Publications by authors named "Chih-Yuan Fu"

100 Publications

Aspirin does not increase the need for haemostatic interventions in blunt liver and spleen injuries.

Injury 2021 May 17. Epub 2021 May 17.

Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan; Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan; Medical School, Chang Gung University, Taiwan; Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan.

Purpose: The prohemorrhagic effect of aspirin may cause concern about worse prognoses when treating blunt hepatic or splenic injuries. This study investigated whether preinjury aspirin yields an increasing need for haemostatic interventions.

Methods: Admission and outpatient records were extracted from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with splenic or hepatic injuries were identified, and those with preinjury nonaspirin APAC or with penetrating injuries were excluded. The primary outcome measurement was the necessity of invasive procedures to stop bleeding, including transarterial embolization (TAE) and surgeries. One-to-two propensity score matching (PSM) was used to minimize selection bias. Multilogistic regression (MLR) analysis was used to identify factors associated with haemostatic interventions.

Results: A total of 20,470 patients had blunt hepatic injuries, and 15,235 had blunt splenic injuries, of whom 691 (3.4%) and 667 (4.4%) used preinjury aspirin, respectively. In the blunt hepatic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (6.1% vs 6.1%, p = 1.000), exploratory laparotomy (3.3% vs 4.3%, p = 0.312), hepatectomy (3.0% vs 2.7%, p = 0.686) or hepatorrhaphy (14.3% vs 15.0%, p = 0.683)). Regarding the blunt splenic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (11.5% vs 10.6%, p = 0.553), splenectomy (43.5% vs 41.4%, p = 0.230) or splenorrhaphy (3.0% vs 3.3%, p = 0.117)). An MLR analysis showed that preinjury aspirin did not increase the need for haemostatic interventions in either cohort.

Conclusions: Preinjury aspirin use is not associated with increased haemostatic procedures in blunt hepatic or splenic injuries.
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http://dx.doi.org/10.1016/j.injury.2021.05.025DOI Listing
May 2021

Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment.

Front Surg 2021 15;8:616320. Epub 2021 Apr 15.

Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Percutaneous cholecystostomy (PC) has become an important procedure for the treatment of acute cholecystitis (AC). PC is currently applied for patients who cannot undergo immediate laparoscopic cholecystectomy. However, the management following PC has not been well-reviewed. The efficacy of PC tubes has already been indicated, and compared to complications of other invasive biliary procedures, complications related to PC are rare. Following the resolution of AC, patients who can tolerate anesthesia and the surgical risk should undergo interval cholecystectomy to reduce the recurrence of biliary events. For patients unfit for surgery, whether owing to comorbidities, anesthesia risks, or surgical risks, expectant management may be applied; however, a high incidence of recurrence has been noted. In addition, several interesting issues, such as the indications for cholangiography via the PC tube, removal or maintenance of the PC catheter before definitive treatment, and timing of elective surgery, are all discussed in this review, and a relevant decision-making flowchart is proposed. PC is an effective and safe intervention, whether as expectant treatment or bridge therapy to definitive surgery. High-level evidence of post-PC care is still necessary to modify current practices.
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http://dx.doi.org/10.3389/fsurg.2021.616320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083985PMC
April 2021

Predicting outcomes of abdominal surgical emergencies in the elderly population using a CT muscle gauge.

Aging Clin Exp Res 2021 Apr 5. Epub 2021 Apr 5.

Division of Trauma and Emergency Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC.

Background: Frailty has been shown to be an independent negative predictor of surgical outcomes in geriatric patients. Traditional measurements of muscle strength and mass are impractical in emergency settings, and computed tomography (CT)-measured skeletal muscle mass has been proposed as an alternative. However, the cutoff values for low muscle mass are still unknown, and their impact on abdominal emergencies in the elderly population is unclear.

Methods: A total of 462 young trauma patients aged 18-40 years were analyzed to establish sex-specific reference cutoff values for the CT-measured muscle index (MI) and muscle gauge (MG) values. The impacts of low MI and MG values were investigated in 1192 elderly patients (aged ≥ 65 years) undergoing abdominal surgery.

Results: The sex-specific cutoff values for MI and MG were determined by adopting European Working Group on Sarcopenia in Older People 2 guidelines. The correlation between MG and aging was significantly stronger than that between MI and ageing. With regard to the MG, the L4 psoas muscle gauge (L4 PMG) was further investigated in an elderly cohort owing to its high predictive value and ease of use in the clinical setting. A low L4 PMG value was an independent risk factor for overall complications and mortality in elderly patients with abdominal emergencies.

Conclusion: The current study was the largest study investigating the correlations between MG values and aging in the Asian population. A low L4 PMG value may help surgeons during preoperative decision making regarding geriatric patients with abdominal emergencies.
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http://dx.doi.org/10.1007/s40520-020-01769-9DOI Listing
April 2021

How much could a low COVID-19 pandemic change the injury trends? A single-institute, retrospective cohort study.

BMJ Open 2021 03 16;11(3):e046405. Epub 2021 Mar 16.

Trauma and Critical Care Center, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan

Objectives: COVID-19 has changed the epidemiology of trauma. However, Taiwan is a country with a low COVID-19 threat, and people's daily lives have remained mostly unchanged during this period. The purpose of this study is to investigate whether the trend of trauma incidence and the service of trauma care is affected by the relatively minor COVID-19 pandemic in Taiwan.

Design: A single-institute, retrograde cohort study.

Setting: An observational study based on the trauma registry of Chang Gung Memorial Hospital (CGMH).

Participants: Trauma patients presented to the emergency department of CGMH in the period of 1 January to 30 June 2020 (week 1 to week 26) were designated as the COVID-19 group, with 1980 patients in total. Patients of the same period in 2015-2019 were designated as the pre-COVID-19 group, with 10 334 patients overall.

Primary And Secondary Outcome Measures: The primary outcome is the incidence of trauma admission. Differences in trauma mechanism, severity, location and outcome were also compared in both groups.

