Clinical Significance of Malnutrition Risk in Severe Trauma Patients: A Single-Center Study

Purpose@#A suboptimal nutritional status is often observed among hospitalized patients across all medical/surgical specialties. The objective of the present study was to (1) analyze the prevalence of malnutrition in severe trauma patients and (2) evaluate the relationship between malnutrition and select clinical outcomes. @*Materials and Methods@#This retrospective study was conducted between October 2015 and March 2017 at the Pusan National University Hospital Trauma Center. Of a total of 3,560 patients, 945 were enrolled in this study. Patients were checked for malnutrition using a nutrition assessment tool by the hospital nutrition support team. The parameters assessed included serum albumin, the ratio of actual body weight to ideal body weight (%), total lymphocyte count, appetite, and gastrointestinal problems. Clinical outcomes under consideration included 1) mortality, 2) length of hospitalization, and 3) length of stay in the intensive care unit (ICU). @*Results@#The total prevalence of malnutrition in hospitalized trauma patients was 55.0% (n=520). Malnutrition risk was the independent prognostic factor of mortality in severe trauma patients (adjusted odds ratio [OR]=3.440;95% confidence interval [CI]=1.401~8.447, P=0.007). Risk factors of malnutrition were age over 65 years (adjusted OR=2.393; 95% CI=1.699~3.370, P<0.001), injury severity score (adjusted OR=1.034, 95% CI=1.012~1.056, P=0.002), length of hospitalization (adjusted OR=1.104; 95% CI=1.007~1.020, P<0.001), and length of stay in the ICU (adjusted OR=1.050; 95% CI=1.029~1.072, P<0.001). @*Conclusion@#Malnutrition is widespread in hospitalized patients with severe trauma and results in suboptimal clinical outcomes. Thus, patients at high risk of malnutrition should be monitored carefully during hospitalization.

Relevant Clinical Findings of Patients with Extraperitoneal Bladder Injury Associated with Pelvic Fracture Who Underwent Operative Management: A 6-Year Retrospective Study

Purpose@#Management options for extraperitoneal bladder injury (EBI) associated with pelvic fracture are variable. Predictive factors of operative management (OM) in patients with EBI associated pelvic fracture have not been previously addressed. This study assessed the current epidemiology of blunt traumatic urinary bladder injury and evaluated relevant clinical findings of patients with EBI associated with pelvic fracture who received OM. @*Methods@#Patients with urinary bladder injury with or without pelvic fracture from blunt trauma from January 1, 2014 to December 31, 2019 were identified from the institute trauma registry (n = 12,891). Demographics, mechanism of injury, type of urinary bladder injury, pelvic fracture configuration, and management options were analysed in the study population (n = 9,894). @*Results@#Of the 1,400 patients who had pelvic and/or acetabular fracture, 32 (2.3%) had urinary bladder injury. Of the 8,494 patients without pelvic and/or acetabular fracture, 12 (0.1%) had nonpelvic fracture urinary bladder injury. The total incidence of urinary bladder injuries in the study population was 0.4% (44/9,894). Patients with EBI associated with pelvic fracture who underwent OM, had a higher frequency of high-grade pelvic injury (100% vs 0%, p = 0.015), concomitant pelvic surgery (75.0% vs 0%, p = 0.001), and non-lateral compression type pelvic fracture (62.5% vs 10.0%, p = 0.043) compared with patients who underwent non-operative management of EBI. @*Conclusions@#These data suggest that OM may be considered especially in patients with EBI associated with pelvic fracture with high grade pelvic injury, concomitant pelvic surgery, and nonlateral compression type pelvic fracture.

Traumatic Hemothorax Caused by Thoracic Wall and Intrathoracic Injuries:Clinical Outcomes of Transcatheter Systemic Artery Embolization

