P. Kilen2, A. Greenbaum1, R. Miskmins1, R. Preda1, T. Howdieshell1, S. Lu1, S. West1 1University Of New Mexico HSC,Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA
Introduction: The impact of integrating trauma specialists and emergency general surgeons on trauma patient outcomes has been debated. Complex hepatopancreatobiliary (HPB) injuries present a particular challenge and often require specialized care. At our institution both fellowship-trained trauma and critical care (TCC) specialists and general surgeons (GS) are responsible for the care of trauma patients. We predicted there would be no difference in the initial management or outcomes of patients sustaining complex HPB trauma between general and trauma specialist surgeons.
Methods: A retrospective review of patients who underwent operative intervention for complex HPB trauma (defined as liver AAST grade III-V, pancreas II-V and duodenum II-V, and extrahepatic biliary injuries) from May 2008 to August 2015 at an ACS-verified Level I trauma center was performed. We employed our state trauma database and chart review to obtain demographics, initial vital signs, ISS, length of stay (LOS), the training level of the initial attending surgeon, HPB-directed interventions, frequency of damage control laparotomy (DCL) versus primary closure, drain placement, infectious complications and mortality. Statistical analyses were performed with Chi-square and Fisher exact tests. Student’s t-Tests were used to compare means of continuous values. P-values < 0.05 were considered significant.
Results: A total of 173 patients met inclusion criteria. Between the GS group (n=37) and TCC group (n=136), there were no significant differences in patient demographics, mechanism of injury, presence of shock or need for intubation on admission, mean ISS, or GCS, initial vital signs or physiologic derangement on laboratory studies. Most injuries were high-grade hepatic (84.6% for GS and 76.3% for TCC; p=0.492). TCC treated more pancreas injuries (15.8% of all injuries vs. GS 7.7%) though this was not statistically significant. Primary abdominal closure rates between GS and TCC (28.9% vs. 31.9% respectively) and DCL with temporary abdominal closure (71.1% vs. 69.1%) were performed at similar rates (p=0.85). There were no significant differences in HPB-directed interventions at the initial operation (39.5% GS vs. 55.11% TCC; p=0.13). No differences in mean operative pRBCs (2.6 vs. 3.6; p=0.28), estimated blood loss (1.2L vs. 1.7L TCC; p=0.11) rates of angioembolization, or intraoperative cholangiogram were found. In patients that were closed at the primary operation, TCC were more likely to place an intraabdominal drain than GS (76.2% vs. 36.4%; p=0.03). Both ICU LOS, total LOS, and septic complications of GS and TCC were comparable, as was 30-day mortality (13.2% vs. 10.3%; p=0.77).
Conclusion:
We found no major differences between general and fellowship-trained trauma and critical care surgeons in the initial operative management or clinical outcomes of complex HPB trauma at our Level I trauma center. The frequent and proper use of DCL likely contribute to these findings.