Results: A decrease in trauma incidence during March and April 2020 was noticed. Significant change (p<0.001) in trauma mechanisms was discovered, with decreased burn (5.8% vs 3.6%) and assault (4.8% vs 1.2%), and increased transport accidents (43.2% vs 47.2%) and suicide (0.2% vs 1.0%) in the COVID-19 cohort. A shift in injury locations was also found with a 5% decrement of workplace injuries (19.8% vs 14.8%, p<0.001).

Conclusion: The limited COVID-19 outbreak in Taiwan has led to a decreased incidence of trauma patients, and the reduction is mostly attributed to the decline in workplace injuries.
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http://dx.doi.org/10.1136/bmjopen-2020-046405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969767PMC
March 2021

Impact of highest drain fluid amylase levels on surgical outcomes and postoperative interventions in patients undergoing pancreaticoduodenectomy.

Asian J Surg 2021 Mar 2. Epub 2021 Mar 2.

Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.

Objectives: The clinical significance of the highest drain fluid amylase (DFA) level beyond pancreaticoduodenectomy (PD) postoperative day three (POD 3) remains unclear. This study investigated the impact of highest DFA level beyond POD 3 on postoperative pancreatic fistula (POPF) severity and outcomes of patients undergoing PD with POPF.

Methods: Patient demographics of biochemical POPF and clinically relevant POPF (CR-POPF) were compared. Predictive factors were assessed using binary logistic regression. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of highest DFA (beyond POD 3). We compared length of hospital stay, surgical mortality rates, and need for postoperative interventions by highest DFA level.

Results: Patients with CR-POPF had an older age (p = 0.039), required intraoperative blood transfusion (p = 0.006), and had greater highest DFA levels (p = 0.001) than those with biochemical POPF. The optimal highest DFA cutoff was 2014.5 U/L. Multivariate analysis showed that percentage of patients with intraoperative blood transfusion (p = 0.011; odds ratio, 3.716) and a highest DFA > 2014.5 U/L beyond POD 3 (p = 0.001; odds ratio, 5.722) was predictive of CR-POPF.

Conclusion: Highest DFA > 2014.5 U/L beyond POD 3 is an independent predictor for CR-POPF. At a highest DFA >2014.5 U/L, 30-day surgical mortality rate, length of stay, and need for postoperative interventions did not differ.
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http://dx.doi.org/10.1016/j.asjsur.2021.01.041DOI Listing
March 2021

Changes in trends during the COVID-19 lockdown: An urban, Level-1 trauma centers experience.

Am J Surg 2021 Feb 20. Epub 2021 Feb 20.

Department of Trauma and Burn, Cook County Health, Chicago, IL, USA.

Background: A community lockdown has a profound impact on its citizens. Our objective was to identify changes in trauma patient demographics, volume, and pattern of injury following the COVID-19 lockdown.

Methods: A retrospective review was conducted at a Level-1 Trauma Center from 2017 to 2020.

Results: A downward trend in volume is seen December-April in 2020 (R = 0.9907). February through April showed an upward trend in 2018 and 2019 (R 0.80 and R = 0.90 respectively), but a downward trend in 2020 (R = 0.97). In April 2020, there was 41.6% decrease in total volume, a 47.4% decrease in blunt injury and no decrease in penetrating injury. In contrast to previous months, in April the majority of injuries occurred in home zip codes.

Conclusions: A community lockdown decreased the number of blunt trauma, however despite social distancing, did not decrease penetrating injury. Injuries were more likely to occur in home zip codes.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896123PMC
February 2021

Incidental Findings on Whole-body Computed Tomography in Major Trauma Patients: Who and What?

Am Surg 2021 Feb 26:3134821998685. Epub 2021 Feb 26.

Department of Trauma and Emergency Surgery, 38014Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Purpose: Whole-body computed tomography (WBCT) scans are frequently used for trauma patients, and sometimes, nontraumatic findings are observed. We aimed to investigate the characteristics of patients with nontraumatic findings on WBCT.

Methods: From 2013 to 2016, adult trauma patients who underwent WBCT were enrolled. The proportions of nontraumatic findings in different anatomical regions were studied. Nontraumatic findings were classified and evaluated as clinically important findings and findings that needed no further follow-up or treatment. The characteristics of the patients with nontraumatic findings were analyzed and compared with those of patients without nontraumatic findings.

Results: Two hundred seventeen patients were enrolled in this study during the 3-year study period, and 89 (41.0%) patients had nontraumatic findings. Nontraumatic findings were found more frequently in the abdomen (69.2%) than in the head/neck (17.3%) and chest regions (13.5%). In total, 31.3% of the findings needed further follow-up or treatment. Patients with nontraumatic findings that needed further management were significantly older than those without nontraumatic findings (57.3 vs. 38.9; < .001), particularly those with abdominal nontraumatic findings (57.9 vs. 41.3; < .001). A significantly higher proportion of women were observed in the group with head/neck nontraumatic findings that needed further management than in the group without nontraumatic findings (56.3% vs 24.9%; = .015).

Conclusions: Whole-body computed tomography could provide alternative benefits for nontraumatic findings. Whole-body computed tomography images should be read carefully for nontraumatic findings, particularly for elderly patients or the head/neck region of female patients. A comprehensive program for the follow-up of nontraumatic findings is needed.
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http://dx.doi.org/10.1177/0003134821998685DOI Listing
February 2021

Surviving traumatic cardiac arrest: Identification of factors associated with survival.

Am J Emerg Med 2021 May 15;43:83-87. Epub 2021 Jan 15.

Department of Trauma and Burn Surgery, John H. Stroger Hospital of Cook County, Chicago IL, USA. Electronic address:

Introduction: The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED).

Methods: The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed.

Results: A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99).

Conclusion: Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.
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http://dx.doi.org/10.1016/j.ajem.2021.01.020DOI Listing
May 2021

Age itself or age-associated comorbidities? A nationwide analysis of outcomes of geriatric trauma.

Eur J Trauma Emerg Surg 2021 Jan 27. Epub 2021 Jan 27.

Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA.

Purpose: Geriatric trauma patients present physiological challenges to care providers. A nationwide analysis was performed to evaluate the roles of age alone versus age-associated comorbidities in the morbidity and mortality of elderly patients with blunt abdominal trauma (BAT).

