TOTALLY LAPAROSCOPIC LIVER RESECTION: NEW BRAZILIAN EXPERIENCE

Background

Despite the increasing number of laparoscopic hepatectomy, there is little published experience.

Aim

To evaluate the results of a series of hepatectomy completely done with laparoscopic approach.

Methods

This is a retrospective study of 61 laparoscopic liver resections. Were studied conversion to open technique; mean age; gender, mortality; complications; type of hepatectomy; surgical techniques applied; and simultaneous operations.

Results

The conversion to open technique was necessary in one case (1.6%). The mean age was 54.7 years (17-84), 34 were men. Three patients (4.9%) had complications. One died postoperatively (mortality 1.6%) and no deaths occurred intraoperatively. The most frequent type was right hepatectomy (37.7%), followed by bisegmentectomy (segments II-III and VI-VII). Were not used hemi-Pringle maneuvers or assisted technic. Six patients (8.1%) underwent simultaneous procedures (hepatectomy and colectomy).

Conclusion

Laparoscopic hepatectomy is feasible procedure and can be considered the gold standard for various conditions requiring liver resections for both benign to malignant diseases.     

Advanced age and incidence of atrial fibrillation in the postoperative period of aortic valve replacement

Objective

This study aims to describe the correlation between age and occurrence of atrial fibrillation after aortic stenosis surgery in the elderly as well as evaluate the influence of atrial fibrillation on the incidence of strokes, hospital length of stay, and hospital mortality.

Methods

Cross-sectional retrospective study of > 70 year-old patients who underwent isolated aortic valve replacement.

Results

348 patients were included in the study (mean age 76.8±4.6 years). Overall, post-operative atrial fibrillation was 32.8% (n=114), but it was higher in patients aged 80 years and older (42.9% versus 28.8% in patients aged 70-79 years, P=0.017). There was borderline significance for linear correlation between age and atrial fibrillation (P=0.055). Intensive Care Unit and hospital lengths of stay were significantly increased in atrial fibrillation (P<0.001), but there was no increase in mortality or stroke associated with atrial fibrillation.

Conclusion

Post-operative atrial fibrillation incidence in aortic valve replacement is high and correlates with age in patients aged 70 years and older and significantly more pronounced in patients aged 80 years. There was increased length of stay at Intensive Care Unit and hospital, but there was no increase in mortality or stroke. These data are important for planning prophylaxis and early treatment for this subgroup.     

Surgical management of pleural empyema in the very elderly

INTRODUCTION

Parapneumonic pleural empyema is a critical illness. Age is an acknowledged risk factor for both pneumonia and pleural empyema. Furthermore, elderly patients often have severe co-morbidity. In the case of pleural empyema, their clinical condition is likely to deteriorate fast, resulting in life threatening septic disease. To prevent this disastrous situation we adapted early surgical debridement as the primary treatment option even in very elderly patients. This study shows the outcome of surgically managed patients with pleural empyema who are 80 years or older.

METHODS

The outcomes of 222 consecutive patients who received surgical therapy for parapneumonic pleural empyema at a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified.

RESULTS

There were 159 male and 63 female patients. The mean age was 60.5 years and the overall in-hospital mortality rate was 7%. Of the 222 patients, 37 were 80 years or older (range: 80–95 years). The frequencies of predominantly cardiac co-morbidity and high ASA (American Society of Anesthesiologists) grades were significantly higher for very elderly patients (p<0.001). A minimally invasive approach was feasible in 34 cases (92%). Of the 37 patients aged over 80, 36 recovered while one died from severe sepsis (in-hospital mortality 3%). There was no significant difference in mortality between the very elderly and the younger sufferers (p=0.476).

CONCLUSIONS

Early surgical treatment of parapneumonic pleural empyema shows excellent results even in very elderly patients. Despite considerable co-morbidity and often delayed diagnosis, minimally invasive surgery was feasible in 34 patients (92%). The in-hospital mortality of very elderly patients was low. It can therefore be concluded that advanced age is no contraindication for early surgical therapy.     

Emergency surgery for colorectal cancer does not result in nodal understaging compared with elective surgery

Background

It has been suggested that inadequate lymph node harvest may result in pathologically understaged or indeterminate staging of patients with colorectal cancer (CRC). We compared the adequacy of nodal staging in patients undergoing emergency surgery compared with elective surgery for CRC.

