Selective non-operative management of penetrating abdominal injuries at Northern European trauma centers: the NordiPen Study.

PURPOSE: A selective nonoperative management (SNOM) of penetrating abdominal injuries (PAI) is a standard of care in numerous established trauma centers. However, available evidence supporting SNOM of PAI in European settings remains scarce. Thus, we performed a multi-center study at selected Northern European trauma centers to investigate the management and outcomes of PAI. We hypothesized that despite a low number of penetrating injuries in included trauma centers, SNOM is successfully utilized with outcomes comparable with trauma centers with a high number of PAI. METHODS: All adult patients admitted to participating trauma centers in the Northern European region with PAI between 1/2015 and 12/2016 were retrospectively reviewed. Primary outcomes were mortality and success rate of SNOM. RESULTS: Overall, 119 patients were included. Median age was 38 (28-47) years. SNOM was initiated in 55 patients (46.0%) with 94.5% success rate. Three patients (5.5%) failed SNOM and had a delayed laparotomy with one gastric injury, one small bowel injury and one patient with a bleeding from mesentery. Overall mortality of the cohort was 5.0%. However, all patients in the SNOM group survived. Higher median ISS, median Abbreviated Injury Scale score of the abdomen, rate of combined anterior and posterior wounds, rate of in-hospital complications and longer hospital length of stay were observed in the immediate laparotomy group compared to the SNOM group. CONCLUSIONS: SNOM of PAI is a safe practice even in regions with a low prevalence of penetrating injuries. The outcomes in our study are comparable with results from trauma centers treating larger numbers of patients with PAI.

Choice of First Emergency Room Affects the Fate of Patients With Acute Mesenteric Ischaemia: The Importance of Referral Patterns and Triage.

OBJECTIVES: Despite modern advances in diagnosis and treatment, acute arterial mesenteric ischaemia (AMI) remains a high mortality disease. One of the key modifiable factors in AMI is the first door to operation time, but the factors attributing to this parameter are largely unknown. The aim of this study was to evaluate the factors affecting delay, with special focus on the pathways to treatment. METHODS: This was a single academic centre retrospective study. Patients undergoing intervention for AMI caused by thrombosis or embolism of the superior mesenteric artery between 2006 and 2015 were identified from electronic patient records. Patients not eligible for intervention or with chronic, subacute onset, colonic only, venous, or non-occlusive mesenteric ischaemia were excluded. Patients were divided into two groups according to the first speciality examining the patient (surgical emergency room [SER], surgeon examining the patient first or non-surgical emergency room [non-SER], internist examining the patient first). The primary endpoint was first door to operation time and secondary endpoints were length of stay and 90 day mortality. RESULTS: Eighty-one patients with AMI were included. Fifty patients (62%) died during the first 30 days and 53 (65%) within 90 days. Presenting first in non-SER (vs. SER) was independently associated with a first door to operation time of over 12 h (OR 3.7 [95% CI 1.3-10.2], median time 15.2 h [IQR 10.9-21.2] vs. 10.1 h [IQR 6.9-18.5], respectively, p = .025). The length of stay was shorter (median 6.5 days [4.0-10.3] vs. 10.8 days [7.0-22.3], p = .045) and 90 day mortality was lower in the SER group (50.0% vs. 74.5%, p = .025). CONCLUSIONS: The first specialty that the patient encounters seems to be crucial for both delayed management and early survival of AMI. Developing fast/direct pathways to a unit with both gastrointestinal and vascular surgeons offers the possibility of improving the outcome of AMI.