Purpose@#We aimed to assess the clinical efficacy of transcatheter arterial embolization (TAE) for treating hemothorax caused by chest trauma. @*Materials and Methods@#Between 2015 and 2019, 68 patients (56 male; mean age, 58.2 years) were transferred to our interventional unit for selective TAE to treat thoracic bleeding. We retrospectively investigated their demographics, angiographic findings, embolization techniques, technical and clinical success rates, and complications. @*Results@#Bleeding occurred mostly from the intercostal arteries (50%) and the internal mammary arteries (29.5%). Except one patient, TAE achieved technical success, defined as the immediate cessation of bleeding, in all the other patients. Four patients successfully underwent repeated TAE for delayed bleeding or increasing hematoma after the initial TAE. The clinical success rate, defined as no need for thoracotomy for hemostasis after TAE, was 92.6%. Five patients underwent post-embolization thoracotomy for hemostasis. No patient developed major TAE-related complications, such as cerebral infarction or quadriplegia. @*Conclusion@#TAE is a safe, effective and minimally invasive method for controlling thoracic wall and intrathoracic systemic arterial hemorrhage after thoracic trauma. TAE may be considered for patients with hemothorax without other concomitant injuries which require emergency sur-gery, or those who undergoing emergency TAE for abdominal or pelvic hemostasis.

Traumatic Hemothorax Caused by Thoracic Wall and Intrathoracic Injuries:Clinical Outcomes of Transcatheter Systemic Artery Embolization

Purpose@#We aimed to assess the clinical efficacy of transcatheter arterial embolization (TAE) for treating hemothorax caused by chest trauma. @*Materials and Methods@#Between 2015 and 2019, 68 patients (56 male; mean age, 58.2 years) were transferred to our interventional unit for selective TAE to treat thoracic bleeding. We retrospectively investigated their demographics, angiographic findings, embolization techniques, technical and clinical success rates, and complications. @*Results@#Bleeding occurred mostly from the intercostal arteries (50%) and the internal mammary arteries (29.5%). Except one patient, TAE achieved technical success, defined as the immediate cessation of bleeding, in all the other patients. Four patients successfully underwent repeated TAE for delayed bleeding or increasing hematoma after the initial TAE. The clinical success rate, defined as no need for thoracotomy for hemostasis after TAE, was 92.6%. Five patients underwent post-embolization thoracotomy for hemostasis. No patient developed major TAE-related complications, such as cerebral infarction or quadriplegia. @*Conclusion@#TAE is a safe, effective and minimally invasive method for controlling thoracic wall and intrathoracic systemic arterial hemorrhage after thoracic trauma. TAE may be considered for patients with hemothorax without other concomitant injuries which require emergency sur-gery, or those who undergoing emergency TAE for abdominal or pelvic hemostasis.

Relevant Clinical Findings of Patients with Extraperitoneal Bladder Injury Associated with Pelvic Fracture Who Underwent Operative Management: A 6-Year Retrospective Study

Purpose@#Management options for extraperitoneal bladder injury (EBI) associated with pelvic fracture are variable. Predictive factors of operative management (OM) in patients with EBI associated pelvic fracture have not been previously addressed. This study assessed the current epidemiology of blunt traumatic urinary bladder injury and evaluated relevant clinical findings of patients with EBI associated with pelvic fracture who received OM. @*Methods@#Patients with urinary bladder injury with or without pelvic fracture from blunt trauma from January 1, 2014 to December 31, 2019 were identified from the institute trauma registry (n = 12,891). Demographics, mechanism of injury, type of urinary bladder injury, pelvic fracture configuration, and management options were analysed in the study population (n = 9,894). @*Results@#Of the 1,400 patients who had pelvic and/or acetabular fracture, 32 (2.3%) had urinary bladder injury. Of the 8,494 patients without pelvic and/or acetabular fracture, 12 (0.1%) had nonpelvic fracture urinary bladder injury. The total incidence of urinary bladder injuries in the study population was 0.4% (44/9,894). Patients with EBI associated with pelvic fracture who underwent OM, had a higher frequency of high-grade pelvic injury (100% vs 0%, p = 0.015), concomitant pelvic surgery (75.0% vs 0%, p = 0.001), and non-lateral compression type pelvic fracture (62.5% vs 10.0%, p = 0.043) compared with patients who underwent non-operative management of EBI. @*Conclusions@#These data suggest that OM may be considered especially in patients with EBI associated with pelvic fracture with high grade pelvic injury, concomitant pelvic surgery, and nonlateral compression type pelvic fracture.