Methods

Using a prospectively collected CRC surgery database at a tertiary care centre, we performed a cohort study. The mean number of lymph nodes harvested and the proportion of patients who had inadequate staging (< 12 nodes harvested) were compared between emergency and elective surgery cohorts. Our analysis was adjusted for tumour site, type of resection, surgical training and pathologic stage.

Results

A total of 1279 of 1356 (94%) enrolled patients had nodal data available for analysis; 161 (13%) patients had emergency surgery and 1118 (87%) had elective surgery. The mean number of nodes removed was higher in the emergency surgery group (mean difference +2.8, 95% confidence interval [CI] 0.6–5.1, p = 0.012). The proportion of patients with inadequate nodal staging did not differ between groups (emergent 16%, elective 17%, p = 0.79). The odds of adequate nodal staging, adjusting for site, type of resection, training and stage was no different between groups (OR 0.80, 95% CI 0.47–1.35, p = 0.41).

Conclusion

The evidence does not support the common belief that emergency surgery is more commonly understaged in CRC. Our data suggest emergency surgery resulted in a significant increase in the average number of nodes harvested, with no difference in inadequate nodal staging.     

Splenectomy results from an 18-year single centre?experience

Introduction

Splenectomy is performed both as an emergency procedure following trauma and electively when indicated for haematological disease. Postsplenectomy patients receive immunotherapy vaccines and continuous antibiotic prophylaxis. Despite well documented concerns regarding complications and overwhelming postsplenectomy infection (OPSI) risk, there appears to be only a small amount of consistent data on long-term outcomes. The authors therefore present their postsplenectomy patient outcomes over an 18-year follow-up period.

Methods

One hundred and five postsplenectomy patients operated on between 1991 and 2011 were identified from pathology codes and their case notes were reviewed. Eighty-eight patients (83.8%) were followed up for at least five years or until death.

Results

Of the 105 splenectomy patients (58 were male), the median age was 54 years (range: 10–87 years) and the median survival was 80 months. Operative morbidity and mortality rates were 21.0% (n=22) and 8.6% (n=9) respectively. Thirty-seven patients (27 males) underwent an emergency splenectomy with a median age, operative morbidity and operative mortality of 51 years, 13.5% and 21.6% (n=8) respectively. This compares with 68 patients (35 males) undergoing an elective splenectomy with the same parameters respectively of 55 years, 25.0% and 1.5% (n=1). Excluding operative deaths, multivariate analysis revealed age (p=0.002) as the only significant and independent prognostic indicator. Immunotherapy and antibiotic prophylaxis rates for the emergency cohort were 92.6% and 88.9% respectively, compared with 90.2% and 93.4% for the elective cohort. At follow-up, no patients were readmitted with OPSI.

Conclusions

Over an 18-year period and a diverse indication for splenectomy, we have identified no evidence of OPSI. However, a significant operative mortality was associated with traumatic splenic rupture.     

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001–2006

Background

In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres.

Methods

We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model.

Results

After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54–3.22) or hospital stay (RR 0.96, 95% CI 0.65–1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00–1.48).

Conclusion

Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.     

Hospital mortality under surgical care

INTRODUCTION

The ‘hospital standardised mortality ratio’ (HSMR) has been used in England since 1999 to measure NHS hospital performance. Large variations in reported HSMR between English hospitals have recently led to heavy criticism of their use as a surrogate measure of hospital performance. This paper aims to review the mortality data for a consultant general surgeon contributed by his NHS trust over a 3-year period as part of the trust''s HSMR calculation and evaluate the accuracy of coding the diagnoses and covariates for case mix adjustment.

SUBJECTS AND METHODS

The Dr Foster Intelligence database was interrogated to extract the NHS trust''s HSMR benchmark data on inpatient mortality for the surgeon from 1 April 2006 to 31 March 2009 and compared to the hospital notes.

RESULTS

30 patients were identified of whom 12 had no evidence of being managed by the surgeon. This represents a potential 40% inaccuracy rate in designating consultant responsibility. The remaining 18 patients could be separated into ‘operative’ (11 patients) and ‘non-operative’ (7 patients) groups. Only 27% in the operative group and 43% of the non-operative mortality group respectively had a Charlson co-morbidity index recorded despite 94% of the cases having significant co-morbidities

CONCLUSIONS

Highlighting crude and inaccurate clinician-specific mortality data when only 1-5% of deaths under surgical care may be associated with avoidable adverse events seems potentially irresponsible.     

