Pub Date : 2024-06-04DOI: 10.1186/s13017-024-00542-x
Marco Milone, Pietro Anoldo, Nicola de’Angelis, Federico Coccolini, Jim Khan, Yoram Kluger, Massimo Sartelli, Luca Ansaloni, Luca Morelli, Nicola Zanini, Carlo Vallicelli, Gabriele Vigutto, Ernest E. Moore, Walter Biffl, Fausto Catena
Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety. The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres. Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs.
{"title":"The role of RObotic surgery in EMergency setting (ROEM): protocol for a multicentre, observational, prospective international study on the use of robotic platform in emergency surgery","authors":"Marco Milone, Pietro Anoldo, Nicola de’Angelis, Federico Coccolini, Jim Khan, Yoram Kluger, Massimo Sartelli, Luca Ansaloni, Luca Morelli, Nicola Zanini, Carlo Vallicelli, Gabriele Vigutto, Ernest E. Moore, Walter Biffl, Fausto Catena","doi":"10.1186/s13017-024-00542-x","DOIUrl":"https://doi.org/10.1186/s13017-024-00542-x","url":null,"abstract":"Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety. The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres. Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141246550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed. This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score. Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival. While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.
{"title":"Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma and its performance in Japan over the past 18 years: a nationwide descriptive study","authors":"Hiromasa Hoshi, Akira Endo, Ryo Yamamoto, Kazuma Yamakawa, Keisuke Suzuki, Tomohiro Akutsu, Koji Morishita","doi":"10.1186/s13017-024-00548-5","DOIUrl":"https://doi.org/10.1186/s13017-024-00548-5","url":null,"abstract":"Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed. This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score. Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival. While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141182449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-31DOI: 10.1186/s13017-024-00537-8
Belinda De Simone, Elie Chouillard, Mauro Podda, Nikolaos Pararas, Gustavo de Carvalho Duarte, Paola Fugazzola, Arianna Birindelli, Federico Coccolini, Andrea Polistena, Maria Grazia Sibilla, Vitor Kruger, Gustavo P Fraga, Giulia Montori, Emanuele Russo, Tadeja Pintar, Luca Ansaloni, Nicola Avenia, Salomone Di Saverio, Ari Leppäniemi, Andrea Lauretta, Massimo Sartelli, Alessandro Puzziello, Paolo Carcoforo, Vanni Agnoletti, Luca Bissoni, Arda Isik, Yoram Kluger, Ernest E Moore, Oreste Marco Romeo, Fikri M Abu-Zidan, Solomon Gurmu Beka, Dieter G Weber, Edward C T H Tan, Ciro Paolillo, Yunfeng Cui, Fernando Kim, Edoardo Picetti, Isidoro Di Carlo, Adriana Toro, Gabriele Sganga, Federica Sganga, Mario Testini, Giovanna Di Meo, Andrew W Kirkpatrick, Ingo Marzi, Nicola déAngelis, Michael Denis Kelly, Imtiaz Wani, Boris Sakakushev, Miklosh Bala, Luigi Bonavina, Joseph M Galante, Vishal G Shelat, Lorenzo Cobianchi, Francesca Dal Mas, Manos Pikoulis, Dimitrios Damaskos, Raul Coimbra, Jugdeep Dhesi, Melissa Red Hoffman, Philip F Stahel, Ronald V Maier, Andrey Litvin, Rifat Latifi, Walter L Biffl, Fausto Catena
Background: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.
Methods: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.
Results: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.
