The Use and Impact of a Decision Support Tool for Appendicitis Treatment.

OBJECTIVE: Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict. BACKGROUND: For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (eg, recurrence vs surgical complications) and benefits (eg, more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options, and DSTs that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent with the Comparing Outcomes of Drugs and Appendectomy trials, our group developed a DST for appendicitis treatment ( www.appyornot.org ). METHODS: A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021 and 2023. Treatment preferences before and after the use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST. RESULTS: A total of 8243 people from 66 countries and all 50 U.S. states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% ( P < 0.0001). Of those who completed the Ottawa Decisional Conflict Score (DCS; n = 356), 52% reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25 to 50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75. CONCLUSIONS: The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.

Jejunal Carcinoid Tumors Presenting as Small Bowel Obstruction.

Carcinoid tumors are the most common form of gut neuroendocrine tumors, however, they rarely present with small bowel obstruction. We present a case of a 65-year-old woman without prior abdominal operations who presented with symptoms of small bowel obstruction. Computed tomography (CT) showed multiple air fluid levels and a transition point in the left mesentery with two soft tissue densities at the same level. The patient was taken to the operating room for surgical exploration, which showed two intramural masses in the mid and distal jejunum, which surgical pathology showed to be stage IIIB carcinoid tumor.

Prehospital Trauma Care.

Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.

Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma.

INTRODUCTION: High-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. METHODS: A retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. RESULTS: Of 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75-40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. CONCLUSIONS: Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.

Contemporary Management and Outcomes of Injuries to the Inferior Vena Cava: A Prospective Multicenter Trial From PROspective Observational Vascular Injury Treatment.

INTRODUCTION: Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury. METHODS: The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics. RESULTS: 140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay. CONCLUSIONS: Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.

A Rare Case of Subcutaneous Insulin Resistance Presumed to be due to Paraneoplastic Process in Pancreatic Adenocarcinoma.

OBJECTIVE: We describe a rare case of profound subcutaneous insulin resistance (SIR) presumed due to a paraneoplastic process caused by pancreatic adenocarcinoma that improved with intravenous insulin and tumor resection. METHODS: An 80-year-old man with previously well-controlled type 2 diabetes mellitus had worsening glycemic control (hemoglobin A1C increase of 6.5% to 8.6% over 4 months) following a recent diagnosis of pancreatic adenocarcinoma. His blood glucose was uncontrolled at 600 mg/dL despite rapid up-titration of a subcutaneous basal-bolus insulin regimen totaling 1000 units/d. Extensive evaluation of insulin resistance including insulin antibodies and anti-insulin receptor antibodies was negative. Due to clinical deterioration, the patient underwent pancreaticoduodenectomy before the completion of neoadjuvant chemotherapy. The patient received intravenous insulin before surgery, which resulted in rapid improvement in glycemic control. The patient's blood glucose normalized, and he was maintained on metformin monotherapy following pancreaticoduodenectomy. RESULTS: This patient had evidence of SIR in the setting of pancreatic adenocarcinoma. SIR was likely a paraneoplastic process as glycemic control improved after tumor resection. Interestingly, the patient did not have hyperinsulinemia but rather evidence of ß-cell dysfunction, which highlights the possibility of exogenous insulin resistance. CONCLUSION: Paraneoplastic processes due to pancreatic adenocarcinoma can cause SIR, marked by profound hyperglycemia and deteriorating functional status. It is, therefore important to recognize this rare syndrome and appropriately escalate to a higher level of care and consider proceeding with tumor resection.

Meet your surgical team: The impact of a resident-led quality improvement project on patient satisfaction.

BACKGROUND: Patients often have an incomplete understanding of the levels of training and roles of the various surgical providers in teaching hospitals, leading to patient confusion and dissatisfaction. METHODS: Pre-intervention discharge surveys were administered to gastrointestinal surgery inpatients (10/2016-02/2017) to evaluate sentiments regarding their surgical team. During the intervention period (02/2017-05/2017), patients at admission received "facesheets" containing team member profiles, photos, training level, and roles. These patients were evaluated using the survey, and pre- and post-intervention scores compared. RESULTS: 153 pre- and 100 post-intervention surveys were collected. There was a significant increase in patients reporting it was important to know the surgical team members and that they knew team member roles (p ≤ 0.05). Scores in every domain of the satisfaction survey improved in the post-intervention period, although not reaching statistical significance. CONCLUSIONS: Improving how patients perceive their interactions with their surgical team has implications on patient satisfaction and hospital quality metrics.

Spontaneous seromuscular laceration of the sigmoid colon: a case report.

Injury to bowel can result in high morbidity and death. Bowel injuries typically occur after external trauma to the abdomen. Bowel injury in the absence of external trauma is rare. Here, we report a 36-year-old male presenting with a sigmoid colon laceration likely due to long-standing constipation.