Aortic Trauma in Scotland – A Population Based Study

OBJECTIVES: This population-based study aims to determine the incidence, mechanisms and outcomes of aortic trauma in patients from Scotland between 1992-2002. METHODS: Patients with aortic trauma were identified from the Scottish Trauma Audit Group database. Demographics, mechanism of injury, initial management and outcome were analysed. RESULTS: 165 (0.3%) patients suffered trauma to the thoracic or abdominal aorta. Of these, 130 (79%) patients had an injury of the thoracic aorta, 33 (20%) an injury of the abdominal aorta and two (1%) had injuries of both. There were 123 (75%) men and 42 (25%) women with a median (range) age of 36 (14-90) years. Blunt trauma was responsible for 121 (73%) injuries, of which road traffic accidents were the most common mechanism. A further 44 (27%) aortic injuries were due to penetrating trauma, of which assault was the most common cause. The median (range) Injury Severity Score was 43 (16-75). Ninety (55%) patients died in the emergency department while 59 (32%) underwent attempted operative repair. The operative mortality was 35 (59%) of 59 patients and overall mortality 141 (86%) of 165 patients. CONCLUSIONS: The incidence of aortic trauma presenting to Scottish hospitals is low. The majority of patients do not survive to surgical repair and operative and overall mortality remain prohibitive.     

Esophagogastric Trauma in Scotland

Background

This study was designed to investigate the incidence of esophageal (ET) and gastric trauma (GT) in Scotland and to identify factors associated with adverse outcome.

Methods

Population-based study of a prospective multicenter database of 52,887 trauma patients, admitted to 25 hospitals from 1992 to 2002.

Results

Thirty patients [0.06?%; median age, 32?year (range, 15–79); 86.7?% male] sustained ET [17 (56.7?%) blunt vs. 13 (43.3?%) penetrating]. The most common causes of injury were road traffic accidents (RTAs; n?=?11; 36.7?%) and assaults (n?=?10; 33.3?%). Most patients (n?=?25; 83.3?%) had injury severity scores (ISS) >15, consistent with severe trauma. Fifteen patients (50?%) underwent surgery, of whom 8 (53.3?%) died. Another 13 patients died, yielding an overall mortality rate of 70?%. In contrast, 149 patients [0.29?%; median age, 28?year (range, 13–74); 90.6?% male] sustained GT [124 (83.2?%) penetrating vs. 25 (16.8?%) blunt]. The predominant cause was assault (n?=?119; 79.9?%). Most patients (n?=?134; 89.9?%) underwent surgery, of which 23 (17.2?%) died. Another 12 patients died, yielding an overall mortality rate of 23.5?%. Factors associated independently with GT mortality included higher ISS, lower Glasgow coma scale (GCS), and hemodynamic compromise.

Conclusions

Esophagogastric trauma occurs predominantly in young males. The incidence of GT, although low, is five times that of ET. Predominant mechanisms of GT are penetrating compared with blunt for ET. Both ET and GT are commonly found in the presence of other multiple injuries, and are associated with high mortality. Operative management of GT is associated with reduced mortality, but outcome is worse for patients with hemodynamic compromise, low GCS, and high ISS.     

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

Background There is ongoing debate on how variations in surgical technique affect outcomes in pancreatic cancer. This population-based study examines current surgical practice and outcomes for cancer of the pancreatic head. Methods All patients 18 to 85 years old diagnosed with nonmetastatic adenocarcinoma of the pancreatic head from 1998 through 2003 were identified from the Surveillance, Epidemiology and End Results (SEER) Program registry. Multivariable regression was used to elucidate factors associated with the type of pancreaticoduodenectomy performed, extent of lymph node (LN) assessment, early mortality, and late survival. Results Overall, 2111 patients were included in the study, with 83.7% treated with a standard Whipple pancreaticoduodenectomy (PD). However, there was marked regional variation in the use of pylorus-preserving pancreaticoduodenectomy (PPPD; range, .03%–32.0%; P < .0001) and total pancreatectomy (TP; range, .04%–19.5%; P < .0001). TP was associated with significantly higher early mortality (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.1; P < .0001), but late survival did not differ significantly between TP, PPPD, and PD (P = .69). Significant variation was also seen in the number of LN assessed (range across SEER regions, 7.3–13.5; P < .0001). Decreased LN assessment reduced the odds of diagnosing a patient as node positive and was associated with worse late survival. Conclusions In this population-based study, we found marked clinically important variability in the surgical treatment of adenocarcinoma of the pancreatic head, with respect to the use of TP, PPPD, or PD, and the extent of LN assessment. Further research is warranted to elucidate the underlying reasons, and to clarify the role of adequate lymphadenectomy.     