Conclusions: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
{"title":"The 2023 WSES guidelines on the management of trauma in elderly and frail patients.","authors":"Belinda De Simone, Elie Chouillard, Mauro Podda, Nikolaos Pararas, Gustavo de Carvalho Duarte, Paola Fugazzola, Arianna Birindelli, Federico Coccolini, Andrea Polistena, Maria Grazia Sibilla, Vitor Kruger, Gustavo P Fraga, Giulia Montori, Emanuele Russo, Tadeja Pintar, Luca Ansaloni, Nicola Avenia, Salomone Di Saverio, Ari Leppäniemi, Andrea Lauretta, Massimo Sartelli, Alessandro Puzziello, Paolo Carcoforo, Vanni Agnoletti, Luca Bissoni, Arda Isik, Yoram Kluger, Ernest E Moore, Oreste Marco Romeo, Fikri M Abu-Zidan, Solomon Gurmu Beka, Dieter G Weber, Edward C T H Tan, Ciro Paolillo, Yunfeng Cui, Fernando Kim, Edoardo Picetti, Isidoro Di Carlo, Adriana Toro, Gabriele Sganga, Federica Sganga, Mario Testini, Giovanna Di Meo, Andrew W Kirkpatrick, Ingo Marzi, Nicola déAngelis, Michael Denis Kelly, Imtiaz Wani, Boris Sakakushev, Miklosh Bala, Luigi Bonavina, Joseph M Galante, Vishal G Shelat, Lorenzo Cobianchi, Francesca Dal Mas, Manos Pikoulis, Dimitrios Damaskos, Raul Coimbra, Jugdeep Dhesi, Melissa Red Hoffman, Philip F Stahel, Ronald V Maier, Andrey Litvin, Rifat Latifi, Walter L Biffl, Fausto Catena","doi":"10.1186/s13017-024-00537-8","DOIUrl":"10.1186/s13017-024-00537-8","url":null,"abstract":"<p><strong>Background: </strong>The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.</p><p><strong>Methods: </strong>Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.</p><p><strong>Results: </strong>The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.</p><p><strong>Conclusions: </strong>The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.</p>","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11140935/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141181181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abdominal computed tomography (CT) scan is a crucial imaging modality for creating cross-sectional images of the abdominal area, particularly in cases of abdominal trauma, which is commonly encountered in traumatic injuries. However, interpreting CT images is a challenge, especially in emergency. Therefore, we developed a novel deep learning algorithm-based detection method for the initial screening of abdominal internal organ injuries. We utilized a dataset provided by the Kaggle competition, comprising 3,147 patients, of which 855 were diagnosed with abdominal trauma, accounting for 27.16% of the total patient population. Following image data pre-processing, we employed a 2D semantic segmentation model to segment the images and constructed a 2.5D classification model to assess the probability of injury for each organ. Subsequently, we evaluated the algorithm’s performance using 5k-fold cross-validation. With particularly noteworthy performance in detecting renal injury on abdominal CT scans, we achieved an acceptable accuracy of 0.932 (with a positive predictive value (PPV) of 0.888, negative predictive value (NPV) of 0.943, sensitivity of 0.887, and specificity of 0.944). Furthermore, the accuracy for liver injury detection was 0.873 (with PPV of 0.789, NPV of 0.895, sensitivity of 0.789, and specificity of 0.895), while for spleen injury, it was 0.771 (with PPV of 0.630, NPV of 0.814, sensitivity of 0.626, and specificity of 0.816). The deep learning model demonstrated the capability to identify multiple organ injuries simultaneously on CT scans and holds potential for application in preliminary screening and adjunctive diagnosis of trauma cases beyond abdominal injuries.
{"title":"The application of deep learning in abdominal trauma diagnosis by CT imaging","authors":"Xinru Shen, Yixin Zhou, Xueyu Shi, Shiyun Zhang, Shengwen Ding, Liangliang Ni, Xiaobing Dou, Lin Chen","doi":"10.1186/s13017-024-00546-7","DOIUrl":"https://doi.org/10.1186/s13017-024-00546-7","url":null,"abstract":"Abdominal computed tomography (CT) scan is a crucial imaging modality for creating cross-sectional images of the abdominal area, particularly in cases of abdominal trauma, which is commonly encountered in traumatic injuries. However, interpreting CT images is a challenge, especially in emergency. Therefore, we developed a novel deep learning algorithm-based detection method for the initial screening of abdominal internal organ injuries. We utilized a dataset provided by the Kaggle competition, comprising 3,147 patients, of which 855 were diagnosed with abdominal trauma, accounting for 27.16% of the total patient population. Following image data pre-processing, we employed a 2D semantic segmentation model to segment the images and constructed a 2.5D classification model to assess the probability of injury for each organ. Subsequently, we evaluated the algorithm’s performance using 5k-fold cross-validation. With particularly noteworthy performance in detecting renal injury on abdominal CT scans, we achieved an acceptable accuracy of 0.932 (with a positive predictive value (PPV) of 0.888, negative predictive value (NPV) of 0.943, sensitivity of 0.887, and specificity of 0.944). Furthermore, the accuracy for liver injury detection was 0.873 (with PPV of 0.789, NPV of 0.895, sensitivity of 0.789, and specificity of 0.895), while for spleen injury, it was 0.771 (with PPV of 0.630, NPV of 0.814, sensitivity of 0.626, and specificity of 0.816). The deep learning model demonstrated the capability to identify multiple organ injuries simultaneously on CT scans and holds potential for application in preliminary screening and adjunctive diagnosis of trauma cases beyond abdominal injuries.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140845387","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-27DOI: 10.1186/s13017-024-00544-9
Yuhan Qi, Jiarong Wang, Ding Yuan, Pengchao Duan, Li Hou, Tiehao Wang
For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21–0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20–0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75–1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%–27%). Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.
