Gallbladder perforation is a rare complication following blunt abdominal trauma, largely due to its anatomical protection within the liver parenchyma. We present the case of a male in his 50s who sustained multiple traumatic injuries following high-impact motor vehicle collision. He was initially admitted with haemodynamic compromise necessitating emergency trauma laparotomy, splenectomy and a traumatic diaphragmatic hernia repair. There was no evidence of gallbladder or liver injury in the preoperative abdominal CT scan or laparotomy. Despite this, he developed new RUQ pain, anaemia and early signs of sepsis on day 17 day after his initial presentation with repeat imaging confirming gallbladder perforation consistent with acalculous cholecystitis in the context of critical illness. This was managed radiologically with a percutaneous cholecystostomy drain. This case illustrates the diagnostic challenges and management of acalculous cholecystitis with perforation in critical illness, highlighting ischaemia, biliary stasis, and hypoperfusion mechanisms.

BACKGROUND:To report management and survival outcomes of gallbladder cancer (GBC) in the United Kingdom and to identify prognostic factors associated with disease-free survival (DFS) and overall survival (OS). METHODS:Patients undergoing surgery for GBC between January 2014 and December 2022 across 24 UK centres were included. Demographic, treatment, histopathological, and survival data were analysed. RESULTS:516 patients underwent surgery for GBC, with a median follow-up of 25 months. Patients with T3-T4 tumours more frequently presented with jaundice, had non-incidental disease, and underwent major hepatectomy compared with those with T1-T2 tumours. Advanced stage, nodal metastasis, vascular invasion, and perineural invasion were more common in patients undergoing major hepatectomy, which was also associated with higher major morbidity and 30-day mortality. Propensity score-matched analysis demonstrated no significant benefit in DFS or OS among patients who received adjuvant therapy compared with those who did not. On multivariable analysis, T3-T4 stage, nodal disease, and perineural invasion predicted poorer DFS, while T3-T4 stage and nodal disease predicted worse OS. DISCUSSION:This nationwide study demonstrates the evolution of management practices for GBC in the UK. Adverse tumour biology remains the principal determinant of survival following surgery for GBC.

Abstract Background Patients with severe liver injury may carry a high risk of complications with significant mortality. Non-operative management (NOM) is increasingly common for severe injuries and may be associated with lower morbidity when compared with surgery. Objective To evaluate the incidence of NOM for severe liver trauma (American Association for the Surgery of Trauma (AAST) Grade IV and V) and compare outcomes for NOM vs operative management. Methods All patients admitted between 2012–2022 with severe liver trauma to Birmingham and Nottingham Major Trauma Centres (MTCs) were identified from a validated dataset. Outcomes were compared between those managed by surgery vs treated by NOM. Adjusted multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for surgical management, survival rates, and development of liver-specific complications (adjusting for age, sex, ISS, AAST grade, polytrauma). Results There were 190 patients; median age 28 years (IQR 20–41); 134 (71%) were male. Median ISS was 27 (IQR 17–41). Overall mortality was 7% (14/190). 122/190 (64%) patients were managed initially by NOM, with only 8/122 (7%) requiring subsequent surgery. Multivariable logistic regression models showed higher ISS, lower SBP on admission, Grade V injuries and penetrating trauma to be independent predictors for surgical treatment. 34/190(18%) patients had liver-specific complications. There was no difference between NOM and operative management groups for 30-day mortality (p = 0.145), but patients in the NOM group had shorter ICU (p < 0.001) and total lengths of stay (p < 0.001) compared to the operative group. Conclusion In this modern MTC setting, a high proportion of patients with severe liver trauma were managed by NOM with a low failure rate. Overall mortality rate was low, but liver-specific complications were common. These data support the evolution of traumatic liver injury management in the UK and favour NOM even in severe liver injuries where patient physiology allows. Trial registration This study was approved by Nottingham University Hospital Clinical Audit Team (ID Reference 22-709C) and University Hospitals Birmingham NHS Foundation Trust Clinical Audit Registration and Management System (ID Reference CARMS 19146). Consent for participation in the study was not obtained as this was a large retrospective audit with anonymised data. Level of evidence Level III.

