Common postbariatric surgery emergencies for the acute care surgeon: What you need to know.

ABSTRACT: The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient. LEVEL OF EVIDENCE: Literature Synthesis and Expert Opinion; Level V.

Prospective, multicenter study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (XenMatrix™ AB Surgical Graft) for hernia repair in all centers for disease control and prevention wound classes: 24-month follow-up cohort.

Prospective, multicenter, single-arm study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (AC-PDM) in a cohort involving all centers for disease control and prevention wound classes in ventral/incisional midline hernia repair (VIHR). Materials and methods: Seventy-five patients (mean age 58.6±12.7 years; BMI 31.3±4.9 kg/m2) underwent ventral/incisional midline hernia repair with AC-PDM. Surgical site occurrence (SSO) was assessed in the first 45 days post-implantation. Length of stay, return to work, hernia recurrence, reoperation, quality of life, and SSO were assessed at 1, 3, 6, 12, 18, and 24 months. Results: 14.7% of patients experienced SSO requiring intervention within 45 days post-implantation, and 20.0% thereafter (>45 d post-implantation). Recurrence (5.8%), definitely device-related adverse events (4.0%), and reoperation (10.7%) were low at 24 months; all quality-of-life indicators were significantly improved compared to baseline. Conclusion: AC-PDM exhibited favourable results, including infrequent hernia recurrence and definitely device-related adverse events, with reoperation and SSO comparable to other studies, and significantly improved quality of life.

When to stay out of the abdomen: Extending extraperitoneal approaches to complex ventral and incisional hernias-A video-based guide to the technique.

BACKGROUND: Ventral and incisional hernias are common surgical pathologies managed by acute care surgeons and also an area of exploration in repair options and approaches. Several new minimally invasive techniques have been developed to better tailor the repair to the individual patient and minimize the risk of intra-abdominal complications, particularly in patients with significant adhesions from prior surgery or trauma. The extended totally extraperitoneal approach to incisional ventral hernias allows the repair of complex hernias while entirely avoiding entry into the peritoneal cavity. METHODS: We present video clips demonstrating key steps to minimally invasive extended totally extraperitoneal Rives-Stoppa and transversus abdominis release procedures to complex incisional and ventral hernias. CONCLUSION: The application of robotic-assisted laparoscopic surgery has enabled surgeons to expand the use of minimally invasive techniques for a variety of operations. Hernia repair in particular has seen the most rapid growth because of the enhanced ability to suture on the anterior abdominal wall. This video illustrates the key technical points to performing a safe and effective repair without the need for intraperitoneal access.

Outcomes of Open Complex Ventral Hernia Repairs With Retromuscular Placement of Poly-4-Hydroxybutyrate Bioabsorbable Mesh.

Purpose. Optimal technique and mesh selection still debated for complex ventral hernias. Limited data exists on bioabsorbable meshes in high-risk patients. We evaluated our experience. Methods. Retrospective review was conducted following institutional review board approval for ventral hernia repairs using a single bioabsorbable mesh between February 2014 and November 2017. Patient and hernia details characterized. Outcomes evaluated. Results. 20 ventral hernia repairs identified, 10 males, 10 females. Mean body mass index was 35 ± 7.4 kg/m2, and mean age 47 ± 13 years. Comorbid conditions were diabetes 35% and hypertension 40%. Fifty-five percent had American Society of Anesthesiologist scores of 3. Hernia Characteristics: Ventral Hernia Working Group Grade 3 hernias were 80%, and remainder grade 2. Forty percent of hernias were Centers for Disease Control class III, and remainder were class I and II. The mean defect size was 533 cm2 ± 500. Repair for prior open abdomens was 45%, recurrent hernias 20%, incisional 15%, incarcerated 10%, incisional with parastomal 5%, and primary ventral 5%. Concomitant bowel procedures in 8, (40%). All cases had retromuscular mesh placement (transversus abdominus release 65%, Rives-Stoppa 35%). Surgical site occurrences were 20% (surgical site infection 10%, seroma 10%). Overall hospital stay 5 ± 3 days. Ileus occurred in 20%. One postoperative death due to fatal arrhythmia. There were no recurrences with mean follow-up 21.1 months. Conclusions. Complex hernia repairs using bioabsorbable mesh were conducted in a small cohort of high-risk patients. These data demonstrate good outcomes with limited morbidity and mortality. There were no recurrences.