Methods: Patients with BAT registered in the National Trauma Data Bank from 2013 to 2015 were analyzed using propensity score matching (PSM) to evaluate the mortality rate, complication rate, hospital length of stay (LOS), intensive care unit (ICU) LOS and ventilator days between young (age < 65) and elderly (age ≥ 65) patients. An adjusted multivariate logistic regression (MLR) model was also used to evaluate the effect of age itself and age-associated comorbidities on mortality.

Results: There were 41,880 patients with BAT during the study period. In elderly patients, the injury severity score (ISS) decreased with age, but the mortality rate increased inversely (from 5.0 to 13.5%). Under a similar condition and proportion of age-associated comorbidities after a well-batched PSM analysis, elderly patients had significantly higher mortality rates (8.0% vs. 1.9%, p < 0.001), higher complication rates (35.1% vs. 30.6%, p < 0.001), longer hospital LOS (8.9 vs. 8.1 days, p < 0.001), longer ICU LOS (3.7 vs. 2.7 days, p < 0.001) and more ventilator days (1.1 vs. 0.5 days, p < 0.001) than young patients. Furthermore, the MLR analysis showed that age itself served as an independent factor for mortality (odds ratio: 1.049, 95% CI 1.043-1.055, p < 0.001), but age-associated comorbidity was not.

Conclusion: In patients with BAT, age itself appeared to have an independent and deleterious effect on mortality, but age-associated comorbidity did not.
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http://dx.doi.org/10.1007/s00068-020-01595-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7839290PMC
January 2021

Diagnosis-Related Group (DRG)-Based Prospective Hospital Payment System can be well adopted for Acute Care Surgery: Taiwanese Experience with Acute Cholecystitis.

World J Surg 2021 Apr 16;45(4):1080-1087. Epub 2021 Jan 16.

Department of Trauma and Emergency Surgery, Linkou Branch of Chang Gung Memorial Hospital, No. 5, Fuxing St, Guishan Dist, Taoyuan City, 33305, Taiwan.

Background: Laparoscopic cholecystectomy (LC) is a common procedure for cholelithiasis paid by diagnostic-related groups (DRGs) systems. However, acute cholecystitis (AC) patients usually have heterogeneous conditions that compromise the successful implementation of DRGs. We evaluated the quality/efficiency of treating AC patients under the DRG system in Taiwan.

Methods: All AC patients who underwent LC between October 2015 and December 2016 were included. Patient demographics, treatment outcomes, and financial results were analyzed. Patients were reimbursed by one of the two DRG schemes based on their comorbidities/complications (CC): DRG-1, LC without CC; and DRG-2, LC with CC. Hospitals were reimbursed the costs incurred if they were below the lower threshold (balanced sector); with the outlier threshold if costs were between the lower and outlier thresholds (profitable sector); and with the outlier threshold plus 80% of the exceeding cost if costs were higher than the outlier threshold (profit-losing sector).

Results: Among 246 patients, 114 were paid by DRG-1, and 132 were by DRG-2. In total, 195 of 246 patients underwent LC within 1 day after admission, and patients with mild AC had shorter hospital stays than those with moderate or severe AC. The complication rate was 7.3% with only one mortality. In total, 92.1% of patients in DRG-1 and 90.9% of patients in DRG-2 were profitable. The average margin per patient was 11,032 TWD for DRG-1 and 24,993 TWD for DRG-2.

Conclusions: DRGs can be well adopted for acute care surgery, and hospitals can still provide satisfactory services without losing profit.
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http://dx.doi.org/10.1007/s00268-020-05904-5DOI Listing
April 2021

Alternative application of percutaneous cholecystostomy in patients with biliary obstruction.

Abdom Radiol (NY) 2021 06 2;46(6):2891-2899. Epub 2021 Jan 2.

Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.

Purpose: Percutaneous cholecystostomy (PC) is an important modality for acute cholecystitis and has been applied for other clinical scenarios as well. In the present study, we aimed to investigate an alternative use of PC for obstructive jaundice.

Methods: From January 2012 to December 2018, eligible subjects were selected from patients undergoing PC in our institute. The characteristics, spectrum of underlying disease, indication for PC performance, details of the procedure, and treatment effect were all investigated.

Results: During the study period, 1364 patients underwent PC. Seventy patients fulfilled the defined inclusion criteria. While 47 patients were diagnosed with malignant biliary obstruction with or without cholangitis, 23 patients were diagnosed with nonmalignant biliary obstruction and acute cholangitis. There were 63 patients (90%) diagnosed with acute cholangitis. Pancreatic cancer (n = 24, 51%) and advanced malignancy (n = 28, 59%) were noted mostly in the group with malignant biliary obstruction. Treatment effects were proven by laboratory data, including the white blood cell count, C-reactive protein level, and hepatic function.

Conclusion: PC can temporize definitive therapies and serve as an alternative treatment for patients with nonmalignant conditions. For patients with advanced malignancy, PC can serve as a palliative procedure that has a high success rate and low complication rate and effectively relieves biliary obstruction.
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http://dx.doi.org/10.1007/s00261-020-02898-5DOI Listing
June 2021

Is massive hemothorax still an absolute indication for operation in blunt trauma?

Injury 2021 Feb 24;52(2):225-230. Epub 2020 Dec 24.

Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5 Fu-Xing Street, Guishan District, Taoyuan City, Taiwan.

Background: Surgery is usually suggested to treat massive haemothorax (MHT). The MHT criteria are based on penetrating trauma observations in military scenarios; the need for surgery in blunt trauma patients remains questionable. This study aimed to determine the characteristics of blunt trauma patients with MHT who required surgery.

Methods: Patients who presented to the emergency department (ED) with traumatic haemothorax or pneumothorax, heart and lung injuries, and thoracic blood vessel injuries from Jan 1, 2014, to Dec 31, 2018, were reviewed. The inclusion criterion was a chest tube drainage amount that met the MHT criteria. Therapeutic operations were defined as those involving surgical haemostasis; otherwise, operations were considered non-therapeutic. The non-therapeutic operation group included the patients who received nonoperative management. The characteristics of the therapeutic and non-therapeutic operation groups were compared.

