Matthew Jeffrey Martin

Traumatic abdominal wall hernia (TAWH) is an uncommon but clinically important consequence of both blunt and penetrating abdominal trauma. It is defined by disruption of the abdominal wall musculature and fascia with herniation of intra-abdominal or retroperitoneal contents through the defect. Although penetrating abdominal wall defects are usually apparent and can often be primarily closed during operative exploration, blunt TAWH is significantly more heterogeneous and challenging. The skin may remain intact while the muscle, fascia, neurovascular supply, and bony attachments are disrupted. The reported incidence of TAWH varies according to imaging strategy and trauma population, but frank herniation remains rare, occurring in <1% of blunt trauma patients in most contemporary series. The major management challenge is deciding whether the patient requires immediate trauma laparotomy or laparoscopy, acute abdominal wall repair, staged management with same-admission repair, or delayed hernia repair/abdominal wall reconstruction. Evidence remains primarily dominated by retrospective single-center series, multicenter registry studies, and systematic reviews with heterogeneous definitions and follow-up. Although traditional dogma had taught that these repairs should always be performed in a delayed fashion, recent multicenter data, systematic reviews, and surgeon experience suggest that timing of repair, type of repair, and mesh use must be individualized; bowel injury, contamination, defect location, and patient physiology are more important than a universal early-versus-delayed algorithm. This article summarizes the practical issues the trauma and acute care surgeon needs to know: diagnosis, classification, associated injuries, indications for exploration, repair timing, operative strategy, management of lateral and posterior defects, mesh use in contaminated fields, and associated outcomes.

Traumatic hemothorax is a common consequence of thoracic injury, with management strategies ranging from observation to tube thoracostomy and operative intervention. This Western Trauma Association algorithm provides a practical framework for the evaluation and management of patients with traumatic hemothorax. Recommendations were developed through review of the available literature, including randomized and observational studies, supplemented by expert consensus where high-quality evidence is limited. The proposed pathway incorporates patient physiology, hemothorax size, adequacy of pleural drainage, and evidence of ongoing hemorrhage to guide management decisions. Because clinical circumstances, institutional resources, and local practice patterns vary, the algorithm is intended to support rather than replace individualized clinical judgment. It may be used as a bedside reference and as a framework for the development of institution-specific protocols. LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association; Level V.

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Background: Same-admission cholecystectomy in mild and moderate biliary pancreatitis is known to be associated with reduced rates of recurrent biliary complications. While practice guidelines recommend same-admission cholecystectomy, the contemporary management of mild and moderate biliary pancreatitis remains unknown. The objective of this study is to assess practice patterns of same-admission cholecystectomy following mild and moderate biliary pancreatitis. Methods: The National Inpatient Sample was queried for patients (age ≥ 18 years) with biliary pancreatitis between January 2016 and December 2021. The Modified Bedside Index for Severity in Acute Pancreatitis was used to identify patients with mild and moderate pancreatitis. Management strategies included non-operative management (NOM) and same-admission cholecystectomy. Multivariable Cox regression evaluated the association between clinical variables and same-admission cholecystectomy. Results: A total of 482,705 patients with mild and moderate pancreatitis were identified, with 283,435 (59%) undergoing same-admission cholecystectomy. Compared to White patients, Black patients were younger (54 years [interquartile range: 37–66] vs. 63 years [47–75], p < 0.001), more likely to be female (69% vs. 57%, p < 0.001), and had lower Elixhauser Comorbid Index (ECI) (3 [0–10] vs 3 [0–10], p = 0.013). Multivariable Cox regression showed that younger age (hazard ratio [HR] 0.993 per 1-year increment, 95% confidence interval (CI) 0.993–0.994, p < 0.001), female sex (HR 1.157, 95% CI 1.136–1.178, p < 0.001), lower ECI (HR 0.947, 95% CI 0.946–0.948, p < 0.001), and White race (HR 1.208, 95% CI 1.171–1.247, p < 0.001) as well as Hispanic (HR 1.320, 95% CI 1.274–1.368, p < 0.001) as compared to Black race had increased likelihood of undergoing same-admission cholecystectomy. Conclusion: Despite current recommendations, same-admission cholecystectomy was found to be underutilized in mild and moderate pancreatitis and was less likely to be performed in Black patients compared to White and Hispanic patients.

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Gastric outlet obstruction (GOO) can result from several etiologies. GOO due to peptic ulcer disease occurs in fewer than 5% of all patients with complicated duodenal ulcers and in <1% to 2% of those with gastric ulcers. Malignant disease is now a more common etiology. Patients with GOO present with severe vomiting, abdominal pain, severe dehydration, and electrolyte derangement requiring resuscitation. The initial imaging evaluation is a computed tomography scan with po contrast, which will demonstrate the obstruction and possible etiologies. An EGD should be done to assess the degree of GOO structure and obtain a tissue biopsy. The management of benign GOO can range from balloon dilation that can be repeated or consider other endoscopic options. Surgical management of severe GOO is occasionally required with either pyloroplasty or resection of the GOO with a Billroth I/II or Roux-en-Y reconstruction. Management of malignant disease can become complex, as the initial goal would be operative management of resectable malignant disease. If not resectable, there are several endoscopic alternatives to bypassing an obstruction. Surgical bypass options with a Billroth II are still an option.

BACKGROUND: Temporary vascular shunts (TVS) are used for initial stabilization and delayed arterial repair, but their overuse may worsen outcomes. This study evaluates the impact of TVS on reintervention and amputation rates following peripheral arterial repair (PAR). METHODS: Retrospective analysis (2012–2023) of the PROspective Observational Vascular Injury Treatment (PROOVIT) registry. Patients who underwent PAR were categorized into two groups: TVS before PAR versus immediate repair (IR). Propensity score matching (1:3) balanced patient characteristics and injury severity. The primary outcome was reintervention, with secondary outcomes including amputation, thrombosis, and length of stay. RESULTS: Among 1,182 PAR patients, 67 (5.7%) received TVS. TVS was most commonly placed in the femoral (42%), brachial (30%), and popliteal arteries (15%). After matching, 67 TVS patients were compared with 201 no-TVS (IR) patients. Reintervention rates were comparable (13.6% vs. 15.9%, p =0.655), as were amputation (1.5% vs. 9%, p =0.051) and thrombosis (9% vs. 6%, p =0.40). In addition, median length of stay was similar (12 vs. 9 d, p =0.243) within cohorts. CONCLUSIONS: TVS did not significantly impact reintervention, amputation, thrombosis, or length of stay following PAR. TVS and delayed repair achieved comparable outcomes compared with IR of peripheral arterial injuries. ( J Trauma Acute Care Surg 2026;00:000–000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.