Professor Ian Aird: Master of surgical education.

Ian Aird (1905-1962) was a Scottish surgeon renowned for his textbook: "A companion in surgical studies", a uniquely single-author work of thousands of pages. It was an essential study for young surgeons aspiring to pass the FRCS (Edin) examination. He was appointed Chair of Surgery of the Royal Postgraduate Medical School at Hammersmith Hospital in London. Under his direction, his faculty developed a pump oxygenator, used it successfully for the first time in a patient and introduced cardiac surgery in Russia. They also pioneered kidney transplantation in Britain. Aird himself discovered the relationship of blood groups to cancer and peptic ulceration. He became famous for the surgical separation of conjoined twins from Nigeria, fame that created conflicts with medical authority on the issue of cooperating with the press. He became frustrated when the medical council refused to support and sponsor funding for research. Sadly, even his indomitable energy and brilliance could not see him through his depression. He committed suicide at the age of 57.

Meckel's diverticulum and the eponymous legend.

Johann Friedrich Meckel (1781-1833) was a 19th century anatomist born into an eminent dynasty. He was a professor of anatomy, pathology, and zoology at the University of Halle, in Central Germany. The diverticulum, a congenital remnant of the vitellointestinal duct was named after him. Other eponyms include Meckel's cartilage, Meckel syndrome, and Meckel-Serres law of recapitulation. His concepts in comparative anatomy, embryology, and teratology anticipated Darwin. This review is a short tribute to this legend and his prolific contributions. LEVEL: Historic review, level V.

Management of duodenal trauma: A retrospective review from the Panamerican Trauma Society.

INTRODUCTION: The operative management of duodenal trauma remains controversial. Our hypothesis is that a simplified operative approach could lead to better outcomes. METHODS: We conducted an international multicenter study, involving 13 centers. We performed a retrospective review from January 2007 to December of 2016. Data on demographics, mechanism of trauma, blood loss, operative time, and associated injured organs were collected. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure, and mortality. We used the Research Electronic Data Capture tool to store the data. Poisson regression using a backward selection method was used to identify independent predictors of mortality. RESULTS: We collected data of 372 patients with duodenal injuries. Although the duodenal trauma was complex (median Injury Severity Score [ISS], 18 [interquartile range, 2-3]; Abbreviated Injury Scale, 3.5 [3-4]; American Association for the Surgery of Trauma grade, 3 [2-3]), primary repair alone was the most common type of operative management (80%, n = 299). Overall mortality was 24%. On univariate analysis, mortality was associated with male gender, lower admission systolic blood pressure, need for transfusion before operative repair, higher intraoperative blood loss, longer operative time, renal failure requiring renal replacement therapy, higher ISS, and associated pancreatic injury. Poisson regression showed higher ISS, associated pancreatic injury, postoperative renal failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors of mortality. Duodenal suture line leak was statistically significantly lower, and patients had primary repair over every American Association for the Surgery of Trauma grade of injury. CONCLUSIONS: The need for transfusion prior to the operating room, associated pancreatic injuries, and postoperative renal failure are predictors of mortality for patients with duodenal injuries. Primary repair alone is a common and safe operative repair even for complex injuries when feasible. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Developing congenital heart surgery in India: The travails and triumphs of a pioneer.

Professor IM Rao, from All India Institute of Medical Sciences, New Delhi, was a pioneering cardiac surgeon who, against overwhelming odds, developed congenital heart surgery in India. He made many contributions to the evolution of his specialty, spanning more than four decades and three countries. This is a brief report of his professional life and accomplishments.

Metabolomics and Precision Medicine in Trauma: The State of the Field.

Trauma is a major problem in the United States. Mortality from trauma is the number one cause of death under the age of 45 in the United States and is the third leading cause of death for all age groups. There are approximately 200,000 deaths per year due to trauma in the United States at a cost of over $671 billion in combined healthcare costs and lost productivity. Unsurprisingly, trauma accounts for approximately 30% of all life-years lost in the United States. Due to immense development of trauma systems, a large majority of trauma patients survive the injury, but then go on to die from complications arising from the injury. These complications are marked by early and significant metabolic changes accompanied by inflammatory responses that lead to progressive organ failure and, ultimately, death. Early resuscitative and surgical interventions followed by close monitoring to identify and rescue treatment failures are key to successful outcomes. Currently, the adequacy of resuscitation is measured using vital signs, noninvasive methods such as bedside echocardiography or stroke volume variation, and other laboratory endpoints of resuscitation, such as lactate and base deficit. However, these methods may be too crude to understand cellular and subcellular changes that may be occurring in trauma patients. Better diagnostic and therapeutic markers are needed to assess the adequacy of interventions and monitor responses at a cellular and subcellular level and inform clinical decision-making before complications are clinically apparent. The developing field of metabolomics holds great promise in the identification and application of biochemical markers toward the clinical decision-making process.