Results: Forty-four patients were enroled in the study. Six patients received conservative treatment and were discharged uneventfully. Eleven patients underwent non-therapeutic operations. The patients with surgical bleeding had a high pulse rate (125.0 (111.0, 135.0) vs. 116.0 (84.0, 121.0) bpm, p = 0.013); low systolic blood pressure (SBP) after resuscitation (106.0 (84.0, 127.0) vs. 121.0 (116.0, 134.0) mmHg, p = 0.040); low pH (7.2 (7.2, 7.3) vs. 7.4 (7.3, 7.4), p = 0.002); and low bicarbonate (17.8 (14.6, 21.5) vs. 21.4 (17.0, 21.5) mEq/L, p = 0.038), low base excess (-9.1 (-13.4, -4.5) vs. -3.8 (-10.1, -0.7), p = 0.028), and high lactate (5.7 (3.3, 7.8) vs. 1.8 (1.7, 2.8) mmol/L, p = 0.002) levels.

Conclusion: Conservative treatment could be performed selectively in patients with MHT. Lactate could be a predictor of the need for surgical intervention in blunt trauma patients with MHT.
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http://dx.doi.org/10.1016/j.injury.2020.12.016DOI Listing
February 2021

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures.

Surg Endosc 2020 Nov 30. Epub 2020 Nov 30.

Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, No. 5 Fuxing St., Guishan District, Taoyuan City, 33305, Taiwan.

Background: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18.

Method: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared.

Results: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC.

Conclusion: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.
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http://dx.doi.org/10.1007/s00464-020-08162-7DOI Listing
November 2020

Artificial intelligence-based education assists medical students' interpretation of hip fracture.

Insights Imaging 2020 Nov 23;11(1):119. Epub 2020 Nov 23.

Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsing Street, Kwei-Shan District, Taoyuan, Taiwan.

Background: With recent transformations in medical education, the integration of technology to improve medical students' abilities has become feasible. Artificial intelligence (AI) has impacted several aspects of healthcare. However, few studies have focused on medical education. We performed an AI-assisted education study and confirmed that AI can accelerate trainees' medical image learning.

Materials: We developed an AI-based medical image learning system to highlight hip fracture on a plain pelvic film. Thirty medical students were divided into a conventional (CL) group and an AI-assisted learning (AIL) group. In the CL group, the participants received a prelearning test and a postlearning test. In the AIL group, the participants received another test with AI-assisted education before the postlearning test. Then, we analyzed changes in diagnostic accuracy.

Results: The prelearning performance was comparable in both groups. In the CL group, postlearning accuracy (78.66 ± 14.53) was higher than prelearning accuracy (75.86 ± 11.36) with no significant difference (p = .264). The AIL group showed remarkable improvement. The WithAI score (88.87 ± 5.51) was significantly higher than the prelearning score (75.73 ± 10.58, p < 0.01). Moreover, the postlearning score (84.93 ± 14.53) was better than the prelearning score (p < 0.01). The increase in accuracy was significantly higher in the AIL group than in the CL group.

Conclusion: The study demonstrated the viability of AI for augmenting medical education. Integrating AI into medical education requires dynamic collaboration from research, clinical, and educational perspectives.
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http://dx.doi.org/10.1186/s13244-020-00932-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683624PMC
November 2020

Potential use of peptic ulcer perforation (PULP) score as a conversion index of laparoscopic-perforated peptic ulcer (PPU) repair.

Eur J Trauma Emerg Surg 2020 Nov 21. Epub 2020 Nov 21.

Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan 333, Linkou, Taiwan.

Background: Laparoscopic repair is a well-accepted treatment modality for perforated peptic ulcer (PPU). However, intraoperative conversion to laparotomy is still not uncommon. We aimed to identify preoperative factors strongly associated with conversion.

Methods: A retrospective review of records of all PPU patients treated between January 2011 and July 2019 was performed. Patients were divided into three groups: laparoscopic repair (LR), conversion to laparotomy (CL), and primary laparotomy (PL). Patient demographics, operative findings, and outcomes were compared between the groups. Logistic regression analyses were performed, taking conversion as the outcome.

Results: Of 822 patients, there were 236, 45, and 541 in the LR, CL, and PL groups, respectively. The conversion rate was 16%. Compared with those in the LR group, patients in the CL group were older (p < 0.001), had higher PULP scores (p < 0.001), had higher ASA scores (p < 0.001) and had hypertension (p = 0.003). PULP score was the only independent risk factor for conversion. The area under the curve (AUC) for the PULP score to predict conversion was 75.3%, with a best cut-off value of ≥ 4. The operative time was shorter for PL group patients than for CL group patients with PULP scores ≥ 4. For patients with PULP scores < 4, LR group patients had a shorter length of stay than PL group patients.

Conclusion: The PULP score may have utility in predicting and minimizing conversion for laparoscopic PPU repair. Laparoscopic repair is the procedure of choice for PPU patients with PULP scores < 4, while open surgery is recommended for those with PULP scores ≥ 4.
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http://dx.doi.org/10.1007/s00068-020-01552-5DOI Listing
November 2020

Association between Torso Gunshot Wound Volumes of Trauma Centers and Outcomes of Torso Gunshot Wound Patients. A Propensity-Matched Nationwide Cohort Study.

Prehosp Emerg Care 2021 Mar 9:1-9. Epub 2021 Mar 9.