对于创伤性下肢动脉损伤，目前尚不清楚是进行血管内治疗（ET）更好，还是进行开放手术修复（OSR）更好。本研究旨在比较创伤性下肢动脉损伤的 ET 与 OSR 的临床疗效。研究人员在 Medline、Embase 和 Cochrane 数据库中检索了相关研究。报告 ET 或 OSR 结果的队列研究和病例系列研究符合纳入条件。采用Robins-I工具和18项工具评估偏倚风险。主要结果为截肢。次要结果包括筋膜切开术或筋膜室综合征、死亡率、住院时间和下肢神经损伤。我们使用随机效应模型计算汇总估计值。共有32项存在低度或中度偏倚风险的研究被纳入荟萃分析。结果显示，与接受OSR的患者相比，接受ET的患者发生大截肢（OR=0.42，95% CI 0.21-0.85；I2=34%）和筋膜切开术或室间综合征（OR=0.31，95% CI 0.20-0.50，I2=14%）的风险明显降低。两组患者的全因死亡率无明显差异（OR = 1.11，95% CI 0.75-1.64，I2 = 31%）。ET修复术患者的住院时间短于OSR修复术患者（MD=-5.06，95% CI -6.76至-3.36，I2=65%）。据报道，OSR患者术中神经损伤的发生率为15%（95% CI 6%-27%）。血管内治疗可能是外伤性下肢动脉损伤患者的更好选择，因为它可以降低截肢、筋膜切开或筋膜室综合征和神经损伤的风险，并缩短住院时间。
{"title":"Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury","authors":"Yuhan Qi, Jiarong Wang, Ding Yuan, Pengchao Duan, Li Hou, Tiehao Wang","doi":"10.1186/s13017-024-00544-9","DOIUrl":"https://doi.org/10.1186/s13017-024-00544-9","url":null,"abstract":"For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21–0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20–0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75–1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%–27%). Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140651541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-25DOI: 10.1186/s13017-024-00545-8
Paula Ferrada, Alberto García, Juan Duchesne, Megan Brenner, Chang Liu, Carlos Ordóñez, Carlos Menegozzo, Juan Carlos Salamea, David Feliciano
Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries. A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded. The study included 278 eligible patients, with 61.5% falling within the “CAB” cohort and 38.5% in the “ABC” cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries. Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.
{"title":"Comparing outcomes in patients with exsanguinating injuries: an Eastern Association for the Surgery of Trauma (EAST), multicenter, international trial evaluating prioritization of circulation over intubation (CAB over ABC)","authors":"Paula Ferrada, Alberto García, Juan Duchesne, Megan Brenner, Chang Liu, Carlos Ordóñez, Carlos Menegozzo, Juan Carlos Salamea, David Feliciano","doi":"10.1186/s13017-024-00545-8","DOIUrl":"https://doi.org/10.1186/s13017-024-00545-8","url":null,"abstract":"Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries. A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded. The study included 278 eligible patients, with 61.5% falling within the “CAB” cohort and 38.5% in the “ABC” cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries. Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140642706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-16DOI: 10.1186/s13017-024-00543-w
Gennaro Perrone, Mario Giuffrida, Fikri Abu-Zidan, Vitor F. Kruger, Marco Livrini, Gabriele Luciano Petracca, Giorgio Rossi, Antonio Tarasconi, Brian W. C. A. Tian, Elena Bonati, Ricardo Mentz, Federico N. Mazzini, Juan P. Campana, Elisabeth Gasser, Reinhold Kafka-Ritsch, Daniel M. Felsenreich, Christopher Dawoud, Stefan Riss, Carlos Augusto Gomes, Felipe Couto Gomes, Ricardo Alessandro Teixeira Gonzaga, Cassio Alfred Brattig Canton, Bruno Monteiro Pereira, Gustavo P. Fraga, Leticia Gonçalves Zem, Vinicius Cordeiro-Fonseca, Renato de Mesquita Tauil, Boyko Atanasov, Nikolay Belev, Nikola Kovachev, L. Juan José Meléndez, Ana Dimova, Stefan Dimov, Zdravko Zelić, Goran Augustin, Branko Bogdanić, Trpimir Morić, Elie Chouillard, Melinda Bajul, Belinda De Simone, Yves Panis, Francesco Esposito, Margherita Notarnicola, Lelde Lauka, Anna Fabbri, Hassen Hentati, Iskander Fnaiech, Venara Aurélien, Marie Bougard, Maxime Roulet, Zaza Demetrashvili, Irakli Pipia, Giorgi Merabishvili, Konst..
Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. After 100 years since the first Hartmann’s procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment’s choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.
