Use Of Nonoperative Management Research Articles

Incidence of Surgery for Pediatric Wrist Ganglion Cysts.

While diagnosis of ganglion cysts of the wrist in the pediatric population is common, data on management are limited. This study describes a nationwide analysis of the incidence and treatment of pediatric ganglion cysts. Patients who were diagnosed with a wrist ganglion cyst were identified from the PearlDiver database. Exclusion criteria included age over 18 years, incidence of different cyst diagnosis codes, fewer than 6 months of records prior to first diagnosis, and fewer than 2 years of follow-up. The use of imaging and common treatments for ganglion cysts including bracing, aspiration/injection, and surgery were noted. Patients were followed for 2 years, and factors associated with undergoing surgery were analyzed. Trends in the diagnosis and surgical management of ganglion cysts by age were observed. A total of 33 884 patients with a ganglion cyst on the wrist were identified. Diagnoses increased exponentially with age, while the percentage of patients who underwent surgery increased linearly with age. Those who underwent surgery tended to be older and were more likely to be female. These patients were also more likely to have undergone ultrasound or magnetic resonance imaging. There was a statistically significant difference in prior use of nonoperative management between patients that did and did not undergo surgery. This study offers a nationwide analysis of pediatric ganglion cysts. These findings are important to consider during longitudinal patient counseling and surgical planning.

Adherence to General Medical Council guidance regarding disclosure of alternative treatments during the consent process.

General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis. We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy. Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it (p<0.001). In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries.

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Recent Changes in the Management of High-Grade Blunt Pancreatic Injury in Children: A Nationwide Trend Analysis.

The optimal management of pediatric patients with high-grade blunt pancreatic injury (BPI) involving the main pancreatic duct remains controversial. This study aimed to assess the nationwide trends in the management of pediatric high-grade BPI at pediatric (PTC), mixed (MTC), and adult trauma centers (ATC). This is a retrospective observational study of the National Trauma Data Bank. We included pediatric patients (age 16 years or less) sustaining high-grade BPI (Abbreviated Injury Scale 3 or more) from 2011 to 2021. Patients who did not undergo pancreatic operation were categorized into the nonoperative management (NOM) group. Trauma centers were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric), and ATC (level I/II adult only). Primary outcome was the proportion of patients undergoing NOM, and secondary outcomes included the use of ERCP and in-hospital mortality. A Cochran-Armitage test was used to analyze the trend. A total of 811 patients were analyzed. The median age was 9 years (interquartile range 6 to 13), 64% were male patients, and the median injury severity score was 17 (interquartile range 10 to 25). During the study period, there was a significant upward linear trend in the use of NOM and ERCP among the overall cohort (range 48% to 66%; p trend = 0.033, range 6.1% to 19%; p trend = 0.030, respectively). The significant upward trend for NOM was maintained in the subgroup of patients at PTC and MTC (p trend = 0.037), whereas no significant trend was observed at ATC (p trend = 0.61). There was no significant trend in in-hospital mortality (p trend = 0.38). For the management of pediatric patients with high-grade BPI, this study found a significant trend toward increasing use of NOM and ERCP without mortality deterioration, especially at PTC and MTC.

The national utilization of nonoperative management for smallrenal masses over 10 years.