BACKGROUND:The primary aim of this study was to provide contemporary, real-world data on the management approaches and survival outcomes of patients with incidental gallbladder cancer (GBC) following cholecystectomy in the UK. The secondary aim was to identify prognostic factors associated with survival. METHODS:Patients diagnosed with incidental GBC following cholecystectomy between January 2014 and December 2022 across 24 centres were included. Data collected comprised demographics, treatment details, histopathological findings, and survival outcomes. RESULTS:During the study interval, 285 patients had incidental GBC. The median follow-up was 31 months, with 5-year disease-free survival (DFS) and overall survival (OS) of 41.5% and 45.1% respectively. Of the 193 patients (67.7%) who underwent liver resection, most (97.9%) underwent segment 4B/5 resection. Patients with incidental GBC who underwent liver resection had significantly improved DFS (51 versus 15 months, P < 0.001) and OS (72 versus 26 months, P < 0.001) compared with those who did not. In addition, patients who completed adjuvant chemotherapy had better DFS (35 versus 15 months, P = 0.021) and OS (47 versus 26 months, P = 0.009) compared with those who did not. On multivariable analysis, nodal metastases were independently associated with poorer DFS (HR 2.04 (95% c.i. 1.30 to 3.20), P = 0.002), while advanced tumour (T3-T4) stage (HR 1.70 (95% c.i. 1.04 to 2.77), P = 0.034) and nodal metastases (HR 2.15 (95% c.i. 1.33 to 3.48), P = 0.002) predicted poorer OS. CONCLUSION:Patients who underwent liver resection after incidental GBC had significantly better survival than those who did not proceed to further surgery. Adverse tumour biology was associated with poorer survival.

Background: Traumatic rib fractures cause significant acute pain. Patients are at risk of hypoventilation, atelectasis, hypoxia, retained secretions, pneumonia, respiratory failure, and death. Effective analgesia is thought to reduce these adverse outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous, and epidural routes of administration. Erector spinae plane (ESP) block, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking. Methods: To determine if a definitive trial of ESP block and catheter in rib fractures is possible, we conducted a multicentre, randomised, controlled pilot study with feasibility assessment. Adults with rib fractures were randomised in a 1:1 ratio to either (i) ESP blockade and catheter, or (ii) placebo ESP blockade and catheter, both for 72 h. In addition, all participants received multimodal analgesia. Participants and outcome assessors were blinded. The primary feasibility outcomes were recruitment rate (target: ≥1.11 participants/site/month), retention rate (target: ≥80%), and trial acceptability assessed by staff interview. Pre-specified red–amber–green criteria were agreed to determine feasibility of a future definitive clinical trial on this topic. Results: Twenty-five participants (mean [standard deviation] age 57 [16] yr, number of rib fractures 5 [3]) were recruited from three UK major trauma centres at a rate of 0.69 participants per site per month. Retention to 6-week follow-up was 80%. Based on our criteria, the current study design is not feasible for adoption into a definitive trial. For future research in this area, we recommend substantial modification to (i) the intervention, (ii) means of bias reduction, and (iii) timing and nature of outcome measure assessments. Conclusions: Based on pre-specified criteria, a definitive examination of the clinical effectiveness of ESP block in the analgesic management of adults after blunt force chest wall injury is only feasible if substantial amendments to trial processes piloted in this study are undertaken. An open-label assessment of single-shot ESP block, applying patient-reported average pain intensity of the first 24 h as the primary outcome, and conducted at sites with established ESP analgesic pathways, may overcome the most significant feasibility barriers identified by the present study. Clinical trial registration: ISRCTN49307616.