Pancreatic Trauma Revisited*

Abstract Pancreatic trauma is rare with an incidence between one and two percent in patients with abdominal trauma. Morbidity and mortality, however, are significant with rates approaching 40–45% in some reports. The majority of patients with injuries to the pancreas have associated trauma to other organs which are primarily responsible for the high mortality rate. The continuity of the main pancreatic duct is the most important determinant of outcome after injury to the pancreas. If there is no evidence of ductal injury on fine-cut CT or on ERCP, nonoperative management is chosen. The indications for operative management are as follows: (1) peritonitis on physical examination; (2) hypotension and a positive FAST; and (3) evidence of disruption of the pancreatic duct on fine-cut CT or on ERCP. After exposure and evaluation of the extent of injuries to the pancreas and duodenum, a decision must be made on the procedure. For pancreatic contusions, hematomas, or small lacerations, simple external drainage or pancreatorrhaphy with drainage can be performed. For ductal transection at the neck, body, or tail, the procedure of choice is a distal pancreatectomy or Roux-en-Y distal pancreatojejunostomy. If the patient has suffered a ductal transection at the head of the pancreas without injury to the duodenum, a Roux-en-Y distal pancreatojejunostomy or anterior Roux-en-Y pancreatojejunostomy is the operation of choice. For combined pancreatoduodenal injuries, the options are repair and drainage, diversion via a pyloric exclusion procedure, or pancreatoduodenectomy. Complications of pancreatic injuries include fistulas and intra-abdominal abscesses, and an occasional pancreatic pseudocyst. Key Words *Please see related articles in Eur J Trauma Emerg Surg 33;3:221–37     

胰腺损伤的诊断与治疗

目的探讨胰腺损伤的诊断和治疗方法。方法回顾性分析16例胰腺损伤患者的临床资料。结果胰腺损伤属Ⅰ级3例,Ⅱ级5例,Ⅲ级4例,Ⅳ级3例,Ⅴ级1例;系单纯胰腺损伤3例,合并其他器官损伤13例。术前确诊为胰腺损伤者9例,另7例分别诊断为：脾破裂1例,肝破裂1例,开放性腹部损伤2例,空腔脏器穿孔、弥漫性腹膜炎3例。8例胰腺Ⅰ～Ⅱ级损伤者行清创、缝扎止血及胰腺周围双套管引流术;4例Ⅲ级损伤者行胰体尾切除＋脾切除术;3例Ⅳ级损伤者,行近端胰腺断端缝合、胰管缝扎加胰体尾空肠Roux-en-Y吻合术;对1例Ⅴ级损伤者行胰十二指肠切除术。术后发生胰瘘5例;治愈13例,死亡3例。结论早期诊断、及时手术探查以及术中选择合理的手术方式,对降低胰腺损伤的并发症和死亡率和改善胰腺损伤的预后均十分重要。     

Trauma audit: experience in north-east Scotland.

The management of 125 patients with trauma treated at Aberdeen Royal Infirmary from 1 January 1988 has been analysed using a microcomputer-based hospital trauma registry incorporating trauma and injury severity scores (TRISS) methodology. These patients fulfilled the North American Major Trauma Outcome Study (MTOS) inclusion criteria and were the first for whom data were available. Sixty-six patients had multiple injuries, of whom 52 were suffering from major trauma (defined as an injury severity score of 16 or greater). There were 14 deaths in the series, three (21 per cent) of which were considered to be preventable. Surgery was required in 84 (67.2 per cent) patients, of whom 59 (70 per cent) were operated on by a consultant or senior registrar. Five of six critically injured patients who died from their injuries were operated on by a consultant.     

Splenic Trauma in Scotland: Demographics and Outcomes

Background Splenic trauma is a common organ injury following blunt abdominal trauma. In order to establish the contemporary epidemiology of blunt splenic trauma in Scotland and to detect risk factors associated with patient outcomes, analysis of a multi-center database of trauma patients was performed. Methods The study used data from a prospectively collated multicenter trauma database containing the details of 52,215 trauma patients admitted to participating Scottish hospitals over an 11-year period. Results 672 (1.3%) patients (530 males, 142 females) with splenic trauma were identified; of them, 579 (86.2%) had blunt trauma and 93 (13.8%) had penetrating trauma. The mean age of patients with blunt splenic trauma was 35.7 years (33.8 years for males, 42.0 years for females). Increasing age and female sex was significantly associated with mortality. The most common mechanism for injury was road traffic accidents (71%). In the series, 93.8% of patients had concomitant injuries including head injuries (46.5%), thoracic injuries (37.7%) and liver injuries (30%). A total of 299 (51.6%) patients proceeded to laparotomy, and 256 (44.2%) patients required ICU support. The overall mortality was 33.5%, and the median Injury Severity Score was 48 in patients who died, compared to 22 in those who survived. Increased mortality was associated with concomitant aortic, cardiac, or abdominal injuries. A number of independent risk factors were associated with increased risk of mortality, including concomitant injuries, increased age, and increased Injury Severity Score. Conclusions The incidence of splenic trauma is low, but it accounts for significant mortality. Outcome in the present study was worse in those with advanced age and associated injuries.     