Management of small renal masses often involves a nonoperative approach, but there is a paucity of information about the use and associated predictors of such approaches. This study aimed to determine the trends in and predictors of use of nonoperative management of small renal masses. Using data from the National Cancer Database for localized small renal masses (N0/M0, cT1a) diagnosed between 2010 and 2020, we conducted a cross-sectional study. Nonoperative management was defined as expectant management (active surveillance or watchful waiting) or focal ablation. Adjusted odds ratios (AORs) were calculated using multivariable logistic regression models. Of the 156 734 patients included, 10.5% underwent expectant management, and 13.9% underwent focal ablation. Later year of diagnosis was associated with a higher likelihood of nonoperative management. In 2020, the odds of receiving expectant management and focal ablation were 90% (AOR = 1.90, 95% confidence interval [CI] = 1.71 to 2.11) and 44% (AOR = 1.44, 95% CI = 1.31 to 1.57) higher, respectively, than in 2010. Black patients had increased odds of expectant management (AOR = 1.47, 95% CI = 1.39 to 1.55) but decreased odds of focal ablation (AOR = 0.93, 95% CI = 0.88 to 0.99). Over the decade, the use nonoperative management of small renal masses increased, with expectant management more frequently used than focal ablation among Black patients. Possible explanations include race-based differences in physicians' risk assessments and resource allocation. Adjusting for Black race in calculations for glomerular filtration rate could influence the differential uptake of these techniques through deflated glomerular filtration rate calculations. These findings highlight the need for research and policies to ensure equitable use of less invasive treatments in small renal masses.

A Growing Divide? Social Determinants of the Use of Nonoperative Management of Rectal Cancer and Its Impact on Survival

IntroductionNonoperative management (NOM) of locally advanced rectal cancer was described as early as 2004. Initial national data demonstrated increase in utilization of NOM from 1998 to 2010, but newer national utilization data are not available. MethodsWe performed a retrospective cohort study using the National Cancer Database to assess utilization and 5-y overall survival (OS) of NOM of locally advanced rectal cancer. All patients had American Joint Committee on Cancer stage 2 or 3 rectal cancer, were over 40 y old, received both chemotherapy and radiation therapy, and were not being treated with palliative intent. Results74,780 patients were analyzed. 64,540 (86.2%) underwent a definitive resection, 10,330 (13.8%) had NOM. Utilization of NOM steadily increased from 11.3% in 2010 to 18.6% in 2018. Multivariate regression identified the highest predictors of utilization of NOM to be uninsured status, government insurance, Black race, and treatment at a community cancer center. Multivariate regression identified NOM as the highest hazard for mortality (hazard ratio = 2.286, confidence interval 2.209-2.366). After propensity score matching, the mean estimated 5-y OS was 52.0% for those managed operatively compared to 39.8% for those managed nonoperatively. ConclusionsFrom 2004 to 2018, the utilization of NOM of locally advanced rectal cancer significantly increased. However, there was a significant discrepancy in OS in comparison to surgical resection for these patients. Further study is needed to determine the long-term oncologic safety of NOM.

SP9.1 Increasing use of non-operative management in high grade splenic trauma

Abstract Aims The aim was to review the success of non-operative management (NOM) in the management of splenic trauma at our Major Trauma Centre (MTC). Methods We performed a retrospective data collection of all adults presenting to a London MTC with radiological evidence of splenic injury between 2014 and 2021. Electronic patient records were reviewed. Splenic injury was graded by a consultant radiologist. Patients too unstable to undergo a pre-operative CT for radiological injury grading were excluded from the analysis. Results Data was available for 337 patients, of which 28 patients went straight to theatre without imaging. 234 (75.7%) patients had AAST grade I-III splenic injury, 52 (16.8%) had grade IV and 23 (7.4%) had grade V injury. Successful NOM was achieved in 88.5% of patients with grade I-III splenic injury, 78.8% grade IV and 26.1% grade V injury. Patients with grade IV injury were more likely to undergo NOM without embolisation compared to grade V injury (OR=13.14, p=0.00058). The proportion of NOM grade IV injury increased significantly from 2017 to 2021 (OR= 16.94, p=0.001). There was also a significant difference between the rate of successful embolisation between grade IV and V splenic injury (OR=9.27, p=0.0003). Of patients undergoing operative management, grade I-III patients had a significantly higher chance of spleen salvage compared to grade IV-V patients (OR=34.5, p&amp;lt;0.00001). Conclusions This data demonstrates our increasing confidence in NOM for successful management of high-grade (IV-V) splenic trauma. Further research is required to identify specific patient characteristics associated with successful use of NOM.

