computed tomography findings. Leukocytosis was defined as white blood cell count >10. G1 identified AA cases March 2018 - February 2020 and G2 March 2020 – March 2021. Data was analyzed using SPSS software, p<0.05 was considered significant.ResultsOf 239 patients with AA over 3 years, G1 totaled 184 (77%) in 2 years pre-pandemic and G2 had 55 (23%) during first year pandemic. Mean age, gender and ethnicity were similar for G1 and G2. AS and AAST were compared for G1 and G2, Table 1. G2 had significantly greater overall AS of >7 (p=0.038) and higher AAST (p=0.016). Only three patients tested positive for SARS-CoV-2 and 9 (16%) of G2 were transferred to a tertiary care center.ConclusionAlthough there was a decline in number of AA evaluated in our emergency department, the severity of AA was heightened during the pandemic. Healthcare providers need to have a high index of suspicion of increased severity with AA complications.

Predictive factors for nephrectomy in renal trauma; assessment of a 6-point score.

To evaluate predictive and associated risk factors for nephrectomy in renal trauma and assess a 6-point score for surgical decision-making. This multicenter, retrospective, and observational study assessed 247 subjects with blunt or penetrating kidney trauma. Kidney injuries were classified according to the American Association for the Surgery of Trauma (AAST) Injury Scoring Scale. Renal trauma was classified as "low-grade" (Grades I-III), Grade IV, and Grade V. Subjects were compared according to conservative treatment (CTrt.) or nephrectomy. Predictive factors were evaluated with a multiple regression model. A 6-point score was evaluated with a ROC analysis. Patients requiring nephrectomy had a lower mean arterial pressure MAP compared to CTrt, 64.71mmHg (SD ± 10.26) and 73.86 (SD ± 12.42), respectively (p = < 0.001). A response to IV solutions was observed in 90.2% of patients undergoing CTrt. (p = < 0.001, OR = 0.211, 95%CI = 0.101-0.442). Blood lactate ≥ 4mmol/L was associated with nephrectomy (p = < 0.001). A hematoma ≥ 25mm was observed in 41.5% of patients undergoing nephrectomy compared to 20.1% of CTrt. (p = 0.004, OR = 9.29, 95% CI = 1.37-5.58). A logistic regression analysis (p = < 0.001) showed that blood lactate ≥ 4mmol/L (p = 0.043), an inadequate response to IV solutions (p = 0.041) and renal trauma grade IV-V (p = < 0.001), predicted nephrectomy. A 6-point score with a cut-off value ≥ 3 points showed 83% sensitivity and 87% specificity for nephrectomy with an AUC of 89.9% (p = < 0.001). An inadequate response to IV solutions, a lactate level ≥ 4mmol/L, and grade IV-V renal trauma predict nephrectomy. A score ≥ 3 points showed a good performance in this population.

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.

Abstract No. 87 Splenic artery embolization in grade V blunt splenic injury: 10-year retrospective review

The role of splenic artery embolization (SAE) in Grade V blunt splenic injury is poorly defined given the propensity of this population to proceed directly to splenectomy. Additionally, the definition of Grade V injury recently changed in the American Association for the Surgery of Trauma (AAST) 2018 update to include vascular injury with active bleeding extending into the peritoneum. The purpose of this study was to evaluate the outcomes of Grade V SAE in stable and unstable patients over the past 10 years.

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.

Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention.

Computed tomography volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research. BACKGROUND Several ordinal grading systems are used in deciding whether to perform angioembolization (AE) or splenectomy following blunt splenic injury (BSI). The 2018 American Association for the Surgery of Trauma (AAST) Organ Injury Scale incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision making. PURPOSE The purpose of this study is to compare performance of computed tomography (CT) volumetry-based quantitative modeling to the 1994 and 2018 AAST Organ Injury Scale and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or AE. MATERIALS AND METHODS Adult BSI patients (age ≥18 years) scanned with dual-phase CT prior to intervention at a single Level I trauma center from 2017 to 2019 were included in this retrospective study (n = 174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included (1) SPY and (2) the composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. Area under the receiver operating characteristic curve (AUC) for ordinal systems and volumetric models were compared. RESULTS Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85—SPY, 0.82—composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p = 0.66, 0.14) for both endpoints and were significantly improved over Thompson scoring (0.76, p = 0.02; 0.77, p = 0.04). CONCLUSION Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.

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 ...

