Review and prediction of trauma mortality

Quality management principles stipulate that outcome after injury is dependent upon patient factors, injury severity, structures and processes of care in a trauma system. Structures refers to the context in which care is delivered, including material resources, equipment and competence of involved personnel. Processes refers to what is literally done by the personnel involved in patient care. In this thesis, we examine the different aspects of this conceptual model with outcome as the main focus. Historically, trauma mortality has been the standard quality outcome measure. However, nontrauma related deaths and patients that are dead on arrival (DOA) in registries, complicates the interpretation of trauma mortality statistics. In Paper I, we demonstrated by clinical review of all deaths during 2007-2011 in a Level I trauma centre (Karolinska University Hospital – Solna [KUH]), that 30-day trauma mortality included 10.5% of non-trauma related deaths and the exclusion of DOAs significantly reduced the mortality rate. We concluded that review of all trauma deaths was necessary to correctly interpret trauma mortality. Analysis of preventable death (PD) is another quality outcome measure. The World Health Organization (WHO) has defined PD by the use of survival prediction models which calculates a probability of survival (Ps): non-PD with a Ps <25%, and potentially PD with a Ps >50%. In Paper II, we used a multidisciplinary peer review during 2012-2016, to identify the proportion of potentially PD and errors committed at KUH, and to evaluate the use of the WHO’s Ps cut-offs as a tool to identify the right patients to review, i.e., exclude non-PD from review or to focus review on potentially PD. We used the North American Trauma and Injury Severity Score (TRISS) and the Norwegian Survival Prediction Model in Trauma (NORMIT) to calculate the Ps. When applying the cut-off limits to the groups of non-PDs and potentially PDs for review, both models missed cases that otherwise needed to be reviewed. We concluded that peer review of all trauma deaths is essential in preventability analysis. Survival prediction models, which adjust for case-mix, have been developed to allow comparisons of the quality of trauma care between centres and over time. In Paper III, we used TRISS based risk-adjusted survival to compare two Scandinavian Level I trauma centres (KUH and Oslo University Hospital – Ullevål) during 2009-2011 and concluded that the model had its shortcomings when applied in a Scandinavian setting. The model lacks adjustments for age as a continuous variable and does not include comorbidity which, if included, could improve survival prediction in Scandinavian trauma populations. In Paper IV, we tested the accuracy of NORMIT and its later update (NORMIT 2), in regards to survival prediction, in two Swedish trauma populations; one national population including all hospitals admitting trauma patients in Sweden and one subpopulation of patients admitted to a single designated Level I trauma centre (KUH) during 2014-2016. We concluded that NORMIT 2 can be used to predict survival in a Swedish trauma centre population, but both NORMIT models performed poorly in a more heterogeneous national trauma population

Development and external validation of DISPAIR fistula risk score for clinically relevant postoperative pancreatic fistula risk after distal pancreatectomy

This study describes the development and external validation of the DISPAIR score, a preoperative clinical prediction model to estimate the risk of postoperative pancreatic fistula after distal pancreatectomy. It is based on three variables measured before operation: pancreatic thickness, transection site, and history of diabetes. On external validation, it showed satisfactory discrimination (area under the curve 0.80) and calibration (slope 0.719, intercept 0.192) for predicting pancreatic fistula. Background Highly utilized risk scores for clinically relevant postoperative pancreatic fistula (CR-POPF) have guided clinical decision-making in pancreatoduodenectomy. However, none has been successfully developed for distal pancreatectomy. This study aimed to develop and validate a new fistula risk score for distal pancreatectomy. Methods Patients undergoing distal pancreatectomy at Helsinki University Hospital, Finland from 2013 to 2021, and at Karolinska University Hospital, Sweden, from 2010 to 2020, were included retrospectively. The outcome was CR-POPF, according to the 2016 International Study Group of Pancreatic Surgery definition. Preoperative clinical demographics and radiological parameters such as pancreatic thickness and duct diameter were measured. A logistic regression model was developed, internally validated with bootstrapping, and the performance assessed in an external validation cohort. Results Of 668 patients from Helsinki (266) and Stockholm (402), 173 (25.9 per cent) developed CR-POPF. The final model consisted of three variables assessed before surgery: transection site (neck versus body/tail), pancreatic thickness at transection site, and diabetes. The model had an area under the receiver operating characteristic curve (AUROC) of 0.904 (95 per cent c.i. 0.855 to 0.949) after internal validation, and 0.798 (0.748 to 0.848) after external validation. The calibration slope and intercept on external validation were 0.719 and 0.192 respectively. Four risk groups were defined in the validation cohort for clinical applicability: low (below 5 per cent), moderate (at least 5 but below 30 per cent), high (at least 30 but below 75 per cent), and extreme (75 per cent or more). The incidences in these groups were 8.7 per cent (11 of 126), 22.0 per cent (36 of 164), 63 per cent (57 of 91), and 81 per cent (17 of 21) respectively. Conclusion The DISPAIR score after distal pancreatectomy may guide decision-making and allow a risk-adjusted outcome comparison for CR-POPF.Peer reviewe

Surgical Outcome After Distal Pancreatectomy With and Without Portomesenteric Venous Resection in Patients with Pancreatic Adenocarcinoma:A Transatlantic Evaluation of Patients in North America, Germany, Sweden, and The Netherlands (GAPASURG)