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.

Treatment of Severe Blunt Splenic Injury Varies Across Race and Insurance Type of Pediatric Patients

IntroductionRacial and ethnic disparities in the management of adult patients with blunt splenic injuries (BSIs) have been previously demonstrated. It is unknown if similar disparities exist in pediatric patients with BSIs. Management of BSIs can include operative management, but nonoperative management (NOM) is preferred. This study assesses the association of race and insurance status on use of NOM among pediatric (aged < 18 y) patients following BSI. Materials and methodsData were abstracted from the American College of Surgeons Trauma Quality Improvement Program Participant Use Files for calendar years 2013-2017. Multivariate logistic regression was used to evaluate the associations between race or insurance status and NOM while controlling for injury severity, age, and facility type. Secondary outcomes included blood transfusion within 24 h and hospital length of stay. ResultsWe analyzed 1436 pediatric BSI patients. Black, non-Hispanic patients were less likely (odds ratio: 0.45, 95% confidence interval: 0.21-1.02, P = 0.043) to undergo NOM and stayed 0.6 d longer (P = 0.010) than White, non-Hispanic patients. Uninsured patients were less likely (odds ratio: 0.52, 95% CI: 0.25-1.11, P = 0.080) to undergo NOM and publicly insured patients stayed 0.24 d (P = 0.048) longer than privately insured patients. ConclusionsWe found disparities in use of NOM for Black patients and uninsured patients as well as differences in length of stay. These results extend the literature on racial and socioeconomic disparities in care of trauma patients to pediatric BSI patients. Addressing these disparities requires additional studies aimed at identifying the underlying causes.

Is there an increase in elective utilization of non-operative management for rectal cancer?

e15533 Background: There is growing evidence for the efficacy of a watch-and-wait or nonoperative management (NOM) strategy following chemoradiation with or without total neoadjuvant therapy for rectal cancer as an approach to organ preservation. Consequently, there has been growing interest and acceptance of this approach among both patients and providers. This study aims to analyze the use of the NOM strategy for patients with non-metastatic rectal cancer over the past decade and the patient and facility-level factors associated with its utilization. Methods: We performed an observational cohort study identifying patients from the National Cancer Database diagnosed between 2010-2020 with invasive, non-metastatic rectal adenocarcinoma. Patients who received chemotherapy and radiation without surgery were categorized as having received NOM. All other patients who received curative-intent surgery with or without chemotherapy and radiation were classified as the standard of care (SOC) cohort. Utilization of NOM was analyzed over time. Logistic regression analysis was utilized to identify patient and facility-level factors associated with NOM. Results: In total, 107,786 patients were included for analysis, of which 14,870 (13.8%) received NOM over the study period and 92,916 (86.2%) received SOC. The use of NOM steadily increased over the study period, from 10.3% in 2010 to 20.7% in 2020. Compared to SOC, NOM was associated with patients who were Black (16.9% vs 13.6% White, p &lt; 0.001), had Medicaid or no insurance (15.3% vs 13.4% Private/Medicare insurance, p &lt; 0.001), were older than 75 years (18.9% vs 12.8% younger than 75, p &lt; 0.001), and had high Charlson-Deyo comorbidity score (16.2% vs 14.0% no comorbidities, p &lt; 0.001). Facility factors associated with greater use of NOM included treatment at community cancer programs (OR 1.44, 95% CI 1.35-1.54, p &lt; 0.001) compared to treatment at comprehensive cancer centers. Facilities stratified by incident rectal cancer patient volume demonstrated an inverse relationship with NOM management, with low volume institutions having the highest NOM rate (p &lt; 0.001). Subgroup analysis of patients &lt; 75 years old, with private insurance, and without co-morbidities treated at institutions in the top quartile of volume showed NOM rates to similarly increase over the study period, from 6.4% to 13.7% (p &lt; 0.001). Conclusions: The use of the NOM strategy for patients with non-metastatic rectal cancer has increased over the past decade. While traditionally an approach for patients who were poor surgical candidates, the increasing trend for NOM among younger patients with fewer comorbidities and private insurance suggests that there is growing interest in elective NOM over the past decade. Ongoing prospective studies of NOM will shed light regarding the long-term efficacy of this approach compared to traditional surgical SOC.