Emergency Department Laparotomy Can Be a Resuscitative Option for Patient with Cardiac Arrest and Impending Arrest due to Intra-Abdominal Hemorrhage

Purpose@#Managing patients with hemorrhagic shock is mainly dependent on stopping the bleeding as fast as possible. Emergency Department laparotomy (EDL) is considered one of the approaches to control intra-abdominal bleeding rapidly. This study aims to evaluate the outcomes of EDL in a regional trauma center of Pusan National University Hospital in a 4-year period. @*Methods@#The medical records and data of patients who underwent EDL from January 2016 to December 2019 were analyzed. Patients who underwent preperitoneal pelvic packing only or did not receive surgery immediately after EDL were excluded. @*Results@#Twenty-four patients who underwent EDL were included in the study. 18 patients had sustained blunt trauma, and 6 suffered from penetrating injuries. Small bowel mesentery and liver injuries were the most frequent. Increase of median systolic blood pressure (SBP) after EDL was 55.5 mmHg. Four (16.7%) out of the 24 survived; one of the four survivors received cardiopulmonary resuscitation (CPR). In the nonsurvivor group, Injury Severity Score was significantly higher (p = 0.013), initial pH was lower (p = 0.035) and the amount of packed red blood cells transfusion after EDL was significantly higher (p = 0.013) than those in the survivor group. @*Conclusion@#The mortality rate was very high in trauma patients who were required EDL. Although EDL was not proved to be an effective procedure for resuscitation in trauma patients, it could be considered as one of the treatment options for trauma patients in extremis. Further studies are required to examine the effects of EDL.

Emergency Department Laparotomy Can Be a Resuscitative Option for Patient with Cardiac Arrest and Impending Arrest due to Intra-Abdominal Hemorrhage

Purpose@#Managing patients with hemorrhagic shock is mainly dependent on stopping the bleeding as fast as possible. Emergency Department laparotomy (EDL) is considered one of the approaches to control intra-abdominal bleeding rapidly. This study aims to evaluate the outcomes of EDL in a regional trauma center of Pusan National University Hospital in a 4-year period. @*Methods@#The medical records and data of patients who underwent EDL from January 2016 to December 2019 were analyzed. Patients who underwent preperitoneal pelvic packing only or did not receive surgery immediately after EDL were excluded. @*Results@#Twenty-four patients who underwent EDL were included in the study. 18 patients had sustained blunt trauma, and 6 suffered from penetrating injuries. Small bowel mesentery and liver injuries were the most frequent. Increase of median systolic blood pressure (SBP) after EDL was 55.5 mmHg. Four (16.7%) out of the 24 survived; one of the four survivors received cardiopulmonary resuscitation (CPR). In the nonsurvivor group, Injury Severity Score was significantly higher (p = 0.013), initial pH was lower (p = 0.035) and the amount of packed red blood cells transfusion after EDL was significantly higher (p = 0.013) than those in the survivor group. @*Conclusion@#The mortality rate was very high in trauma patients who were required EDL. Although EDL was not proved to be an effective procedure for resuscitation in trauma patients, it could be considered as one of the treatment options for trauma patients in extremis. Further studies are required to examine the effects of EDL.

Development of Korean Teaching Model for Surgical Procedures in Trauma -Essential Surgical Procedures in Trauma Course-

PURPOSE@#The Essential Surgical Procedures in Trauma (ESPIT) course was developed as a model to teach necessary surgical procedures to trauma physicians. Its goals are to improve knowledge, self-confidence, and technical competence.@*METHODS@#The ESPIT course consisted of five lectures and a porcine lab operative experience. The ESPIT course has been run seven times between February 2014 and April 2016. ESPIT participants completed a questionnaire to assess self-efficacy regarding essential surgical procedures in trauma before and immediately after taking the ESPIT course. Sixty-three participants who completed both pre- and post-course questionnaires on self-efficacy were enrolled in this study.@*RESULTS@#The overall post-ESPIT mean self-efficacy score was higher than the pre-ESPIT mean self-efficacy score (8.3±1.30 and 4.5±2.13, respectively) (p5 years) were also statistically significant (p<0.001).@*CONCLUSIONS@#The data of the ESPIT participants indicated that they felt that the ESPIT course improved their self-efficacy with regard to essential surgical procedures in trauma. The ESPIT course may be an effective strategy for teaching surgical procedures, thus promoting better management of traumatic injuries.