: The number and type of patients treated by trauma centers can vary widely because of a number of factors. There might be trauma centers with a high volume of torso GSWs that are not designated as high-level trauma centers. We proposed that, for torso gunshot wounds (GSWs), the treating hospital's trauma volume and not its trauma center level designation drives patient prognosis. The National Trauma Data Bank was queried for torso GSWs. The characteristics of torso GSWs in trauma centers with different volumes of torso GSWs were compared. The association between torso GSW volumes of trauma centers and the outcomes of torso GSWs were evaluated with propensity score matching (PSM) and multivariate logistic regression (MLR) analysis. There were 618 trauma centers that treated 14,804 torso GSW patients in two years (2014-2015). In 191 level I trauma centers, 82 of them (42.9%, 82/191) treated <1 torso GSW per month. After well-balanced PSM, patients who were treated in higher volume trauma centers (≥9 torso GSWs/month) had a significantly lower mortality rate (7.9% vs. 9.7%). Patients treated in trauma centers with ≥9 torso GSWs/month had a 30.9% (odds ratio = 0.764) lower probability of death than if sent to trauma centers with <9 torso GSWs/month. Treatment in level I or II trauma centers did not significantly affect mortality. There is an uneven distribution of torso GSWs among trauma centers. Torso GSWs treated in trauma centers with ≥9 torso GSWs/month have significantly superior outcomes with regard to survival.
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http://dx.doi.org/10.1080/10903127.2020.1852353DOI Listing
March 2021

An Image-Based Mobile Health App for Postdrainage Monitoring: Usability Study.

J Med Internet Res 2020 08 28;22(8):e17686. Epub 2020 Aug 28.

Department of Physical Medicine and Rehabilitation, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan.

Background: The application of mobile health (mHealth) platforms to monitor recovery in the postdischarge period has increased in recent years. Despite widespread enthusiasm for mHealth, few studies have evaluated the usability and user experience of mHealth in patients with surgical drainage.

Objective: Our objectives were to (1) develop an image-based smartphone app, SurgCare, for postdrainage monitoring and (2) determine the feasibility and clinical value of the use of SurgCare by patients with drainage.

Methods: We enrolled 80 patients with biliary or peritoneal drainage in this study. A total of 50 patients were assigned to the SurgCare group, who recorded drainage monitoring data with the smartphone app; and 30 patients who manually recorded the data were assigned to the conventional group. The patients continued to record data until drain removal. The primary aim was to validate feasibility for the user, which was defined as the proportion of patients using each element of the system. Moreover, the secondary aim was to evaluate the association of compliance with SurgCare and the occurrence of unexpected events.

Results: The average submission duration was 14.98 days, and the overall daily submission rate was 84.2%. The average system usability scale was 83.7 (SD 3.5). This system met the definition of "definitely feasible" in 34 patients, "possibly feasible" in 10 patients, and "not feasible" in 3 patients. We found that the occurrence rates of complications in the SurgCare group and the conventional group were 6% and 26%, respectively, with statistically significant differences P=.03. The rate of unexpected hospital return was lower in the SurgCare group (6%) than in the conventional groups (26%) (P=.03).

Conclusions: Patients can learn to use a smartphone app for postdischarge drainage monitoring with high levels of user satisfaction. We also identified a high degree of compliance with app-based drainage-recording design features, which is an aspect of mHealth that can improve surgical care.
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http://dx.doi.org/10.2196/17686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486677PMC
August 2020

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense.

World J Emerg Surg 2020 08 17;15(1):48. Epub 2020 Aug 17.

Department of Trauma and Emergency Surgery, Linkou branch of Chang Gung Memorial Hospital, 5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan.

Background: The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity.

Methods: Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.

Results: Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered.

Conclusions: Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.
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http://dx.doi.org/10.1186/s13017-020-00328-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433075PMC
August 2020

Authors' Reply: Unstable Hemodynamics is not Always Predictive of Failed Nonoperative Management in Blunt Splenic Injury.

World J Surg 2020 10 15;44(10):3578-3579. Epub 2020 Jul 15.

Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan.

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http://dx.doi.org/10.1007/s00268-020-05697-7DOI Listing
October 2020

Unstable Hemodynamics is not Always Predictive of Failed Nonoperative Management in Blunt Splenic Injury.

World J Surg 2020 09;44(9):2985-2992

Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan.

Background: The advanced technology of interventional radiology may contribute to a rapid and timely angioembolization for hemostasis. We hypothesized that unstable hemodynamics is no longer an absolute contraindication of nonoperative management (NOM) in blunt splenic injury patients using rapid angioembolization.

Methods: From January 2009 to December 2019, blunt splenic injury patients with unstable hemodynamics [initial pulse >120 beats/min or systolic blood pressure <90 mm Hg] were included. Either emergency surgery or angioembolization was performed for hemostasis because of their unstable status. The characteristics of patients who underwent angioembolization or surgery were compared in each group (all patients, patients with hypotension, patients without response to resuscitation and hypotensive patients without response to resuscitation).

Results: A total of 73 patients were included in the current study. With respect to all patients, 68.5% (N = 50) of patients underwent NOM with angioembolization for hemostasis. Patients who underwent angioembolization for hemostasis had a significantly lower base deficit (5.3 ± 3.8 vs. 8.3 ± 5.2 mmol/L, p = 0.006) and a higher proportion of response to resuscitation (82.0% vs. 30.4%, p < 0.001) than did patients who underwent surgery. However, there was no significant difference in the proportion of hypotension (58.0% vs. 65.2%, p = 0.558) between these two groups. There were 44 patients with hypotension, and the angioembolization could be performed in 65.9% (N = 29) of them. Patients who underwent angioembolization had a significantly higher proportion of response to resuscitation than did patients who underwent surgery (89.7% vs. 33.3%, p < 0.001). In hypotensive patients without response to resuscitation (N = 13), 23.1% (N = 3) of the patients underwent angioembolization successfully. There was no significant difference in time to hemostasis procedure between patients who underwent angioembolization or surgery (24.7 ± 2.1 vs. 26.3 ± 16.7 min, p = 0.769). The demographics, vital signs, blood transfusion amount, injury severity, mortality rate and length of stay of patients who underwent angioembolization were not significantly different from patients who underwent surgery in each group.

Conclusions: With a short preparation time of angioembolization, the NOM could be performed selectively for hemodynamically unstable patients with blunt splenic injury. The base deficit serves as an early detector of the requirement of surgical treatment.
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http://dx.doi.org/10.1007/s00268-020-05562-7DOI Listing
September 2020

Obesity May Require a Higher Level of Trauma Care: A Propensity-Matched Nationwide Cohort Study.

Prehosp Emerg Care 2021 May-Jun;25(3):361-369. Epub 2020 May 5.