Recent trends in the management of isolated high-grade splenic injuries: A nationwide analysis.

The feasibility of nonoperative management for high-grade blunt splenic injuries (BSIs) has been suggested in recent studies. The purpose of this study was to assess nationwide trends in the management of isolated high-grade BSIs. We hypothesized that isolated high-grade BSIs are more frequently being managed nonoperatively. The American College of Surgeons Trauma Quality Improvement Program database was queried to identify patients (16 years or older) with isolated high-grade BSIs (Abbreviated Injury Scale, ≥3) between 2013 and 2019. Patients were divided into two groups based on their hemodynamic status (hemodynamically stable [HS] and hemodynamically unstable [HU]). The primary outcome was the rate of total splenectomy each year, and the secondary outcome was the use of splenic angioembolization (SAE). Multiple regression models were created to estimate annual trends in splenectomy and SAE. A total of 6,747 patients with isolated high-grade BSIs were included: 5,714 (84.7%) and 1,033 (15.3%) in HS and HU groups, respectively. In the HS group, the rate of overall splenectomy was significantly decreased (from 22.9% in 2013 to 12.6% in 2019; odds ratio [OR] for 1-year increment, 0.850; 95% confidence interval [CI], 0.815-0.886; p < 0.001), and the use of SAE was significantly increased (from 12.5% in 2013 to 20.9% in 2019; OR, 1.107; 95% CI, 1.065-1.150; p < 0.001). In the HU group, the overall splenectomy rate was unchanged (from 69.8% in 2013 to 50.8% in 2019; OR, 0.931; 95% CI, 0.865-1.002; p = 0.071), whereas SAE was significantly increased (from 12.7% in 2013 to 28.8% in 2019; OR, 1.176; 95% CI, 1.079-1.284; p < 0.001). We observed significant trends toward more frequent use of nonoperative management in high-grade BSIs with hemodynamic stability. Further studies are warranted to define the role of SAE, especially in patients with hemodynamic instability. Therapeutic/Care Management; Level IV.

Return to Play after Posterior Cruciate Ligament Injuries.

Posterior cruciate ligament injuries can be treated conservatively with a structured rehabilitation program or with surgical reconstruction. Treatment algorithms are based on a variety of factors including the patient's presentation, physical exam, and desired level of activity. The goal is to return the patient to their athletic pursuits with a stable and pain-free knee. Return to play and activities should be individualized based on the patient's injury and progression through rehabilitation. This article provides a review of the current treatments for posterior cruciate ligament injuries and the respective rehabilitation protocols, outcomes after each treatment option, and specific return to play criteria. Current research shows excellent outcomes and return to play with conservative treatment of isolated posterior cruciate ligament injuries. Return to play algorithms stress the importance of quadriceps strengthening throughout the recovery process and emphasize inclusion of plyometrics and sport-specific training. Rehabilitation plays a critical role in the outcome after posterior cruciate ligament injury and the ability to return to athletics. The primary focus of post-injury or post-operative rehabilitation is to restore function, as it relates to range of motion, strength, and proprioception, while mitigating swelling and pain. The patients' desired sport and level of play dictate return to play timelines. The literature supports the use of non-operative management of isolated PCL injuries in athletes and non-athletes with excellent functional and patient-reported outcomes.

