Liver surgery: Imaging and image guided therapies

The liver is the most common site of malignant tumors in patients worldwide, including both primary (hepatocellular carcinoma) and metastatic liver cancer (eg colorectal liver metastases). Complete resection or thermal ablation of all tumor deposits currently offers the only potentially curative treatment for patients with a malignancy of the liver. Historically, the liver was considered an organ too fragile and prone to bleeding for elective surgery. Increasing insight in the hepatic vascular and biliary anatomy and the introduction of antisepsis and anesthesia allowed pioneers like Langenbruch and Keene to start performing partial liver resections in the late nineteenth century1,2. Ongoing insight in the hepatic anatomy -like the division of the liver in eight distinct anatomic segments by Couinaud- further encouraged surgeons to perform liver surgery for hepatic neoplasms3. However, until late in the twentieth century, the absence of any form of non-invasive diagnostic imaging severely hampered the application of liver resection at a large scale

De oudere patiënt met multipele ribfracturen

Abstract: Rib fractures resulting from blunt thoracic trauma occur frequently in elderly persons. Although usually due to a low impact trauma mechanism (e.g., fall from standing height), rib fractures are associated with significant morbidity and mortality in the elderly patient. This unfavorable clinical course is most often caused by respiratory insufficiency due to lung edema or pneumonia. This cases series presents three elderly patients who sustained multiple rib fractures and were subsequently admitted to a level I trauma center for treatment. Diagnostic challenges as well as different treatment approaches for this population are discussed. More specifically, age specific indications and contra-indications for intravenous or epidural analgesia and operative rib fixation are discussed. In addition, we show that a multidisciplinary approach, involving a trauma surgeon, anesthesiologist, intensive care physician and physical therapist is paramount for the prevention of potentially lethal complications. Samenvatting: Stomp thoracaal letsel met ribfracturen komt veel voor bij ouderen. Hoewel het traumamechanisme vaak van laag-energetische aard is, is het beloop dikwijls gecompliceerd. De morbiditeit en mortaliteit van deze letsels bij oudere patiënten zijn aanzienlijk. Enerzijds wordt dat verklaard door patiëntgerelateerde factoren, zoals een verminderde fysiologische reserve, comorbiditeit en verhoogde vatbaarheid van weefsels voor het ontstaan van letsel. Anderzijds kan de letselernst in deze populatie eenvoudig worden onderschat. Tijdige herkenning van deze factoren en de gevolgen hiervan, alsmede een multidisciplinaire behandeling zijn van essentieel belang om tot een goede diagnose te komen, een adequate behandeling in te stellen en complicaties te voorkomen. Wij illustreren dit aan de hand van 3 casussen

3D-printed patient specific instruments for corrective osteotomies of the lower extremity

3D-printing has become a promising adjunct in orthopedic surgery over the past years. A significant drop in costs and increased availability of the required hardware and software needed for using the technique, have resulted in a relatively fast adaptation of 3D-printing techniques for various indications. In this review, the role of 3D-printing for deformity corrections of the lower extremity is described.</p

First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study

Purpose: The aim of this study was to compare the rate of first attempt success of endotracheal intubation performed by ambulance nurses in patients with a Glasgow Coma Scale (GCS) of 3 using video laryngoscopy versus direct laryngoscopy. Methods: A prospective cohort study was conducted in a single, independent ambulance service. Twenty of a total of 65 nurse-staffed ambulances were equipped with a video laryngoscope; a classic direct laryngoscope (Macintosh) was available on all 65 ambulances. The primary outcome was first attempt success of the intubation. Secondary outcomes were overall success, time needed for intubation, adverse events, technical or environmental issues encountered, and return of spontaneous circulation (ROSC). Ambulance nurses were asked if the intubation device had affected the outcome of the intubation. Results: The first attempt success rate in the video laryngoscopy group [53 of 93 attempts (

Deferred consent in emergency trauma research:A qualitative study assessing the healthcare professional's opinions