OBJECTIVES:This study aimed to evaluate the feasibility of delivering a vocational rehabilitation intervention (Return to Work After Trauma-ROWTATE), remotely to individuals recovering from traumatic injuries. The primary objectives were to assess therapists' training and competence, adapt the intervention and training for remote delivery and assess the feasibility and fidelity of remote delivery to inform a definitive randomised controlled trial. DESIGN:A mixed-methods feasibility study incorporating (1) telerehabilitation qualitative literature review, (2) qualitative interviews preintervention and postintervention with therapists and patients, (3) a team objective structured clinical examination to assess competency, (4) usefulness of training, attitudes towards (15-item Evidence-Based Practice Attitude Scale) and confidence in (4-item Evidence Based Practice Confidence Scale) evidence-based practice, intervention delivery confidence (8-bespoke questions) and intervention behaviour determinants (51-items Theoretical Domains Framework) and (5) single-arm intervention delivery feasibility study. SETTING:The study was conducted in two UK Major Trauma Centres. The intervention and training were adapted for remote delivery due to the COVID-19 pandemic. PARTICIPANTS:Therapists: Seven occupational therapists (OTs) and clinical psychologists (CPs) were trained, and six participated in competency assessment. Seven OTs and CPs participated in preintervention interviews and surveys; six completed post-intervention interviews and four completed post-training surveys. PATIENTS:10 patients were enrolled in the single-arm feasibility study and 4 of these participated in postintervention qualitative interviews. Inclusion criteria included therapists involved in vocational rehabilitation delivery and patients admitted to major trauma centres. Exclusion criteria included participation in other vocational rehabilitation trials or those who had returned to work or education for at least 80% of preinjury hours. INTERVENTION:The ROWTATE vocational rehabilitation intervention was delivered remotely by trained OTs and CPs. Training included competency assessments, mentoring and adaptation for telerehabilitation. The intervention was delivered over multiple sessions, with content tailored to individual patient needs. RESULTS:Therapists found the training useful, reported positive attitudes (Evidence-Based Practice Attitude Scale mean=2.9 (SD 0.9)) and high levels of confidence in delivering evidence-based practice (range 75%-100%) and the ROWTATE intervention (range 80%-100%). Intervention barriers identified pretraining became facilitators post-training. Half the therapists needed additional support post-training through mentoring or additional training. The intervention and training were successfully adapted for remote delivery. High levels of fidelity (intervention components delivered: OTs=84.5%, CPs=92.9%) and session attendance rates were found (median: OT=97%, CP=100%). Virtually all sessions were delivered remotely (OT=98%, CP=100%). The intervention was acceptable to patients and therapists; both considered face-to-face delivery where necessary was important. CONCLUSIONS:The ROWTATE intervention was delivered remotely with high fidelity and attendance and was acceptable to patients and therapists. Definitive trial key changes include modifying therapist training, competency assessment, face-to-face intervention delivery where necessary and addressing lower fidelity intervention components. TRIAL REGISTRATION NUMBER:ISRCTN74668529.

The role of N-acetylcysteine (NAC) in paracetamol-induced liver injury is well established. Emerging evidence has also identified a role for NAC in non-paracetamol-induced liver injury. Its antioxidant properties have shown value in reducing oxidative stress in ischaemia-reperfusion and other drug-induced injuries [1]. Research for NAC following liver transplantation [2], and its potential role in major hepatectomies is still ongoing [3]. This systematic review aimed to explore literature for use of NAC in patients with traumatic liver injuries. A comprehensive search of Pubmed, Embase, Google Scholar and Cochrane Library databases were performed to identify relevant studies from 2014-2024. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. The study was registered on PROSPERO, CRD42024605773. Fifty-nine papers were identified, however all described injury from controlled trauma (hepatectomies) or ischaemia-reperfusion injury. No studies specifically addressed the use of NAC following blunt or penetrating liver trauma. In those evaluating NAC following major hepatectomies, its use was not associated with significant postoperative benefits. However, in liver transplant, NAC significantly reduced incidence of primary graft nonfunction and postoperative complications. Controversy exists regarding the use of NAC in liver surgery. In major hepatectomies, further research has been advocated, but in liver trauma there are currently no studies addressing the impact of NAC on outcomes. Given the role of NAC in non-traumatic liver injuries, and a potential role in liver transplantation, there is value in future research investigating the use of NAC in blunt and penetrating liver trauma.