{"title":"Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago","authors":"Gennaro Perrone, Mario Giuffrida, Fikri Abu-Zidan, Vitor F. Kruger, Marco Livrini, Gabriele Luciano Petracca, Giorgio Rossi, Antonio Tarasconi, Brian W. C. A. Tian, Elena Bonati, Ricardo Mentz, Federico N. Mazzini, Juan P. Campana, Elisabeth Gasser, Reinhold Kafka-Ritsch, Daniel M. Felsenreich, Christopher Dawoud, Stefan Riss, Carlos Augusto Gomes, Felipe Couto Gomes, Ricardo Alessandro Teixeira Gonzaga, Cassio Alfred Brattig Canton, Bruno Monteiro Pereira, Gustavo P. Fraga, Leticia Gonçalves Zem, Vinicius Cordeiro-Fonseca, Renato de Mesquita Tauil, Boyko Atanasov, Nikolay Belev, Nikola Kovachev, L. Juan José Meléndez, Ana Dimova, Stefan Dimov, Zdravko Zelić, Goran Augustin, Branko Bogdanić, Trpimir Morić, Elie Chouillard, Melinda Bajul, Belinda De Simone, Yves Panis, Francesco Esposito, Margherita Notarnicola, Lelde Lauka, Anna Fabbri, Hassen Hentati, Iskander Fnaiech, Venara Aurélien, Marie Bougard, Maxime Roulet, Zaza Demetrashvili, Irakli Pipia, Giorgi Merabishvili, Konst..","doi":"10.1186/s13017-024-00543-w","DOIUrl":"https://doi.org/10.1186/s13017-024-00543-w","url":null,"abstract":"Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. After 100 years since the first Hartmann’s procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment’s choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140557229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-10DOI: 10.1186/s13017-024-00541-y
Xiao Shuang Ling, Wei Cheng Anthony Brian Tian, Goran Augustin, Fausto Catena
Small bowel obstruction can occur during pregnancy, which, if missed, can lead to dire consequences for both the mother and foetus. Management of this condition usually requires surgical intervention. However, only a small number of patients are treated conservatively. The objective was to review the literature to determine the feasibility of conservative management for small bowel obstruction. A systematic search of the PubMed and Embase databases was performed using the keywords [small bowel obstruction AND pregnancy]. All original articles were then reviewed and included in this review if deemed suitable. Conservative management of small bowel obstruction in pregnant women is feasible if the patient is clinically stable and after ruling out bowel ischaemia and closed-loop obstruction.
{"title":"Can small bowel obstruction during pregnancy be treated with conservative management? A review","authors":"Xiao Shuang Ling, Wei Cheng Anthony Brian Tian, Goran Augustin, Fausto Catena","doi":"10.1186/s13017-024-00541-y","DOIUrl":"https://doi.org/10.1186/s13017-024-00541-y","url":null,"abstract":"Small bowel obstruction can occur during pregnancy, which, if missed, can lead to dire consequences for both the mother and foetus. Management of this condition usually requires surgical intervention. However, only a small number of patients are treated conservatively. The objective was to review the literature to determine the feasibility of conservative management for small bowel obstruction. A systematic search of the PubMed and Embase databases was performed using the keywords [small bowel obstruction AND pregnancy]. All original articles were then reviewed and included in this review if deemed suitable. Conservative management of small bowel obstruction in pregnant women is feasible if the patient is clinically stable and after ruling out bowel ischaemia and closed-loop obstruction.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140541249","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-21DOI: 10.1186/s13017-024-00539-6
Paola Fugazzola, Silvia Carbonell-Morote, Lorenzo Cobianchi, Federico Coccolini, Juan Jesús Rubio-García, Massimo Sartelli, Walter Biffl, Fausto Catena, Luca Ansaloni, Jose Manuel Ramia
A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis. The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO. This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC. 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC. Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.
{"title":"Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study","authors":"Paola Fugazzola, Silvia Carbonell-Morote, Lorenzo Cobianchi, Federico Coccolini, Juan Jesús Rubio-García, Massimo Sartelli, Walter Biffl, Fausto Catena, Luca Ansaloni, Jose Manuel Ramia","doi":"10.1186/s13017-024-00539-6","DOIUrl":"https://doi.org/10.1186/s13017-024-00539-6","url":null,"abstract":"A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis. The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO. This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC. 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC. Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140182803","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. Systematic review registration: UMIN Clinical Trials Registry UMIN000049365.
{"title":"A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures","authors":"Ryo Hisamune, Mako Kobayashi, Karin Nakasato, Taiga Yamazaki, Noritaka Ushio, Katsunori Mochizuki, Akira Takasu, Kazuma Yamakawa","doi":"10.1186/s13017-024-00540-z","DOIUrl":"https://doi.org/10.1186/s13017-024-00540-z","url":null,"abstract":"Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. Systematic review registration: UMIN Clinical Trials Registry UMIN000049365.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140161594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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