Introduction: Severely injured patients are often incapacitated to provide informed consent for clinical studies. Deferred consent could facilitate unbiased enrollment in studies involving these patients. Little is known about how healthcare professionals (HCPs) perceive deferred consent and how this impacts patient enrollment. The aim of this study was to identify factors that could influence HCPs decision-making during recruitment of patients for interventional studies in (pre)hospital emergency trauma research. Methods: This was a qualitative study in which physicians and nurses working in prehospital or in-hospital care were interviewed using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analyzed according to thematic analysis as described by Braun and Clarke. Results: Ten semi-structured interviews were conducted with six physicians and four nurses. Eight themes were identified as being relevant consent related factors influencing HCPs’ decision-making during patient recruitment in studies using deferred consent: (1) HCPs’ lack of knowledge; (2) Patients’ and proxies’ inability to be informed; (3) Practical (im)possibilities for informed consent; (4) Nature of intervention; (5) HCPs’ personal beliefs; (6) Importance of emergency care research; (7) HCPs’ trust in legal base; and (8) Communication and collaboration. Conclusions: Eight consent-related factors influencing HCPs’ decision making were identified. Insufficient knowledge about consent procedures among HCPs leads to significant negative attitudes towards deferred consent.</p

Decision making in prehospital traumatic cardiac arrest; A qualitative study

Background: Despite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. Methods: Twenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. Results: Eight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. Conclusion: Eight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines

A novel method to perform morphological measurements on three-dimensional (3D) models of the calcaneus based on computed tomography (CT)-imaging

Background: While current preoperative and postoperative assessment of the fractured and surgically reconstructed calcaneus relies on computed tomography (CT)-imaging, there are no established methods to quantify calcaneus morphology on CT-images. This study aims to develop a semi-automated method for morphological measurements of the calcaneus on three-dimensional (3D) models derived from CT-imaging. Methods: Using CT data, 3D models were created from healthy, fractured, and surgically reconstructed calcanei. Böhler's angle (BA) and Critical angle of Gissane (CAG) were measured on conventional lateral radiographs and corresponding 3D CT reconstructions using a novel point-based method with semiautomatic landmark placement by three observers. Intraobserver and interobserver reliability scores were calculated using intra-class correlation coefficient (ICC). In addition, consensus among observers was calculated for a maximal allowable discrepancy of 5 and 10 degrees for both methods. Results: Imaging data from 119 feet were obtained (40 healthy, 39 fractured, 40 reconstructed). Semiautomated measurements on 3D models of BA and CAG showed excellent reliability (ICC: 0.87-1.00). The manual measurements on conventional radiographs had a poor-to-excellent reliability (ICC: 0.22-0.96). In addition, the percentage of consensus among observers was much higher for the 3D method when compared to conventional two-dimensional (2D) measurements. Conclusions: The proposed method enables reliable and reproducible quantification of calcaneus morphology in 3D models of healthy, fractured and reconstructed calcanei.</p

A novel method to perform morphological measurements on three-dimensional (3D) models of the calcaneus based on computed tomography (CT)-imaging

Background: While current preoperative and postoperative assessment of the fractured and surgically reconstructed calcaneus relies on computed tomography (CT)-imaging, there are no established methods to quantify calcaneus morphology on CT-images. This study aims to develop a semi-automated method for morphological measurements of the calcaneus on three-dimensional (3D) models derived from CT-imaging. Methods: Using CT data, 3D models were created from healthy, fractured, and surgically reconstructed calcanei. Böhler's angle (BA) and Critical angle of Gissane (CAG) were measured on conventional lateral radiographs and corresponding 3D CT reconstructions using a novel point-based method with semiautomatic landmark placement by three observers. Intraobserver and interobserver reliability scores were calculated using intra-class correlation coefficient (ICC). In addition, consensus among observers was calculated for a maximal allowable discrepancy of 5 and 10 degrees for both methods. Results: Imaging data from 119 feet were obtained (40 healthy, 39 fractured, 40 reconstructed). Semiautomated measurements on 3D models of BA and CAG showed excellent reliability (ICC: 0.87-1.00). The manual measurements on conventional radiographs had a poor-to-excellent reliability (ICC: 0.22-0.96). In addition, the percentage of consensus among observers was much higher for the 3D method when compared to conventional two-dimensional (2D) measurements. Conclusions: The proposed method enables reliable and reproducible quantification of calcaneus morphology in 3D models of healthy, fractured and reconstructed calcanei.</p

Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future

Background: Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the reco

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study

Background: Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation. Methods: This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios. Results: Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items. Conclusions: The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence. Implications for clinical practice: The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients.</p