Objective: Stable patients with less severe injuries are not necessarily triaged to high-level trauma centers according to current guidelines. Obese patients are prone to comorbidities and complications. We hypothesized that stable obese patients with low-energy trauma have lower mortality and fewer complications if treated at Level-I/II trauma centers. Blunt abdominal trauma (BAT) patients with systolic blood pressures ≥90mmHg, Glasgow coma scale ≥14, and respiratory rates at 10-29 were derived from the National Trauma Data Bank between 2013-2015. Per current triage guidelines, these patients are not necessarily triaged to high-level trauma centers. The relationship between obesity and mortality of stable BAT patients was analyzed. A subset analysis of patients with injury severity scores (ISS) <16 was performed with propensity score matching (PSM) to evaluate outcomes between Level-I/II and Level-III/IV trauma centers. Outcomes of obese patients were compared between Level-I/II and Level-III/IV trauma centers. Non-obese patients were analyzed as a control group using a similar PSM cohort analysis. 48,043 stable BAT patients in 707 trauma centers were evaluated. Non-survivors had a significantly higher body mass index (BMI) (28.7 vs. 26.9,  < 0.001) and higher proportion of obesity (35.6% vs. 26.5%,  < 0.001) than survivors. After a PSM (1,502 obese patients: 751 in Level-I/II trauma centers and 751 in Level-III/IV trauma centers), obese patients treated in Level-I/II trauma centers had significantly lower complication rates than obese patients treated in other trauma centers (20.2% vs. 26.6%, standardized difference = 0.151). The complication rate of obese patients treated at Level-I/II trauma centers was 20.6% lower than obese patients treated at other trauma centers. Obesity plays a role in the mortality of stable BAT patients. Obese patients with ISS < 16 have lower complication rates at Level-I/II trauma centers compared to obese patients treated at other trauma centers. Obesity may be a consideration for triaging to Level-I/II trauma centers.
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http://dx.doi.org/10.1080/10903127.2020.1755754DOI Listing
May 2020

Surgical outcomes of patients with maintained or removed percutaneous cholecystostomy before intended laparoscopic cholecystectomy.

J Hepatobiliary Pancreat Sci 2020 Aug 1;27(8):461-469. Epub 2020 May 1.

Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Background: Percutaneous cholecystostomy (PC) followed by definitive cholecystectomy is an alternative treatment for acute cholecystitis (AC). We retrospectively investigated the impact of PC tube removal before definitive cholecystectomy on surgical outcomes.

Methods: From 2012 to 2017, 942 AC patients underwent PC at a single institute. Eligible patients were selected according to inclusion criteria. Demographic data, clinical and laboratory parameters, and treatment outcomes were extracted from medical records. Categorization of patients and subsequent subgroup analysis were based on cholangiography.

Results: The rate of emergent cholecystectomy in the PC tube removal group was higher than that in the PC tube preserved group (OR = 2.969, 95% CI 1.334-6.612, P = 0.008). In subgroup analysis of patients with patent bile flow under cholangiography, the rate of emergent cholecystectomy was higher in the PC tube removal group (OR = 3.173, 95% CI 1.182-8.523, P = 0.022), though the incidence of complications was higher in the PC tube preserved group (P = 0.012). In addition, routine preoperative cholangiography had no clinical impact on surgical outcome.

Conclusion: Percutaneous cholecystostomy tube can be removed before subsequent LC to avoid postoperative complications, though removal of the PC tube is associated with an increased likelihood of emergent cholecystectomy.
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http://dx.doi.org/10.1002/jhbp.740DOI Listing
August 2020

The psoas muscle index distribution and influence of outcomes in an Asian adult trauma population: an alternative indicator for sarcopenia of acute diseases.

Eur J Trauma Emerg Surg 2020 Apr 10. Epub 2020 Apr 10.

Division of Trauma and Emergency Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Background: Sarcopenia has been shown to be an independent negative predictor in various diseases. The measurement of pre-defined criteria of skeletal muscle in patients with acute disease is usually unavailable. Therefore, we evaluate the psoas muscle area based on computed tomography (CT) imaging as an alternative for sarcopenia in an Asian trauma population.

Methods: 939 trauma patients were enrolled and had CT imaging performed primarily for trauma indications. The cross-sectional area of psoas muscle at the base of the fourth lumbar vertebral was measured on these CTs. Psoas muscle index (PMI) was calculated and analyzed to determine sex-specific cut-off values to define the "extremely low psoas muscle index" (ELPMI) group.

Results: Psoas muscle index was significantly higher in males (1065.09 ± 230.51 mm/m in males vs 719.57 ± 147.39 mm/m in females, p < 0.001) and decreased gradually with aging (p < 0.001). PMI of the subset of patients aged 18-40 (n = 462) weas analyzed to determine sex-specific cut-off values for ELPMI. PMI cut-off values for ELPMI (2 SD below mean) were 675 mm/m for males and 490 mm/m for females. The entire trauma cohort was further analyzed, and ELPMI was identified as an independent risk factor for a longer length of intensive unit stay (β coefficient = 3.881, p = 0.011).

Conclusion: Data from young trauma adults were used to establish cut-off values for ELPMI, which is a longer ICU stay predictor. These cut-off values for ELPMI may apply to other acute disease entities.
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http://dx.doi.org/10.1007/s00068-020-01360-xDOI Listing
April 2020

Patients With Combined Thermal and Intraabdominal Injuries: More Salvageable Than Not.

J Burn Care Res 2020 07;41(4):835-840

Department of Trauma and Burn Surgery, Cook County Health, Chicago, Illinois.