Panamerican Trauma Society: The first three decades.

Panamerican Trauma Society was born 30 years ago with the mission of improving trauma care in the Americas by exchange of ideas and concepts and expanding knowledge of trauma and acute illness. The authors, immediate-past leaders of the organization, review the evolution of this assembly of diverse cultures and nationalities.

International rotations: A valuable source to supplement operative experience for acute-care surgery, trauma, and surgical critical care fellows.

BACKGROUND: Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure. METHODS: A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool. RESULTS: The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%). CONCLUSIONS: The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

History of the Innovation of Damage Control for Management of Trauma Patients: 1902-2016.

OBJECTIVE: To review the history of the innovation of damage control (DC) for management of trauma patients. BACKGROUND: DC is an important development in trauma care that provides a valuable case study in surgical innovation. METHODS: We searched bibliographic databases (1950-2015), conference abstracts (2009-2013), Web sites, textbooks, and bibliographies for articles relating to trauma DC. The innovation of DC was then classified according to the Innovation, Development, Exploration, Assessment, and Long-term study model of surgical innovation. RESULTS: The "innovation" of DC originated from the use of therapeutic liver packing, a practice that had previously been abandoned after World War II because of adverse events. It then "developed" into abbreviated laparotomy using "rapid conservative operative techniques." Subsequent "exploration" resulted in the application of DC to increasingly complex abdominal injuries and thoracic, peripheral vascular, and orthopedic injuries. Increasing use of DC laparotomy was followed by growing reports of postinjury abdominal compartment syndrome and prophylactic use of the open abdomen to prevent intra-abdominal hypertension after DC laparotomy. By the year 2000, DC surgery had been widely adopted and was recommended for use in surgical journals, textbooks, and teaching courses ("assessment" stage of innovation). "Long-term study" of DC is raising questions about whether the procedure should be used more selectively in the context of improving resuscitation practices. CONCLUSIONS: The history of the innovation of DC illustrates how a previously abandoned surgical technique was adapted and readopted in response to an increased understanding of trauma patient physiology and changing injury patterns and trauma resuscitation practices.

Trauma Registry of the Pan-American Trauma Society: One year of experience in two hospitals in southwest Colombia.

BACKGROUND: Trauma information systems are needed to improve decision making and to identify potential areas of intervention. OBJECTIVE: To describe the first year of experience with a trauma registry in two referral centers in southwest Colombia. METHODS: The study was performed in two referral centers in Cali. Patients with traumatic injuries seen between January 1 and December 31, 2012, were included. The collected information included demographics, mechanism of trauma, injury severity score (ISS), and mortality. A descriptive analysis was carried out. RESULTS: A total of 17,431 patients were registered, of which 67.8% were male with an average age of 30 (±20) years. Workplace injuries were the cause of emergency consultations in 28.2% of cases, and falls were the most common mechanism of trauma (37.3%). Patients with an ISS ≥15 were mostly found in the 18-35-year age range (6.4%). Most patients who suffered a gunshot wound presented an ISS ≥15. A total of 2.5% of all patients died, whereas the mortality rate was 54% among patients with an ISS ≥15 and a gunshot wound. CONCLUSION: Once the trauma registry was successfully implemented in two institutions in Cali, the primary causes of admission were identified as falls and workplace injuries. The most severely compromised patients were in the population range between 18 and 35 years of age. The highest mortality was caused by gunshot wounds. INTRODUCCIÓN: Los sistemas de información en trauma son requeridos para mejorar la toma de decisiones e identificar potenciales áreas de intervención. OBJETIVO: Describir el primer año de experiencia del registro de trauma en dos centros de referencia de trauma del suroccidente Colombiano. MÉTODOS: Estudio realizado en dos centros de referencia de Cali. Se incluyeron pacientes con trauma o lesiones externas entre el 1-Ene y el 31-Dic-2012. Se recolectó información demográfica, relacionada con mecanismos de trauma, severidad (ISS) y mortalidad. Se presenta un análisis descriptivo. RESULTADOS: Se registraron 17,431 pacientes. El 67.8% de los pacientes eran de género masculino con edad promedio de 30 (±20) años. Las lesiones laborales fueron causa de consulta a urgencias en un 28.2%, y las caídas el mecanismo de trauma más frecuente (37.3%). Los pacientes con ISS ≥15 en su mayoría se encontraban en el rango de edad de 18-35 años (6.4%). El 28% de los pacientes que sufrieron lesión por arma de fuego presentaron un ISS ≥15. El 2.5% de los pacientes murieron y aquellos pacientes con ISS ≥15 y lesión por arma de fuego presentaron mortalidad del 54%. CONCLUSIÓN: una vez se logró implementar el registro de trauma en dos instituciones en Cali, se identificó que la principal causa de ingreso fue secundaria a caídas y las lesiones laborales. Los pacientes más severamente comprometidos están en el rango de población entre 18 a 35 años. La mayor mortalidad se presentó secundario a lesiones de causa externa por arma de fuego.