124 Nightstick Fractures: To Fix or Not to Fix?

Abstract Background A nightstick fracture is an isolated fracture of the ulnar shaft. Non-operative treatment is preferred for simple, non-displaced fractures (&amp;lt;5mm displaced or &amp;lt;50% translation). However, these fractures are associated with a high non-union risk, hence there is a clinician bias towards internal fixation. Aim To review outcomes of treatment of non-displaced nightstick fractures in our unit Methods: Between 2015 and 2020 we identified 90 appropriate patients. 67 patients were treated non-operatively; 23 had surgery. Outcome measures included radiological healing, functional recovery, and complications. Results The mean healing time was similar between the two groups (10 weeks in the non-operative group; 9 weeks in the operative group). The complication rate was similar (26.9% in the non-operative group; 26.1% in the operative group). Following presentation of our findings, we re-audited our nightstick fracture management. Between 2020 and 2021, we identified 19 patients. 16 were treated non-operatively; 3 patients had surgery. This translated to an increase in the proportion of patients managed non-operatively from 74% to 84%. Conclusions With a simple presentation on the outcomes following operative versus non-operative management, we increased the proportion of patients not having surgery. Of the 12 patients who experienced non-union, 6 opted for surgery later, of which only 1 patient had persistent non-union. Offering surgery at the 6-week review if needed provides patients with more time, without adversely affecting their functional outcome. This study advocates the use of non-operative management for non-displaced nightstick fractures initially. The 6-week review could be used to discuss any change in management.

Impact of the COVID-19 pandemic on management and outcomes of children with appendicitis: The Children with AppendicitiS during the CoronAvirus panDEmic (CASCADE) study

AimTo report the impact of the SARS-CoV-2 pandemic on management and outcomes of paediatric appendicitis in the UK and Ireland. MethodsProspective, multicentre observational cohort study at general surgical and specialist paediatric surgical centres in the United Kingdom and Ireland from 1st April to 31st July 2020. Primary outcome was treatment strategy used for acute appendicitis. ResultsThis study includes 2002 children treated for acute appendicitis of a median age of 10 (range 1–15) years and 605 children from a similar data set pre pandemic from 2017. In the pandemic cohort 560/2002(28%) were initially treated non operatively of whom 125/560(22%) proceeded to appendicectomy within initial hospital admission. Non operative treatment wasn't used in the pre pandemic cohort. Diagnostic imaging use was greater during the pandemic compared to pre pandemic (54vs31%; p < 0.00001) but overall use of laparoscopy was similar during both time periods (62.4vs66.6%). Hospital readmission rate was lower (8.7vs13.9%; p = 0.0002) during the pandemic than pre pandemic and Re-intervention rate was similar (2.9vs2.6%;p = 0.42). In cases treated operatively negative appendicectomy rate was lower during the pandemic than pre pandemic (4.4vs15.4%; p =0.0001), and during the pandemic was amongst the lowest ever reported in the UK. ConclusionCOVID-19 has had a significant impact on the management of children with appendicitis in the UK and Ireland. The rate of imaging and the use of non operative management increased, whilst the negative appendicectomy rate reduced. Overall, patient outcomes have not been adversely impacted by change in management during the pandemic. conclusionLevel I. Type of studyPrognosis study.

Diagnostic performance of serum interleukin-6 in pediatric acute appendicitis: a systematic review.