BACKGROUND:The role of liver transplantation as a treatment option for de novo resectable peri-hilar cholangiocarcinoma (pCCA) is controversial. This study investigated the outcomes following resection of early-stage pCCA in the UK. METHODS:Patients undergoing resection for pCCA between 2014 and 2022 across 22 UK centres were included. Early-stage pCCA was defined as tumour size<3cm with no nodal disease (N0) on histopathology analysis. Clinical and survival data were collated. RESULTS:Of the 450 patients included, 138 patients underwent resection for early-stage pCCA. In the early-stage pCCA group, CD ≥ IIIa morbidity was 39.1 % (n = 54) and 90-day mortality was 10.1 % (n = 14). Sixty-four (46.4 %) patients received adjuvant chemotherapy, but this was reduced in those with CD ≥ IIIa morbidity (n = 17, 31.5 %). Early-stage tumours had a significantly lower vascular invasion (n = 57, 41.3 %) and R1 margin (n = 46, 33.3 %) compared to later-stage pCCA [62.2 % (n = 194) and 54.2 % (n = 169) respectively, p < 0.001). The median disease-free and overall survival was significantly better in patients with early-stage pCCA compared to more advanced tumours (p < 0.001). Male gender (p = 0.039) and Post-Hepatectomy Liver Failure (PHLF, p = 0.010) were associated with significantly worse disease-free survival, while biliary drainage (p = 0.013), PHLF (p < 0.001) and vascular invasion (p = 0.030) were associated with significantly poorer overall survival. CONCLUSION:Resection of early-stage pCCA tumours is associated with good clinical and survival outcomes in centralised HPB centres.

Abstract Background Moderately severe or major trauma (injury severity score (ISS) > 8) is common, often resulting in physical and psychological problems and leading to difficulties in returning to work. Vocational rehabilitation (VR) can improve return to work/education in some injuries (e.g. traumatic brain and spinal cord injury), but evidence is lacking for other moderately severe or major trauma. Methods ROWTATE is an individually randomised controlled multicentre pragmatic trial of early VR and psychological support in trauma patients. It includes an internal pilot, economic evaluation, a process evaluation and an implementation study. Participants will be screened for eligibility and recruited within 12 weeks of admission to eight major trauma centres in England. A total of 722 participants with ISS > 8 will be randomised 1:1 to VR and psychological support (where needed, following psychological screening) plus usual care or to usual care alone. The ROWTATE VR intervention will be provided within 2 weeks of study recruitment by occupational therapists and where needed, by clinical psychologists. It will be individually tailored and provided for ≤ 12 months, dependent on participant need. Baseline assessment will collect data on demographics, injury details, work/education status, cognitive impairment, anxiety, depression, post-traumatic distress, disability, recovery expectations, financial stress and health-related quality of life. Participants will be followed up by postal/telephone/online questionnaires at 3, 6 and 12 months post-randomisation. The primary objective is to establish whether the ROWTATE VR intervention plus usual care is more effective than usual care alone for improving participants’ self-reported return to work/education for at least 80% of pre-injury hours at 12 months post-randomisation. Secondary outcomes include other work outcomes (e.g. hours of work/education, time to return to work/education, sickness absence), depression, anxiety, post-traumatic distress, work self-efficacy, financial stress, purpose in life, health-related quality of life and healthcare/personal resource use. The process evaluation and implementation study will be described elsewhere. Discussion This trial will provide robust evidence regarding a VR intervention for a major trauma population. Evidence of a clinically and cost-effective VR intervention will be important for commissioners and providers to enable adoption of VR services for this large and important group of patients within the NHS. Trial registration ISRCTN: 43115471. Registered 27/07/2021.

BACKGROUND:Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy. METHODS:A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round. RESULTS:A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'. CONCLUSION:Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.

Abstract Aims The liver is the most injured abdominal organ, with subsequent significant morbidity and mortality. Over the last 30-years liver trauma management has changed, with an increase in nonoperative versus operative approaches. However, contemporary UK data on how liver trauma is managed is limited. Methods This prospective, multicentre audit was conducted through the National Trauma Research and Innovation Collaborative at 18 participating major trauma centres and units across the UK between 01/01/2021-01/10/2021. Differences in demographics, physiology, injury mechanisms, complications, length of stay, and 30-day mortality were compared between patients undergoing definitive nonoperative, including interventional radiology, or operative management. Univariable tests were used to compare data where appropriate with adjusted odds ratios of 30-day mortality used to assess definitive management via a multivariable model. Results Of 266 patients, 76.69% underwent nonoperative management. Operative patients were significantly younger, median age 29 (IQR 20-41) vs. 34 (IQR 23-52) p=0.0146, sustained more penetrating compared to blunt injuries (62.90% vs. 9.80%, p<0.0001), had more active bleeding on CT (32.65% vs. 5.97%, p<0.0001), required massive transfusions (27.42% vs. 8.33%, p=0.0001), sustained more inpatient complications (29.03% vs. 1.96%, p<0.001) and more physiologically unstable on admission. Operative compared to nonoperative management resulted in a significant 20-fold increase in 30-day mortality, (aOR 20.21, 95%CI 3.28-124.43, p=0.001). Conclusions These findings highlight the current approach to UK liver trauma management. Patients undergoing operative management have significantly greater morbidity and mortality yet may represent the severest of liver injures. Where appropriate nonoperative management should be used following liver trauma to reduce this.