Epidemiology of Fatal Trauma in Italy in 2002 Using Population-Based Registries

Background:   

Population-based registries have been proposed for epidemiologic studies and quality assessment in trauma care because they consider the entire population of a given geographic area.     

胰腺损伤35例诊治分析

目的总结胰腺损伤诊断和治疗的经验。方法回顾性分析我科2005年12月至2010年6月期间收治的35例胰腺损伤患者的临床资料。结果男32例,女3例;年龄11～47岁,平均29岁。损伤程度:Ⅰ、Ⅱ级20例,Ⅲ级12例,Ⅳ级2例,Ⅴ级1例。根据病史、临床症状、血清淀粉酶、腹腔穿刺液淀粉酶检测、B超、CT等诊断。4例行非手术治疗;31例行手术治疗,其中16例行胰腺被膜切开、清创、冲洗、引流,6例行损伤胰腺远端切除,6例行近端缝合、远端空肠Roux-en-Y吻合,2例胰腺主胰管吻合放置支撑管经空肠外引流,1例胰头部严重毁损行胰十二指肠切除术。术前明确诊断24例,术中明确诊断11例。本组死亡5例,均为胰腺复合伤,其中1例肠系膜上动脉损伤合并实质脏器损伤术后24h死亡,4例胰腺严重毁损,术前抗休克后术中探查见胰腺损伤合并2个以上脏器损伤,术后肝、肾功能衰竭,经抢救无效死亡。治愈30例。结论胰腺损伤的术前诊断率较低,围手术期应积极剖腹探查弥补术前不足,外科治疗要根据损伤分级采取个体化方案,贯彻损伤控制性外科理念,不宜盲目扩大手术。     

胰腺切除与胰腺外伤手术胰漏的诊断及防治措施

虽然生长抑素的应用对预防胰漏发挥了重要作用,但胰漏仍然是临床常见的致死性并发症.虽然有作者提出不同的胰肠吻合方式术后胰漏的差异无统计学意义[1],但积极探索预防胰漏的有效方法仍然是临床医生面临的重要课题.近年来,在强调加强围手术期处理、精细化手术操作及充分有效引流等措施的同时,在胰腺切除及胰腺外伤修复手术中采用了一系列新方法,有助于降低胰漏发生率,现就具体措施及方案作一介绍.     

闭合性胰腺损伤的诊治(附16例报道)

目的探讨闭合性胰腺损伤的诊断和合理的手术方式。方法对我院2005～2008年期间收治的16例闭合性胰腺损伤患者的临床资料进行回顾性分析。结果本组术前确诊5例,另11例在术中确诊。根据胰腺损伤的不同分级进行相应的手术治疗,手术均顺利完成。术后无一例出现胰瘘,但出现胰腺假性囊肿1例,腹腔出血1例,腹腔感染2例,死亡2例。结论重视胰腺损伤的早期诊断,选择合理的手术方式及时手术,加强围手术期处理,可提高胰腺损伤的救治成功率。     

Time to CT and Surgery for HPB Trauma in Scotland Prior to the Introduction of Major Trauma Centres

Aims

To assess the time taken to CT and emergency surgery for trauma patients with an injury to liver, spleen or pancreas prior to the introduction of major trauma centres (MTCs) in Scotland.

Methods

A search was performed of the Scottish Trauma Audit Group database for any patient with relevant injuries over a 2-year period. Primary outcome measures were time to CT and emergency surgery. Patient demographics were also recorded.

Results

A total of 211 patients were identified of whom 23 had more than one organ affected. There were a total of 234 injuries (123 liver, 99 splenic and 12 pancreatic) in these patients. A total of 160 injuries (75.8%) suffered blunt trauma. Of 211 patients, 157 underwent emergency CT with a median time to scan of 73 min (range 4–474). Hospitals provisionally designated as MTCs were 9 min faster than non-MTCs in time to CT. There was no difference in time of day. Ninety-nine patients had surgery within 24 h at a median time of 200 min. Twenty-five patients with hypotension on presentation took a median time of 130 min. Only 44 patients (27%) had a CT or emergency surgery within the expected MTC target of 1 h. Thirty-nine patients required transfer to another centre.

Conclusions

Current management of patients with abdominal trauma and haemodynamic instability remains sub-optimal in Scotland when compared to recognized performance indicators of CT and emergency surgery within 1 h. Implementation of a major trauma network in Scotland should improve access to emergency radiology and surgery and efforts to shorten current timelines should improve patient outcomes.