Trauma Registry of the Pan-American Trauma Society: One year of experience in two hospitals in southwest Colombia / Registro de Trauma de la Sociedad Panamericana de Trauma: Un año de experiencia en dos hospitales en el suroccidente colombiano

Abstract Background: Trauma information systems are needed to improve decision making and to identify potential areas of intervention. Objective: To describe the first year of experience with a trauma registry in two referral centers in southwest Colombia. Methods: The study was performed in two referral centers in Cali. Patients with traumatic injuries seen between January 1 and December 31, 2012, were included. The collected information included demographics, mechanism of trauma, injury severity score (ISS), and mortality. A descriptive analysis was carried out. Results: A total of 17,431 patients were registered, of which 67.8% were male with an average age of 30 (±20) years. Workplace injuries were the cause of emergency consultations in 28.2% of cases, and falls were the most common mechanism of trauma (37.3%). Patients with an ISS ≥15 were mostly found in the 18-35-year age range (6.4%). Most patients who suffered a gunshot wound presented an ISS ≥15. A total of 2.5% of all patients died, whereas the mortality rate was 54% among patients with an ISS ≥15 and a gunshot wound. Conclusion: Once the trauma registry was successfully implemented in two institutions in Cali, the primary causes of admission were identified as falls and workplace injuries. The most severely compromised patients were in the population range between 18 and 35 years of age. The highest mortality was caused by gunshot wounds.

Resumen Introducción: Los sistemas de información en trauma son requeridos para mejorar la toma de decisiones e identificar potenciales áreas de intervención. Objetivo: Describir el primer año de experiencia del registro de trauma en dos centros de referencia de trauma del suroccidente Colombiano. Métodos: Estudio realizado en dos centros de referencia de Cali. Se incluyeron pacientes con trauma o lesiones externas entre el 1-Ene y el 31-Dic-2012. Se recolectó información demográfica, relacionada con mecanismos de trauma, severidad (ISS) y mortalidad. Se presenta un análisis descriptivo. Resultados: Se registraron 17,431 pacientes. El 67.8% de los pacientes eran de género masculino con edad promedio de 30 (±20) años. Las lesiones laborales fueron causa de consulta a urgencias en un 28.2%, y las caídas el mecanismo de trauma más frecuente (37.3%). Los pacientes con ISS ≥15 en su mayoría se encontraban en el rango de edad de 18-35 años (6.4%). El 28% de los pacientes que sufrieron lesión por arma de fuego presentaron un ISS ≥15. El 2.5% de los pacientes murieron y aquellos pacientes con ISS ≥15 y lesión por arma de fuego presentaron mortalidad del 54%. Conclusión: una vez se logró implementar el registro de trauma en dos instituciones en Cali, se identificó que la principal causa de ingreso fue secundaria a caídas y las lesiones laborales. Los pacientes más severamente comprometidos están en el rango de población entre 18 a 35 años. La mayor mortalidad se presentó secundario a lesiones de causa externa por arma de fuego.

WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting.

Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.

Defining the cervical spine clearance algorithm: A single-institution prospective study of more than 9,000 patients.

BACKGROUND: Variability exists in the approach to cervical spine (c-spine) clearance after significant trauma. Using concurrently gathered data on more than 9,000 such patients, the current study develops an evidence-based and readily adoptable algorithm for c-spine clearance aimed at timely removal of collar, optimal use of imaging, and appropriate spine consultations. METHODS: Prospective study of adult blunt trauma team alert (TTA) patients presenting at a Level I trauma center who underwent screening computed tomography (CT) to diagnose/rule out c-spine injury (January 2008 to May 2014). Regression analysis comparing patients with and without c-spine injury-fracture and/or ligament-was used to identify significant predictors of injury. The predictors with the highest odds ratio were used to develop the algorithm. RESULTS: Among 9,227 patients meeting inclusion criteria, c-spine injury was identified in 553 patients (5.99%). All 553 patients had a c-spine fracture, and of these, 57 patients (0.6% of entire population and 10.31% of patients with injury) also had a ligamentous injury. No patient with a normal CT result was found to have an injury. The five greatest predictors of ligament injury that follow were used to develop the algorithm: (1) CT evidence of ligament injury; (2) fracture pattern "not" isolated transverse/spinous process; (3) neurologic symptoms; (4) midline tenderness; and (5) Glasgow Coma Scale score <15. CONCLUSION: TTA patients should undergo screening c-spine CT to rule out injury. Most patients will have a negative CT and can have their collars removed. A select group of patients will require collars and spine consultation and a smaller subset of magnetic resonance imaging to rule out ligament injury. LEVEL OF EVEDINCE: Therapeutic study, level III.

Penetrating extremity trauma.

Penetrating extremity trauma (PET) usually becomes less important when present along with multiple truncal injuries. The middle eastern wars documented the terrible mortality and morbidity resulting from PET. Even in civilian trauma, PET can lead to significant morbidity and mortality. There are now well-established principles in the evaluation and management of vascular, bony, soft tissue, and neurologic lesions that will lead to a reduction of the poor outcomes. This review will summarize some of these recent concepts.

DVT surveillance program in the ICU: analysis of cost-effectiveness.

BACKGROUND: Venous Thrombo-embolism (VTE--Deep venous thrombosis (DVT) and/or pulmonary embolism (PE)--in traumatized patients causes significant morbidity and mortality. The current study evaluates the effectiveness of DVT surveillance in reducing PE, and performs a cost-effectiveness analysis. METHODS: All traumatized patients admitted to the adult ICU underwent twice weekly DVT surveillance by bilateral lower extremity venous Duplex examination (48-month surveillance period--SP). The rates of DVT and PE were recorded and compared to the rates observed in the 36-month pre-surveillance period (PSP). All patients in both periods received mechanical and pharmacologic prophylaxis unless contraindicated. Total costs--diagnostic, therapeutic and surveillance--for both periods were recorded and the incremental cost for each Quality Adjusted Life Year (QALY) gained was calculated. RESULTS: 4234 patients were eligible (PSP--1422 and SP--2812). Rate of DVT in SP (2.8%) was significantly higher than in PSP (1.3%) - p<0.05, and rate of PE in SP (0.7%) was significantly lower than that in PSP (1.5%) - p<0.05. Logistic regression demonstrated that surveillance was an independent predictor of increased DVT detection (OR: 2.53 - CI: 1.462-4.378) and decreased PE incidence (OR: 0.487 - CI: 0.262-0.904). The incremental cost was $509,091/life saved in the base case, translating to $29,102/QALY gained. A sensitivity analysis over four of the parameters used in the model indicated that the incremental cost ranged from $18,661 to $48,821/QALY gained. CONCLUSIONS: Surveillance of traumatized ICU patients increases DVT detection and reduces PE incidence. Costs in terms of QALY gained compares favorably with other interventions accepted by society.

Trauma surgery associations and societies: which organizations match your goals?

This focused summary is a multi-institutional, multi-national, and multi-generational project designed to briefly summarize current academic trauma societies for both trainees and faculty alike. The co-authorship is composed of former and/or current presidents from most major trauma organizations. It has particular relevance to trainees and/or recent graduates attempting to navigate the multitude of available trauma organizations.