BackgroundMajor trauma is a leading cause of death and disability in younger individuals and poses a significant public health concern. There is a growing interest in understanding the complex relationships between socioeconomic deprivation and major trauma. Anecdotal evidence suggests that deprivation is associated with more violent and debilitating injuries. There remains a paucity in literature evaluating major trauma outcomes in relation to socioeconomic deprivation.MethodsA comprehensive search of MEDLINE, Embase, and CENTRAL databases was performed to identify studies from 1947 to March 2024. The primary outcome was to establish the distribution of injuries based on deprivation, with secondary outcomes evaluating surgical intervention rates, length of stay, and mortality. Quantitative pooling of data was based on the random-effects model.ResultsFourteen studies and 878,872 trauma patients were included. A substantial proportion (28%) of trauma incidents occurred in the most deprived group. Patients from the lowest socioeconomic group were considerably younger (weighted mean difference [WMD] -9.85 years and 95% confidence intervals [CI] -9.99 to -9.70) and more likely to be male (odds ratio [OR] 1.36 and 95% CI 1.14-1.63). There were no differences in surgical intervention (OR 1.74 and 95% CI 0.97-3.13), length of stay (WMD 1.15 days and 95% CI -0.32-2.62), and mortality (OR 1.04 and 95% CI 0.95-1.14) regardless of background.ConclusionMajor trauma is prevalent in deprived areas and in younger individuals, with an increasing trend of deprivation in male patients. Although the rates of surgery, length of stay, and mortality did not differ between groups, planning of public health interventions should target areas of higher deprivation.

Abstract Background Abdominal traumas only represent 10% of all trauma-related injuries but is associated with significant morbidity and mortality. This is especially true for liver and pancreatic injuries. There is a growing interest in understanding the complex relationships between socioeconomic deprivation and trauma in recent years. Evidence from the US demonstrates that social deprivation is strongly associated with violent traumas and more severe injuries. There is, however, a lack of research examining the relationship between socioeconomic deprivation and severe abdominal traumas. This prospective multicentre audit investigates the association between socioeconomic status and the mechanisms and outcomes of liver and pancreatic traumas. Methods This prospective, multicentre audit was conducted through the National Trauma Research and Innovation Collaborative at18 participating major trauma centres and units in the United Kingdom between 01/01/2021 and 01/10/2021. The differences in patient demographics, mechanism of injury, injury severity score, operative management, length of hospital stay, and mortality were compared between patients from the five socioeconomic groups. The socioeconomic status for each patient was determined using the Index of Multiple Deprivation (IMD) tool, which is a recognised and validated tool published by the UK government. Chi-squared, Fisher’s Exact, and Kruskal-Wallis tests were used to compare categorical variables as appropriate. Results Of the 232 patients included, 75% were male. There is an increasing trend of deprivation in males, with 82.9% of the most deprived patients being male compared to the 66.7% in the least deprived quintile. The most deprived group had a lower comorbidity burden and were younger with a median age of 26 (IQR 19-39) compared to the least deprived group (median age 42, IQR 28-61,p<0.01). Penetrating injuries occurred more frequently in the 3 most deprived groups, although this was not significant (p=0.09). There were no differences in the management, length of stay, and mortality between the 5 socioeconomic groups. Conclusions The findings of this prospective study adds to the growing body of evidence associating socioeconomic deprivation and major trauma in the UK. Despite the differences in patient demographics across the socioeconomic groups, the definitive management and mortality did not differ. The planning and provision of preventative public health intervention should target areas of higher socioeconomic deprivation.