BackgroundPancreatic adenocarcinoma located in the pancreatic body might require a portomesenteric venous resection (PVR), but data regarding surgical risks after distal pancreatectomy (DP) with PVR are sparse. Insight into additional surgical risks of DP-PVR could support preoperative counseling and intraoperative decision making. This study aimed to provide insight into the surgical outcome of DP-PVR, including its potential risk elevation over standard DP.MethodsWe conducted a retrospective, multicenter study including all patients with pancreatic adenocarcinoma who underwent DP +/- PVR (2018-2020), registered in four audits for pancreatic surgery from North America, Germany, Sweden, and The Netherlands. Patients who underwent concomitant arterial and/or multivisceral resection(s) were excluded. Predictors for in-hospital/30-day major morbidity and mortality were investigated by logistic regression, correcting for each audit.ResultsOverall, 2924 patients after DP were included, of whom 241 patients (8.2%) underwent DP-PVR. Rates of major morbidity (24% vs. 18%; p = 0.024) and post-pancreatectomy hemorrhage grade B/C (10% vs. 3%; p = 0.041) were higher after DP-PVR compared with standard DP. Mortality after DP-PVR and standard DP did not differ significantly (2% vs. 1%; p = 0.542). Predictors for major morbidity were PVR (odds ratio [OR] 1.500, 95% confidence interval [CI] 1.086-2.071) and conversion from minimally invasive to open surgery (OR 1.420, 95% CI 1.032-1.970). Predictors for mortality were higher age (OR 1.087, 95% CI 1.045-1.132), chronic obstructive pulmonary disease (OR 4.167, 95% CI 1.852-9.374), and conversion from minimally invasive to open surgery (OR 2.919, 95% CI 1.197-7.118), whereas concomitant PVR was not associated with mortality.ConclusionsPVR during DP for pancreatic adenocarcinoma in the pancreatic body is associated with increased morbidity, but can be performed safely in terms of mortality

Oncological resection and perioperative outcomes of robotic, laparoscopic and open pancreatoduodenectomy for ampullary adenocarcinoma:a propensity score matched international multicenter cohort study

BackgroundAmpullary adenocarcinoma (AAC) typically presents at an early stage due to biliary obstruction and therefore might be specifically suitable for minimally invasive pancreatoduodenectomy (MIPD). However, studies assessing MIPD specifically for AAC, including the robotic and laparoscopic approach, are limited. The aim of this study is to compare short- and long-term oncological resection and perioperative outcomes of robotic (RPD), laparoscopic (LPD) and open pancreatoduodenectomy (OPD) performed specifically for AAC.MethodsIn this multicenter international cohort study, encompassing 35 centers from 11 countries, MIPD versus OPD and subgroup analyses of LPD versus RPD were undertaken. The primary outcomes regarded the oncological resection (R1 resection rate, lymph node yield) and 5-years overall survival. Secondary outcomes were perioperative outcomes (including intra-operative variables, surgical complications and hospital stay).ResultsIn total, patients with AAC who underwent OPD (1721) or MIPD (141) were included. After propensity-score matching, 134 patients per cohort were included. The MIPD group consisted of 53 RPDs and 71 LPDs (50 per group after PSM). There was no difference in overall survival between MIPD and OPD (61.6 % vs 56.2 %, P = 0.215). In the MIPD group, operative time was longer (439 vs 360 min, P &lt; 0.001). Between RPD and LPD, overall survival was not significantly different (75.8 % vs 47.4 %, P = 0.098) and lymph node yield was higher in RPD (21 vs 18, P = 0.014).ConclusionIn conclusion, patients with AAC seem to have comparable oncological resection and perioperative outcomes from MIPD compared to the traditional OPD. Both RPD as LPD appear to be safe alternatives for patients with AAC, which warrants confirmation by future randomized studies.<p/

Surgery for chronic pancreatitis across Europe (ESCOPA):Prospective multicentre study

Background: Randomized trials have demonstrated the superiority of surgery over endoscopy in patients with symptomatic chronic pancreatitis. However, large international studies quantifying the impact of surgery on chronic pancreatitis are lacking. The aim of this study was to evaluate current practice across Europe regarding indications, surgical techniques, and outcomes of surgery for chronic pancreatitis. Methods: A prospective multicentre study of consecutive patients undergoing surgery for symptomatic chronic pancreatitis from 22 centres in 13 countries from 1 June 2021 to 30 November 2022 was conducted. The outcome of interest in patients with pain as an indication was the Izbicki pain score at 6-month follow-up, with complete pain relief defined as an Izbicki pain score ≤10 and partial pain relief defined as an Izbicki pain score &gt;10, but with a &gt;50% decrease compared with the baseline score. Quality of life was assessed using Pancreatitis Quality of Life Instrument (PANQOLI) and 12-Item Short-Form (SF-12) surveys. Predictors of pain relief were analysed using multivariable analysis. Results: Overall, 207 patients underwent surgery (24.6% underwent surgical drainage procedures, 29.5% underwent duodenum-preserving head resections, and 45.9% underwent formal pancreatic resections). Before surgery, 48.8% used opioids and 51.2% had undergone prior endoscopic treatment. Major morbidity occurred in 14.0% and the 90-day mortality rate was 1.4%. Among 113 patients operated on for pain, the median Izbicki pain score decreased from 61.3 to 19.0 at 6 months (P &lt; 0.001). Pain relief was achieved in 72.6% (43 patients reported complete pain relief and 39 patients reported partial pain relief). PANQOLI and SF-12 Physical Component Summary scores improved significantly (P &lt; 0.001). Longer symptom duration (OR 0.95 (95% c.i. 0.90 to 1.00), P = 0.045) and use of opioids before surgery (OR 3.16 (95% c.i. 1.04 to 9.64), P = 0.043) predicted less pain relief. Conclusion: Surgery for chronic pancreatitis across Europe was performed with low morbidity. Patients reported good pain relief and improvements in quality-of-life scores. Multidisciplinary consultation is recommended for all patients with chronic pancreatitis before undergoing any intervention.</p