The effect of gender on the early results of coronary artery bypass surgery in the younger patients' group

Introduction

In this retrospective study, we aimed to determine the risk factors for coronary artery bypass surgery in patients under 45 years of age, and evaluate the early postoperative results and the effect of gender.

Methods

A total of 324 patients under 45 years of age who undergone on-pump coronary artery bypass surgery between April 12, 2004 and January 10, 2012 were included to the study. Patients divided into groups as follows: Group 1 consisted of 269 males (mean age 41.3), Group 2 consisted of 55 females (mean age 41.6). Preoperative risk factors, intraoperative and postoperative data and early mortality rates of the groups were compared.

Results

Smoking rate was significantly higher in Group 1. Diabetes mellitus incidence and body mass index were significantly higher in Group 2 (P values P=0.01; P=0.0001; P=0.04 respectively). The aortic cross-clamping and cardiopulmonary bypass time and number of grafts per patient were significantly higher in Group 1 (P values P=0.04; P=0.04; P=0.002 respectively). There were no deaths in either group.

Conclusion

We found that gender has no effect on early mortality rates of the coronary bypass surgery patients under 45 years.     

Clinical outcome of laparoscopic and open colectomy for right colonic carcinoma

INTRODUCTION

Laparoscopic colorectal surgery has gained widespread acceptance. While many studies have compared laparoscopic and open left-sided resections, there is limited literature on right colonic resections. We aimed to analyse the short-term outcome of laparoscopic (LRH) and open right hemicolectomy (ORH) in our unit.

METHODS

Consecutive patients undergoing elective right hemicolectomies over a period of 28 months were included in the study. No selection criteria were used to allocate the surgical approach. Study parameters included surgical technique, demographic details, ASA grade, body mass index (BMI), length of hospital stay (LOS), post-operative mortality and morbidity, readmission rate and histopathological data.

RESULTS

A total of 164 patients underwent right hemicolectomies during the study period (LRH: 89, ORH: 75). Both groups were comparable in age, sex, BMI, ASA grade, tumour stage and lymph node harvest. Four patients (4.5%) in the laparoscopic group required conversion to open surgery. In resections with curative intent, microscopic margins were positive in two patients (3%) in the ORH group compared to one (1%) in the LRH group. Seven ORH patients had an adverse post-operative outcome (three anastomotic leaks, four deaths); there were no deaths/immediate complications in the LRH group (p<0.05). The median LOS for LRH patients (4 days, range: 2–21 days) was significantly shorter than for ORH patients (8 days, range: 3–38 days) (p<0.0001, Mann–Whitney U test). By day 5, 77% of LRH patients were discharged compared with only 21% of patients in the ORH group. There were two readmissions (2.7%) in the ORH group and nine (10.1%) in the LRH group.

CONCLUSIONS

Our findings demonstrate advantages in favour of LRH in terms of a shorter hospital stay and reduced post-operative major complications. LRH is safe and should therefore be available to all patients requiring colonic resection.     

Current Outcomes of Emergency Large Bowel Surgery

Introduction

Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS.

Methods

A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed.

Results

A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre.

Conclusions

ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.     

Retrospective review of all-terrain vehicle accidents in Alberta

Background

All-terrain vehicles (ATVs) are frequently associated with injuries and deaths. In spite of this, very few guidelines, let alone legal restrictions, exist to guide users of these machines.

Methods

We conducted a standardized review of prospectively collected data from the Alberta Trauma Registry. All patients who were involved in ATV-related traumas from 2003 to 2008 with an Injury Severity Score (ISS) greater than 12 were included. The variables studied were age, sex, type of vehicle, purpose of use, person injured (driver or passenger), ISS, distribution of injuries, length of hospital stay, helmet use and death.

Results

We evaluated 435 patients with ATV-related injuries and ISS greater than 12. The average ISS was 22.8, with an overall mortality of 4.6%; 55% of patients were not wearing helmets, and most of the deaths (85%) occurred among these individuals. Helmet use was associated with a lower risk of mechanical ventilation and of injury to the head and/or cervical spine. Children accounted for 18.9% of all patients and 15% of deaths; 57% of them were wearing helmets at the time of their accidents.

Conclusion

All-terrain vehicle use in Alberta carries a significant risk of injury and death, and there is an association between death and lack of helmet use. A minimum age for ATV use of at least 16 years and a legal requirement for helmet use may increase public awareness of these risks and decrease morbidity and mortality.     