     

Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma: Improvements Needed in Population-Based Registries

Background

Management of patients with borderline resectable/locally advanced (BR/LA) pancreatic adenocarcinoma is based on knowledge of natural history and patterns of treatment failure, information of great importance to large data registries. Using the SEER database, we examined the survival for patients with BR/LA tumors and critically evaluated the utility of the data.

Methods

T3/T4 tumors from 2004 to 2007 were divided into those that involved the portal vein/superior mesenteric vein/gastroduodenal artery/hepatic artery and those that involved the superior mesenteric artery (SMA) or celiac axis. The control group (CG) included patients who were recommended surgery but did not undergo it. Multivariate disease-specific survival analyses were performed using the Cox proportional hazards model.

Results

Of 3,837 patients, 571 patients (15 %) were recommended surgery, and 323 (8 %) underwent surgical resection. We were unable to separate patients into BR/LA based on current NCCN guidelines. We were able to identify vascular involvement but not those who actually underwent vascular resection. Median survival of patients who underwent surgery with SMA and celiac involvement was 12 and 8 months compared with 7 and 6 months, respectively, in the CG (p = .01). Patients who underwent surgical resection with venous involvement had a longer survival than those with arterial involvement (18 vs 12 months, p = .001).

Conclusions

Analysis of patients with BR/LA pancreatic adenocarcinoma who underwent pancreatic resection in the SEER database yielded limited information. New manuals must focus on obtaining information consistent with current advances in the field; our recommendations for optimizing the SEER database are included.     

Surgical Management of Intrahepatic Cholangiocarcinoma - A Population-Based Study

Background Cholangiocarcinoma (CCA) is associated with poor survival and therapeutic nihilism. To date, there has not been an examination of the surgical management of CCA at a population level. Methods Using the Surveillance, Epidemiology and End Results (SEER) database, we identified all patients with intrahepatic CCA diagnosed between 1988 and 2003. Tumors categorized as a single, unilobar lesion with no evidence of vascular invasion were defined as localized. It was then determined whether patients received cancer directed surgery (CDS). Multivariable logistic regression was used to evaluate factors associated with CDS in patients with localized disease. The influence of CDS on overall survival (OS) was evaluated using Kaplan–Meier curves and Cox proportional hazards modeling. Results Only 446 (12%) of 3,756 patients with intrahepatic CCA underwent CDS. On multivariable analysis, non-Klatskin tumor (p < 0.01) and younger age (p = 0.02) was associated with CDS. Localized disease was strongly associated with CDS (p < 0.01); however, only 91 (37%) of these 248 patients underwent CDS. Of patients with localized disease, those who had CDS had significantly better survival than those who did not (p < 0.01), with median overall survival (OS) of 44 months versus 8 months, and five-year OS of 42% versus 4%, respectively. Conclusions Patients with localized CCA who are selected for CDS are strongly associated with improved survival, with rates approaching that found in single institution studies. However, many patients with localized tumors do not receive potentially curative cancer-directed surgery. Further study is warranted to address the barriers to the delivery of appropriate care to these patients. This study was presented in abstract form at the American Society of Clinical Oncology Gastrointestinal Cancers Symposium 2007, and the Society of Surgical Oncology Annual Meeting 2007. Dr. Baxter is supported by a Canadian Institutes of Health New Investigator Award and an American Society of Clinical Oncology Career Development Award. Dr. Law is supported by a Career Scientist Award from the Ministry of Health and Long Term Care.     

Psychosocial Consequences of Genetic Counseling: A Population-Based Follow-up Study

Abstract:  We aimed to examine the psychosocial impact of genetic counseling for hereditary breast and ovarian cancer 1 year following genetic counseling. We conducted a population-based prospective follow-up study of 213 women who received genetic counseling for hereditary breast and ovarian cancer, 319 women who underwent mammography (Reference Group I), and a random sample of 1,070 women from the general population (Reference Group II). The prevalence of anxiety decreased by 4.7% (95% CI: −3.5; 12.8) from baseline to 1 year of follow-up in the Genetic Counseling Group. Likewise, it decreased by 2.5% (95% CI: −4.5; 9.5) in Reference Group I and by 1.1% (95% CI: −2.3; 4.7) in Reference Group II. The prevalence of depression increased equally (1–3%) in the three study groups. 52% of the women referred for genetic counseling experienced cancer-specific distress at baseline and this proportion decreased to 41% after 12 months of follow-up. This decrease of 10.8% (95% CI: 1.4; 20.8) exceeded the decrease observed in both Reference Groups. However, it was statistically significant only in the case of Reference Group II (p = 0.006). Our findings indicate that genetic counseling can help alleviate cancer-specific distress among women with a family history of breast and ovarian cancer. Further, genetic counseling does not appear to have an adverse impact on general anxiety, symptoms of depression, or health-related quality of life.