This study aims to better characterize the course and outcome of the uncommon subset of trauma patients with combined thermal and intraabdominal organ injuries. The National Trauma Data Bank was queried for burn patients with intraabdominal injury treated in all U.S. trauma centers from July 1, 2011 to June 30, 2015. General demographics, Glasgow coma scale (GCS), shock index (SI), Abbreviated Injury Scale (AIS) for burn, Injury Severity Score (ISS), blood transfusions, and abdominal surgery were evaluated. During the 5-year study period, there were 334 burn patients with intraabdominal injury, 39 (13.2%) of which received abdominal surgery. Burn patients who underwent operations had more severe injuries reflected by higher SI, AIS, ISS, blood transfusion, and worse outcomes including higher mortality, longer hospital and ICU length of stay, and more ventilator days compared to patients who did not undergo an operation. Nonsurvivors also exhibited more severe injuries, and a higher proportion received abdominal operation compared to survivors. Multivariate logistic regression analysis revealed that GCS on arrival, SI, AIS, ISS, blood transfusion, and abdominal operation to be independent risk factors for mortality. Propensity score matching to control covariables (mean age, systolic blood pressure on arrival, GCS on arrival, SI, ISS, time to operation, blood transfusion, and comorbidities) showed that of trauma patients who received abdominal operation, those with concomitant burn injury exhibited a higher rate of complications but no significant difference in mortality compared to those without burns, suggesting that patients with concomitant burns are not less salvageable than nonburned trauma patients.
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http://dx.doi.org/10.1093/jbcr/iraa052DOI Listing
July 2020

Early brain computed tomographic angiography to screen for blunt cerebrovascular injuries in patients with polytrauma: Is it necessary?

Am J Emerg Med 2021 01 20;39:121-124. Epub 2020 Jan 20.

Department of Surgery, Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan. Electronic address:

Background: Early diagnosis of blunt cerebrovascular injury (BCVI) is among the most difficult challenges in trauma treatment. This study aimed to determine the optimal timing of computed tomographic angiography (CTA) screening for suspicious BCVI in patients with polytrauma.

Methods: We reviewed the trauma registry and medical records of patients with head and neck injuries from a Level I trauma center between January 2012 and December 2016. Those receiving CTA within 24 h of presentation at the emergency department were the primary CTA group; those who received CTA after 24 h were the delayed CTA group. The basic demographics, indications for CTA, CTA severity grading, and outcomes were compared.

Results: In all, 228 patients received brain CTA. Most were male (75%); the mean age was around 40 years. The 38 patients with positive BCVI had a significantly higher ratio of severe chest trauma (52.6% vs 25.8%, p = 0.001); 26 of them received primary CTA and 12 received delayed CTA. Patients with polytrauma predominated in the delayed CTA group (66.7% vs 30.8%, p = 0.037). Of the patients in the primary CTA group, 26.9% received CTA due to symptomatic presentation (p = 0.047). Patients in the delayed group had better neurological outcomes (83% neurologically intact, vs 38.5%, p = 0.01) and lower mortality (0% vs 26.9%, p = 0.047). The only independent positive prognostic factor was initial motor response ≥M5 (Odds Ratio 21.46, 95% Confidence Interval 2.01-228.71).

Conclusions: For patients with polytrauma, performing brain CTA for BCVI screening in the first 24-h or after may not affect clinical outcome. Initial motor response is the sole indicator for outcome. Delaying the study for to the next 24-hour can be considered in such patients, when regarding hemodynamic stability, the dose of contrast medium, and the radiation exposure.
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http://dx.doi.org/10.1016/j.ajem.2020.01.037DOI Listing
January 2021

Video Coaching Improving Contemporary Technical and Nontechnical Ability in Laparoscopic Education.

J Surg Educ 2020 May - Jun;77(3):652-660. Epub 2019 Dec 16.

Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan. Electronic address:

Objective: A video coaching (VC) system has been developed in surgical education. This study compares the educational effect on technical and nontechnical skills of the VC method for teaching laparoscopic surgery.

Design: We conducted a prospectively randomized study of an education program to teach laparoscopic procedures.

Setting: The study was performed at the Chang Gung Memorial Hospital, a university hospital in Taiwan.

Participants: We enrolled sixteen first- or second-year surgical residents.The participants were randomized into VC and conventional teaching (CT) groups, and their surgical skills were judged by the Global Operation Assessment of Laparoscopic Skills (GOALS) and the Objective Structured Assessment of Technical Skills (OSATS). Nontechnical skills were evaluated by the Non-Technical Skills for Surgeons (NOTSS) assessment and self-efficacy questionnaires (SEQs). After the program, posttraining scores were compared to assess improvements.

Results: The 16 enrolled participants finished the entire course and completed all the videos during the study period. Comparing the VC and CT groups, we found that the pretraining GOALS, OSATS, NOTSS and SEQ scores were similar between both groups. However, after training, the OSATS score gain was higher in the VC groupthan in the CT group (9.25 ± 2.05 vs. 6.50 ± 1.51, p=0.009). Regarding nontechnical skills, the NOTSS score improved more in the VC group than in the CT group (5.50 ± 0.93 vs. 4.25 ± 0.89, p=0.015). The SEQ score was also higher in the VC group (32.13 ± 2.10) than in the CT group (29.50 ± 1.77), with a significant difference (p=0.018).

Conclusion: VC can help surgeons build their expertise using a more accessible method. Additionally, VC can shorten the learning curve and improve self-efficacy, thereby contributing to surgeons' education.
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http://dx.doi.org/10.1016/j.jsurg.2019.11.012DOI Listing
June 2021

Incidence of, Risk Factors for, and Mortality Associated With Severe Acute Kidney Injury After Gunshot Wound.

JAMA Netw Open 2019 12 2;2(12):e1917254. Epub 2019 Dec 2.

Division of Nephrology, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois.

Importance: Acute kidney injury increases the risk of mortality in hospitalized patients. However, incidence of severe acute kidney injury (SAKI) and its association with mortality in civilians with gunshot wounds (GSWs) is not known.

Objective: To determine the incidence of and risk factors associated with SAKI and acute kidney injury requiring dialysis (AKI-D) after GSWs and the association of SAKI and AKI-D with mortality among civilians in the United States.

Design, Setting, And Participants: This retrospective cross-sectional study included civilians with GSW reported to the National Trauma Data Bank between July 1, 2010, and June 30, 2015. Torso GSWs were included in study; GSWs to the head were excluded. The data were analyzed between September and November 2018.

Exposure: Civilians with GSW.