Recurrent Sigmoid Volvulus – Early Resection may Obviate Later Emergency Surgery and Reduce Morbidity and Mortality

INTRODUCTION

Acute sigmoid volvulus is a well recognised cause of acute large bowel obstruction.

PATIENTS AND METHODS

We reviewed our unit''s experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions.

RESULTS

Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group.

CONCLUSIONS

Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mortality from gangrenous bowel developing with a subsequent volvulus, it is our contention that all patients should be considered for definitive surgery after initial colonoscopic decompression, irrespective of the ASA score.     

A single surgeon’s series of transthoracic oesophageal resections

Introduction

Significant controversy persists over the optimum surgical management of oesophageal carcinoma. The authors report on a consecutive personal series of open transthoracic oesophageal resections.

Methods

Data relating to resections performed between mid-1993 and the end of 2010 were analysed. Patient and tumour assessment evolved over this period. Preoperative chemotherapy in appropriate cases was introduced in 2002. A laparotomy and right lateral thoracotomy approach (Ivor–Lewis) was used. In all cases the pylorus was not interfered with, no attempt was made to perform a radical lymphadenectomy but surgical strategy was focused on producing an R0 resection and a hand sewn anastomosis was fashioned.

Results

A total of 165 resections were performed; 130 patients (80%) were male. The median age was 66 years (range: 31–82 years). Eighty per cent had an adenocarcinoma. Sixty-four per cent of the tumours were T3/T4 and sixty-two per cent node positive. Forty patients (24%) had an involved circumferential resection margin (CRM). Five patients (3.0%) had no resection and a quarter (26%) developed morbidity of some form. There was one clinical anastomotic leak (0.6%) and three benign strictures requiring dilation (1.8%). In-hospital mortality was 3.0% (5 patients). Disease specific survival at one, two and five years was 77%, 42% and 36% respectively. Neither CRM involvement nor preoperative chemotherapy influenced survival significantly. No patient required intervention to disrupt the pylorus.

Conclusions

Excellent outcomes are achievable following open transthoracic oesophagectomy without radical lymphadenectomy using a hand sewn gastro-oesophageal anastomosis and without disrupting the pylorus.     

Initial Experience of Laparostomy with Immediate Vacuum Therapy in Patients with Severe Peritonitis

INTRODUCTION

To report our initial experience of laparostomy and immediate intra-abdominal vacuum therapy in patients with severe peritonitis due to intra-abdominal catastrophes.

PATIENTS AND METHODS

Twenty-seven patients underwent emergency laparotomy and laparostomy formation with the application of immediate intra-abdominal TRAC–VAC® therapy (male:female ratio, 1:1.2; median age, 73 years; range, 34–84 years). Predicted mortality was assessed using the P-POSSUM score and compared with clinically observed outcomes.

RESULTS

Ten patients (37%) with a mean predicted P-POSSUM mortality of 72%, died of sepsis and multi-organ failure. Seventeen patients (mean P-POSSUM 48% expected mortality) survived to discharge. One patient with pancreatitis died from small bowel obstruction 1-year post discharge, two patients developed a small bowel fistula. One patient had an allergic reaction to the VAC dressing. Our patients, treated with laparostomy and TRAC VAC therapy, had a significantly improved observed survival when compared to P-POSSUM expected survival (P = 0.004).

CONCLUSIONS

Laparostomy with immediate intraperitoneal VAC therapy is a robust and effective system to manage patients with intra-abdominal catastrophes. There were significantly improved outcomes compared to the mortality predicted by P-POSSUM scores. Damage control surgery with laparostomy formation and intra-abdominal VAC therapy should be considered in patients with severe peritonitis.     

Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales,UK

INTRODUCTION

Epistaxis is the one of the most common otorhinolaryngology emergencies. This study examined the age and sex distribution of all patients admitted with epistaxis to National Health Service (NHS) hospitals in Wales, UK, over a period of 18 years and 9 months.

METHODS

The Patient Episode Database for Wales was examined for all patient admissions with a diagnosis of epistaxis between April 1991 and December 2009. The age and sex of these patients was recorded and the proportion of the underlying population affected was calculated by comparing admission rates to the population data derived from the 1991 and 2001 national population censuses for Wales.