Despite the radiological and analytical advances of the last decades, there is still a significant rate of diagnostic error in pediatric acute appendicitis. In recent years, multiple biomarkers have emerged as potential diagnostic tools. This study aimed to examine the diagnostic performance of serum interleukin-6 in pediatric acute appendicitis. We conducted a systematic review of the literature that involved an extensive search in the main databases of medical bibliography (Medline, PubMed, Web of Science and SciELO). Two independent reviewers selected the relevant articles based on the previously defined inclusion and exclusion criteria. Methodological quality of the selected article was rated using the QUADAS2 index. Data extraction was performed by two independent reviewers. The research in the medical bibliography databases resulted in 68 articles. We removed 26 duplicates. Among the remaining 42 articles, we excluded 33 following the inclusion and exclusion criteria. Of the final 9 studies included in this review, 8 provided measured serum interleukin-6 values, and all of them reported significant differences between groups, but inconsistent results regarding sensitivity and specificity. The diagnostic performance of interleukine-6 alone for the diagnosis of acute appendicitis in children is limited. The sensitivity and specificity of interleukine-6 for the diagnosis of non-complicated acute appendicitis in the pediatric population are moderate but increased in complicated appendicitis. There seems to be a direct relationship between serum level of interleukin-6 and the hours of evolution of abdominal pain in children with acute appendicitis. The increasingly widespread use of non-operative management of acute appendicitis warrants further exploration of the classificatory potential of this marker between complicated and uncomplicated appendicitis. We consider that this may be an avenue of research to explore in the future.

Evaluation of results of fracture head and neck of radius managed by varius methods

Radial head fractures are the most frequent fracture type reported around the elbow. Fractures have been documented to occur in isolation or with other associated osseous and soft tissue injuries. However, despite intensive research into these injuries, controversies still exist regarding the role of further imaging modalities, the use of non-operative management, as well as the indication and technique for operative intervention. To analyses the clinical and functional outcome of patients with head and neck fracture of radius managed by conservative method, open reduction and internal fixation, radial head prosthesis and radial head excision. This study “evaluation of results of fracture head and neck of radius managed by various methods” was carried out in M.K.C.G Medical College, Berhampur from September 2017 to October 2019. Eighty patients of radial head and neck fractures were treated and hereby included in our study. We collected records of the patients by asking the patients history and examining the patients. Essential investigations of all the patients were done. The primary outcome measures were the surgeon reported Mayo Elbow Score (MES) and the patient reported Short Musculoskeletal Function Assessment (SMFA). Current evidence supports open reduction and internal fixation of simple Mason type II fractures. For Mason type III fractures, controversy still exists regarding the optimal treatment. Studies currently show good to excellent results with radial head replacement in the majority of patients with Mason type III fractures with three or more fracture fragments.

Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study.

PurposeThe COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown.MethodsWe performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications.ResultsA total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760).ConclusionIntroduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00423-020-02023-6.

Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases.

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

Is strict adherence to the nonoperative management protocol associated with better outcome in patients with blunt splenic injuries?: A retrospective comparative cross-sectional study.

The nonoperative management (NOM) protocol with angioembolization (AE) presents a trend in dealing with trauma patients with blunt splenic injury (BSI). This study was designed to explore the adverse events and associated risk factors before and after protocol-based NOM of BSI over a 12-year period. A retrospective study was performed on adult trauma patients with BSI who were admitted from 2005 to 2016. The patients were divided into before cohort (2005-2010) and after cohort (2011-2016). Multivariate logistic regression analysis was performed to identify risk factors associated with the morbidity. The primary outcomes are NOM-related mortality and total number of complications, the secondary outcome is the incidence of each complication. The before cohort was composed of 209 patients, and the after cohort had 190 patients. There was a significant increase in the use of AE (from 18.1% to 47.5%, p < 0.001) with a higher incidence of patients who had a shock episode before AE (from 4.2% to 16.5%, p < 0.001). Regarding the outcomes, there were no significant differences in the incidences of NOM-related mortality between the after than before cohorts. However, there were 190 complications in 71 patients in the before cohort but 289 complications in 73 patients in the after cohort. The incidence of complications was significantly higher in the group of after cohort than the group of before cohort. Regarding the complications, the patients in the after cohort were significantly more likely to have adverse events of coagulopathy, acidosis, hyperbilirubinemia, respiratory failure, and acute kidney injury than those in the before cohort. Strict adherence to the NOM protocol in treating patients with BSI without adequate patient selection increased not only the use of NOM but also the possibility of complications and failed to significantly improve the clinical outcomes.