MP20-04 GRADE V RENAL TRAUMA: SUCCESS ROLE FOR CONSERVATIVE MANAGEMENT IN THE NATIONAL TRAUMA DATABANK

You have accessJournal of UrologyCME1 May 2022MP20-04 GRADE V RENAL TRAUMA: SUCCESS ROLE FOR CONSERVATIVE MANAGEMENT IN THE NATIONAL TRAUMA DATABANK Nizar Hakam, Nathan Shaw, Jason Lui, Behnam Nabavizadeh, Kevin Li, Patrick Low, and Benjamin Breyer Nizar HakamNizar Hakam More articles by this author , Nathan ShawNathan Shaw More articles by this author , Jason LuiJason Lui More articles by this author , Behnam NabavizadehBehnam Nabavizadeh More articles by this author , Kevin LiKevin Li More articles by this author , Patrick LowPatrick Low More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Conservative management is now standard for most renal trauma as it decreases complications and nephrectomy rates. However, American Association for the Surgery of Trauma (AAST) grade V injuries renal injuries continue to largely require intervention and sparse data is available on conservative management. We investigate whether conservative management was pursued in patients who survive grade V renal injuries using the National Trauma Databank (NTDB). METHODS: Patients with grade V renal trauma were identified in the 2018 NTDB (n=612). Patients who survived to final hospital discharge were included (n=474). Conservative management was defined by the absence of any surgical or procedural intervention. Percutaneous or cystoscopic drain placement was exempted from procedural intervention. Characteristics of patients who underwent conservative vs non-conservative management were compared. RESULTS: Out of 474 patients, 175 (36.9%) were managed conservatively. In the 299 patients managed non-conservatively, most common interventions were surgical exploration (n=200, 66.9%), nephrectomy (n=196, 65.6%), kidney angioembolization (n=60, 20.1%), open surgical bleeding control (n=37, 12.4%), and surgical repair of the kidney or renal artery (n=22, 7.4%). Patient characteristics are depicted in Table 1, stratified by management approach. Patients managed conservatively had more favorable hemodynamic parameters compared to those managed non-conservatively, exhibiting lower mean pulse rate (99.9 vs 106.2, p=0.01). They had less hypotension on arrival (8.6% vs 17.4%, p=0.008) and received fewer blood transfusion (28% vs 67.2%, p<0.001). They also were younger (mean age 26.7 vs 30.5, p=0.01), less likely to be male (71.4% vs 91.6%, p=0.01), less likely to have sustained a penetrating injury (6.7% vs 51.2%, p <0.001), and had a significantly different distribution of trauma mechanism (Table 1). CONCLUSIONS: A conservative approach may be safe in a subset of patients with grade V renal injury, especially in those who were less likely to be in shock, receive blood transfusion, or sustain penetrating injury. Further research to identify phenotypes amenable to conservative management is warranted to improve patient outcomes. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e318 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nizar Hakam More articles by this author Nathan Shaw More articles by this author Jason Lui More articles by this author Behnam Nabavizadeh More articles by this author Kevin Li More articles by this author Patrick Low More articles by this author Benjamin Breyer 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.

Validation of the American Association for the Surgery of Trauma Organ Injury Scale for Penetrating Colon Injuries.

In 2020, the American Association for the Surgery of Trauma (AAST) published a revision of the organ injury scale (OIS) for bowel injuries. The update included for the first time a separate OIS for penetrating colon injuries as well as imaging criteria. To validate the new OIS and its correlation with outcomes, we performed a retrospective review of patients with penetrating colon injuries (AIS<3 in other body regions) between 2016 and 2020 at a single institution. Sixty-six patients met inclusion criteria. Most were young (29years median) and male (90%). All underwent operative intervention and 23 (34%) had pre-operative imaging. Imaging grade was higher than operative grade in 11 patients (48%). Higher AAST operative grade was associated with a higher likelihood of resection and anastomosis or colostomy, need for damage control laparotomy, and development of intra-abdominal abscess and acute kidney injury. A multicenter study is underway to confirm these findings.

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.

The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 1: Pancreatic and Hepatobiliary Injuries.

Trauma is an important cause of mortality, particularly in the young. While computed tomography (CT) is the mainstay of body imaging in the setting of trauma, magnetic resonance (MR) imaging can be useful in stable patients. Although more commonly used in spinal and musculoskeletal trauma, MR also has a role in abdominopelvic trauma. Broadly, its uses include clarification of equivocal cases, monitoring complications of trauma, particularly with solid organ injury, or as a primary imaging modality for patients with low suspicion for injury for whom avoiding ionizing radiation is a priority-namely, in pediatric and pregnant patients. In this two-part review article, we will review clinical scenarios where this may be encountered, utilizing case examples. This first installment will focus on pancreatic and hepatobiliary injuries. Pancreatic trauma may be difficult to diagnose on CT, and MR may aid in demonstrating pancreatic duct disruption, allowing for accurate grading according to American Association for the Surgery of Trauma (AAST) criteria. It may also be a useful modality for monitoring evolution of pancreatic injuries and/or pseudocyst development, guiding potential stenting, and/or drainage. Biliary injuries are also optimally evaluated with MR, particularly when aided by the use of hepatobiliary contrast material. This can allow for accurate delineation of biliary ductal anatomy and aid in planning percutaneous or endoscopic treatment of bile leaks.

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.