The hospital based Redthread Youth Violence Intervention Programme (YVIP) utilises experienced youth workers to support 11-24 year olds following an episode of violent injury, assault or exploitation who present to the Emergency Department (ED) at the East Midlands Major Trauma Centre (MTC), Nottingham, UK. The YVIP aims to promote personal change with the aim of reducing the incidence of further similar events. We conducted a retrospective, observational, cohort study to examine the association between engagement with the YVIP and re-attendance rates to the ED following a referral to Redthread. We also examined factors associated with engagement with the full YVIP. We found that 573 eligible individuals were referred to the YVIP over two years. Assault with body parts 34.9% (n = 200) or a bladed object 29.8% (n = 171) were the commonest reason for referral. A prior event rate ratio (PERR) analysis was used to compare rates of attendance between those who did and did not engage with the full YVIP. Engagement was associated with a reduction in re-attendances of 51% compared to those who did not engage (PERR 0.49 [95% 0.28-0.64]). A previous attendance to the ED by an individual positively predicted engagement. (OR 2.82 [95% CI 1.07-7.42], P = 0.035). A weekend attendance (OR 0.26 [0.15-0.44], P < 0.001) and a phone call approach (OR 0.25 [0.14-0.47], P = 0.001), rather than a face-to-face approach by a Redthread worker, negatively impacted engagement. In conclusion, assaults with or without a weapon contributed to a significant proportion of attendances among this age group. The Redthread YVIP was associated with reduced rates of re-attendance to the East Midlands MTC among young persons who engaged with the full programme.

BackgroundMechanisms and patterns of injury in children are changing, with violent mechanisms becoming more prevalent over time. Government funding of services for children and young people has reduced nationally over the last decade. We aimed to investigate the trends in admissions of injured children to a Major Trauma Centre (MTC) and examine the relationship between injuries sustained by violent mechanisms and local authority funding of children and youth services within the same catchment area.MethodsA 10-year observational study included all patients aged<18 years treated at a regional MTC between April 2012 and April 2022. Number of admissions with violent trauma, mechanism of injury, requirement for operative intervention and mortality were compared with published annual local authority expenditure reports.Results1126 children were included; 71.3% were boys, with median age 11 years (IQR 3–16). There were 154/1126 (14%) children who were victims of violent trauma; they were more likely to be boys than children injured by non-violent mechanisms (84% vs 69%). The proportion of injuries attributed to violence increased over the study period at the same time as reductions in local authority funding of services for the early years, families and youth services. However, there were insufficient data to formally assess the interdependency between these factors.ConclusionsThe proportion of injuries attributed to violence has increased over time, and government spending on specific children and young people’s services has decreased over the same time period. Further work is needed to examine the interdependency between spending and violent injuries in children, and public health interventions to target violence-related injuries should take into account youth service funding.

Abstract Introduction Major Trauma Training Interface Group (TIG) Fellowships were introduced in 2018 to formalise and enhance the training of surgeons and allied specialists in trauma care. Paediatric surgery is a non-traditional route to trauma surgery. Lessons learned from a fresh perspective may be relevant to surgeons who may not include trauma in their regular practice but may occasionally encounter seriously injured patients requiring emergency management. Method Training involves a 12 month placement; fellows are trained to deliver effective trauma team leadership and/or in the skills and decision making required to perform resuscitative trauma surgery. Important learning points were documented throughout the fellowship. A selection are described below. Results Conclusion Integrated training is immensely valuable in trauma care. Collaboration between trauma units and the regional MTC could optimise shared learning outside formal fellowships.

BackgroundCentralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre.MethodsAll patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V).ResultsThere were 600 patients; the median age was 33 (IQR 22–52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively).ConclusionsOutcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

Abstract Aim Trauma is the leading cause of mortality in the adolescent and young adult population. Adolescents, particularly those aged 16-17 years often fall between provisions of traditional adult and paediatric services. This study examines the outcomes for injured adolescents treated at one combined adult/paediatric UK major trauma centre. Methods An observational study included patients aged 10-24.99 years treated at a single MTC between April 2020 and April 2022. Demographic and injury mechanism and severity (ISS) data were recorded for three subgroups: paediatric (10-15 years), transitional (16-17) and young adult (18-24). Outcomes were compared including length of stay, surgical procedures and mortality. Results 343 patients were included (78.4% male). 16-17 year olds were significantly more likely to be victims of violence and require a longer stay in hospital. Mortality was 4.1% overall. Conclusions It is vital that the specific needs of young people aged 16-17 are recognised in terms of violence reduction and injury prevention strategies, and in planning and delivery of hospital services.