Main Outcomes And Measures: Incidence of SAKI and AKI-D; association of SAKI and AKI-D with mortality.

Results: Most of the 64 059 civilian GSWs affected men (57 431 [89.7%]) and racial/ethnic minorities (36 205 [56.5%] African American individuals; 9681 [15.1%] Hispanic individuals). Incidence of SAKI was 2.3% (1450 of 64 059), and incidence of AKI-D was 0.9% (588 of 64 059). On multivariate analysis, SAKI was associated with older age (odds ratio [OR], 1.02; 95% CI, 1.01-1.02; P < .001), male sex (OR, 1.37; 95% CI, 1.12-1.66; P = .002), diabetes (OR, 1.55; 95% CI, 1.20-2.00; P = .001), hypertension (OR, 1.76; 95% CI, 1.46-2.11; P < .001), Glasgow Coma Scale score (OR, 0.98; 95% CI, 0.96-0.99; P = .002), sepsis (OR, 13.83; 95% CI, 11.77-16.24; P < .001), hollow viscus injury (OR, 2.31; 95% CI, 2.05-2.59; P < .001), and injury severity score (OR, 1.02; 95% CI, 1.01-1.02; P < .001); AKI-D was associated with systolic blood pressure (OR, 0.99; 95% CI, 0.99-1.00; P < .001), sepsis (OR, 1.56; 95% CI, 1.18-2.04; P = .001), and injury severity score (OR, 1.01; 95% CI, 1.01-1.02; P = .001). Mortality was significantly higher in patients with AKI-D (167 of 588 patients [28.4%]) compared with patients with SAKI (172 of 862 [20.0%]) and no SAKI or AKI-D (5521 of 62 609 [8.8%]) (P < .001). Mortality was associated with older age (OR, 1.01; 95% CI, 1.01-1.01; P < .001), systolic blood pressure (OR, 0.997; 95% CI, 0.997-0.998; P < .001), Glasgow Coma Scale score (OR, 0.87; 95% CI, 0.87-0.88; P < .001), SAKI (OR, 2.32; 95% CI, 1.93-2.79; P < .001), AKI-D (OR, 1.46; 95% CI, 1.12-1.90; P < .001), hollow viscus injury (OR, 1.87; 95% CI, 1.76-1.98; P < .001), and higher injury severity score (OR, 1.01; 95% CI, 1.01-1.01; P < .001). After matching for variables except SAKI or AKI-D, patients with SAKI were twice as likely to die than patients without SAKI (320 of 1391 [23.0%] vs 158 of 1391 [11.4%]; P < .001).

Conclusions And Relevance: In this cross-sectional study, SAKI among civilians who experienced GSWs was associated with mortality.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.17254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991197PMC
December 2019

Inequality of trauma care under a single-payer universal coverage system in Taiwan: a nationwide cohort study from the National Health Insurance Research Database.

BMJ Open 2019 11 12;9(11):e032062. Epub 2019 Nov 12.

Trauma and Critical Care Center, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan

​OBJECTIVES: To assess the impact of lower socioeconomic status on the outcome of major torso trauma patients under the single-payer system by the National Health Insurance (NHI) in Taiwan. ​DESIGN: A nationwide, retrospective cohort study. ​SETTING: An observational study from the NHI Research Database (NHIRD), involving all the insurees in the NHI. ​PARTICIPANTS: Patients with major torso trauma (injury severity score ≥16) from 2003 to 2013 in Taiwan were included. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify trauma patients. A total of 64 721 patients were initially identified in the NHIRD. After applying the exclusion criteria, 20 009 patients were included in our statistical analysis. ​PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was in-hospital mortality, and we analysed patients with different income levels and geographic regions. Multiple logistic regression was used to control for confounding variables. ​RESULTS: In univariate analysis, geographic disparities and low-income level were both risk factors for in-hospital mortality for patients with major torso trauma (p=0.002 and <0.001, respectively). However, in multivariate analysis, only a low-income level remained an independent risk factor for increased in-hospital mortality (p<0.001). ​CONCLUSION: Even with the NHI, wealth inequity still led to different outcomes for major torso trauma in Taiwan. Health policies must focus on this vulnerable group to eliminate inequality in trauma care.
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http://dx.doi.org/10.1136/bmjopen-2019-032062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858192PMC
November 2019

Obesity is Associated with Worse Outcomes Among Abdominal Trauma Patients Undergoing Laparotomy: A Propensity-Matched Nationwide Cohort Study.

World J Surg 2020 03;44(3):755-763

Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 1950 West Polk Street, 8th floor, Chicago, IL, 60612, USA.

Introduction: Obesity is associated with increased morbidity and mortality in abdominal trauma patients. The characteristics of abdominal trauma patients with poor outcomes related to obesity require evaluation. We hypothesize that obesity is related to increased mortality and length of stay (LOS) among abdominal trauma patients undergoing laparotomies.

Methods: Abdominal trauma patients were identified from the National Trauma Data Bank between 2013 and 2015. Patients who received laparotomies were analyzed using propensity score matching (PSM) to evaluate the mortality rate and LOS between obese and non-obese patients. Patients without laparotomies were analyzed as a control group using PSM cohort analysis.

Results: A total of 33,798 abdominal trauma patients were evaluated, 10,987 of them received laparotomies. Of these patients, the proportion of obesity in deceased patients was significantly higher when compared to the survivors (33.1% vs. 26.2%, p < 0.001). Elevation of one kg/m of body mass index independently resulted in 2.5% increased odds of mortality. After a well-balanced PSM, obese patients undergoing laparotomies had significantly higher mortality rates [3.7% vs. 2.4%, standardized difference (SD) = 0.241], longer hospital LOS (11.1 vs. 9.6 days, SD = 0.135), and longer intensive care unit LOS (3.5 vs. 2.3 days, SD = 0.171) than non-obese patients undergoing laparotomies.

Conclusions: Obesity is associated with increased mortality in abdominal trauma patients who received laparotomies versus those who did not. Obesity requires a careful evaluation of alternatives to laparotomy in injured patients.
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http://dx.doi.org/10.1007/s00268-019-05268-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223826PMC
March 2020