Clinical Effects of Intra-Abdominal Pressure in Critically Ill Trauma Patients

PURPOSE@#There is increasing interest in intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) in critically ill patients. This study investigated the effects and outcomes of elevated IAP in a trauma intensive care unit (ICU) population.@*METHODS@#Eleven consecutive critically ill patients admitted to the trauma ICU at Pusan National University Hospital Regional Trauma Center were included in this study. IAP was measured every 8–12 hours (intermittently) for 72 hours. IAP was registered as mean and maximal values per day throughout the study period. IAH was defined as IAP ≥12 mmHg. Abdominal compartment syndrome was defined as IAP ≥20 mmHg plus ≥1 new organ failure. The main outcome measure was in-hospital mortality.@*RESULTS@#According to maximal and mean IAP values, 10 (90.9%) of the patients developed IAH during the study period. The Sequential Organ Failure Assessment (SOFA) score was significantly higher in patients with IAP ≥20 mmHg than in those with IAP <20 mmHg (16 vs. 5, p=0.049). The hospital mortality rate was 27.3%. Patients with a maximum IAP ≥20 mmHg exhibited significantly higher hospital mortality rates (p=0.006). Non-survivors had higher maximum and mean IAP values.@*CONCLUSIONS@#Our results suggest that an elevated IAP may be associated with a poor prognosis in critically ill trauma patients.

Heterotopic Ossification in the Abdominal Wall after Exploratory Laparotomy

Heterotopic bone formation in abdominal incisions is a recognized but uncommon sequela of abdominal surgery. On the other hand, the formation of ectopic bone is a well-recognized complication following arthroplasty of the hip. Heterotopic ossification of midline abdominal incision scars is a subtype of myositis ossificans traumatica. Ectopic bone formation of midline abdominal incisions may cause regional pain or discomfort in the patient after surgery. If symptomatic, treatment is complete excision with primary closure. Radiologically, it is important to distinguish this benign entity from postoperative complications. We report a 69-year-old male who underwent exploratory laparotomy for traumatic small bowel perforation. A segment of abnormal hard tissue was found in the abdominal wall. Heterotopic ossification may occur at various sites and is a recognized but infrequent sequela of exploratory laparotomy. This case highlights clinical and etiological features of this finding.

CT Findings of Perforation of the Stomach after Ingestion of Glacial Acetic Acid

The ingestion of corrosive substances often leads to severe morbidity and mortality. Acids produce coagulation necrosis with a lesser degree of penetration, whereas alkalis produce liquefactive necrosis with penetration. Acetic acid is a clear, colorless organic acid with a pungent, vinegar-like odor. The ingestion of highly concentrated acetic acid (glacial acetic acid) may cause a range of complications. On the other hand, perforation of the stomach is extremely rare but it has a high mortality rate. This paper reports a case of perforation of the stomach after the ingestion of glacial acetic acid with suicidal intent in an otherwise healthy 76-year-old woman.

Ki-67 and p53 expression as a predictive marker for early postoperative recurrence in pancreatic head cancer

PURPOSE: This study aimed to evaluate the clinical significance of Ki-67 and p53 expressions in patients with pancreatic head cancer. METHODS: Between May 2008 and April 2013, immunohistochemical staining for Ki-67 and p53 was performed in 34 patients with pancreatic head cancer (ductal adenocarcinoma). All 34 patients underwent pancreaticoduodenectomy at Chonnam National University Hwasun Hospital, Hwasun, Korea. Clinical and histopathological characteristics were analyzed, relative to p53 expression. RESULTS: Thirty (88.2%) and twenty-one (61.7%) of the 34 pancreatic head cancers exhibited positive expression of Ki-67 and p53, respectively. Patients expressing Ki-67 and p53 experienced more frequent tumor recurrences within 1 year after surgical resection (P = 0.003 and P = 0.030, respectively). However, no correlation was detected between Ki-67 and p53 expression. Ki-67 expression was correlated with pathological grade, lymph node metasatsis, and clinical stage (P < 0.05). Importantly, Ki-67 was the independent predictive factor for postoperative recurrence within 1 year in both univariable and multivariable analyses (odds ratio, 27.219; 95% confidence interval, 1.403-528.135; P = 0.029). CONCLUSION: The expression of Ki-67 and p53 are significantly related to early postoperative recurrence within 1 year after surgical resection in pancreatic head cancer. Especially, Ki-67 was the independent predictive factor for postoperative recurrence within 1 year. Therefore, immunohistochemical staining for Ki-67 and p53 may be applied as a predictive marker for early postoperative recurrence in pancreatic head cancer.