RESULTS

A total of 26,725 patients were admitted to NHS hospitals in Wales with epistaxis over the period studied. The proportion of the population admitted with epistaxis increased from the age of 40 onwards. For all ages except patients in the 10–14 years group, a higher proportion of the male population was admitted with epistaxis than the comparable female population. This discrepancy was most pronounced between the ages of 15 and 49 years, with the female-to-male ratio of hospital admissions with epistaxis being 0.55. These ages (15 and 49 years) approximate the average age of menarche and menopause respectively in the UK.

CONCLUSIONS

Women of menstrual age have fewer hospital admissions with epistaxis. This may be due to oestrogens providing protection to the nasal vasculature (as they do to other areas of the vascular tree).     

The impact of systemic fungal infection in patients with perforated oesophagus

INTRODUCTION

Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre.

METHODS

A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 – January 2008).

RESULTS

We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22–87 years). The majority (n=24,89%) presented with spontaneous perforations (Boerhaave’s syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications.

CONCLUSIONS

Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.     

Small-bowel resection for metastatic melanoma

Objective

To determine whether complete resection of small-bowel metastases from melanoma improves patient survival.

Design

A computer-aided chart review.

Setting

Hospitals associated with McGill University.

Patients

Twenty patients (17 men, 3 women), identified from 1524 patients with melanoma, who underwent surgery to the small bowel for metastases. Patient age and clinical presentation, tumour site and stage were recorded.

Intervention

Exploratory laparotomy with complete or partial resection of involved small bowel.

Main Outcome Measures

Operative morbidity, mortality and length of survival related to the extent of small-bowel resection.

Results

Eleven patients had complete resection, 8 patients had partial resection and 1 patient had a palliative bypass only. Long-term survival (ranging from 2 to 10 years) was 36% in those who had complete resection and 0% in those who had partial resection; operative morbidity and mortality were 20% and 15% respectively.

Conclusion

Complete resection of small-bowel metastases in patients with metastatic melanoma can result in long-term survival.     

LACTATE AS PREDICTOR OF MORTALITY IN POLYTRAUMA

Background:

The lactate is a product of anaerobic metabolism; it can be used as a marker on demand and availability of oxygen. Changes in lactate levels can be effectively used as a marker in resuscitation maneuvers, even in patients with stable vital signs.

Aim:

To verify the lactate clearance as a predictor of mortality in trauma patients, in need of intensive care.

Method:

A total of 851 patients were admitted in ICU, in which 146 were victims of multiple trauma; due to the exclusion criteria, were included 117.

Results:

Patients were 87% male, mean age 32.4 years, motorcycle drivers, Glasgow coma scale between 3-8, affected by cranial trauma, followed by abdominal trauma. Was verified mortality up to 48 h and global mortality, that did not show statistical relationship between lactate clearance and mortality (p=0.928).

Conclusion:

There is no correlation between admission lactate or lactate clearance and mortality in patients treated with multiple trauma.     

Influence of a province-wide trauma system on motor vehicle collision process of trauma care and mortality: a 10-year follow-up evaluation

Background

Mature trauma systems have evolved to respond to major injury-related morbidity and mortality. Studies of mature trauma systems have demonstrated improved survival, especially among seriously injured patients. From 1995 to 1998, a province-wide trauma system was implemented in the province of Nova Scotia. We measured the proportion of admissions to a tertiary level trauma centre and the proportion of in-hospital deaths among patients with major injuries as a result of a motor vehicle collisions (MVCs) before and 10 years after provincial trauma systems implementation.

Methods

We identified major trauma patients aged 16 years and older using external cause of injury codes pertaining to MVCs from population-based hospital claims and vital statistics data. Individuals who were admitted to hospital or died because of an MVC in 1993–1994 (preimplementation), were compared with those who were admitted to hospital or died in 2003–2005 (postimplementation).

Results

Postimplementation, there was a 9% increase in the number of seriously injured individuals with primary admission to tertiary care. This increase was statistically significant even after we adjusted for age, head injury and municipality of residence (relative risk [RR] 1.09, 95% confidence interval [CI] 1.04–1.14). The probability of dying while in hospital in the postimplementation period decreased by 29% (adjusted RR 0.57, 95% CI 0.32–1.03), although this difference was not statistically significant.

Conclusion

Individuals seriously injured in MVCs in Nova Scotia were more likely to be admitted to tertiary care after the implementation of a province-wide trauma system. There was a trend toward decreased mortality, but further research is warranted to confirm the survival benefit and delineate other contributing factors.     

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective

We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.

Methods

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.