Deconstructing dogma: Nonoperative management of small bowel obstruction in the virgin abdomen.

BACKGROUND: Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of computed tomography imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin (GG) administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared with that for SBO with PAS. METHODS: A post hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients younger than 18 years, pregnant patients, and patients with evidence of hypotension, bowel strangulation, peritonitis, closed loop obstruction or pneumatosis intestinalis were excluded. The primary outcome was operative exploration rate for SBO with or without PAS. Rate adjustment was accomplished through multivariate logistic regression. RESULTS: Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, sex, prior abdominal surgery including colon surgery, prior SBO admission, and history of cancer. Multivariate analysis showed that PAS (odds ratio [OR], 0.47; p = 0.03) and the use of GG (OR, 0.11; p < 0.01) were independent predictors of successful nonoperative management, whereas intensive care unit admission (OR, 16.0; p < 0.01) was associated with a higher likelihood of need for operation. The use of GG significantly decreased the need for operation in patients with and without PAS. CONCLUSIONS: Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared with those who did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the nonoperative management approach using GG. LEVEL OF EVIDENCE: Therapeutic, level IV.

Minimally invasive approach to incarcerated or strangulated groin hernias: A 2018 EAST Master Class Video Presentation.

Groin hernia repair is one of the most common general surgical procedures performed worldwide. Although only a small percentage will become incarcerated or strangulated, this is an indication for repair. Minimally invasive surgery is becoming the standard of care for most procedures, and we believe this to be a safe and feasible approach for incarcerated or strangulated groin hernias. We present a description of our recommended approach with technical details and accompanying video clips to highlight these techniques.

Minimally invasive surgery techniques for the management of urgent or emergent small bowel pathology: A 2018 EAST Master Class Video Presentation.

Although minimally invasive surgery techniques have been rapidly and widely adopted among nearly all fields of elective surgery, their use by trauma and acute care surgeons for urgent or emergent pathology has somewhat lagged behind. Trauma surgeons are frequently called upon to manage traumatic or emergent surgical small bowel pathology, and many of these may be ideally suited for increased incorporation of minimally invasive surgery techniques. This surgical technique video and associated article provide a technical guide and "how-to" instructions for laparoscopic and other minimally invasive approaches that can be utilized in the management of traumatic small bowel injuries, small bowel obstructions, or other emergent small bowel pathology.

A rare case of fusiform celiac artery aneurysm after penetrating trauma.

INTRODUCTION: Visceral artery aneurysms are an uncommon clinical problem with aneurysms of the celiac artery only making up a small percentage of all visceral artery aneurysms. The more common splenic and hepatic aneurysms are often symptomatic with pain or rupture and associated hemorrhage. PRESENTATION OF CASE: We present a case of an otherwise healthy 30 yo male with an asymptomatic, posttraumatic arterial aneurysm of the celiac artery. He initially presented to our trauma center after sustaining multiple gunshot wounds which required multiple abdominal surgeries. He represented four weeks later with 3 days of flank pain and fever. Extensive workup yielded an incidental finding of 14 mm fusiform aneurysm of the celiac artery with associated dissection. This was not present on imaging during his initial hospitalization. The patient underwent successful endovascular management. DISCUSSION: Visceral artery aneurysms are rare and when identified often require early intervention. Posttraumatic etiologies are often due to penetrating trauma as in the case presented. Modern high resolution imaging can identify those that are not yet symptomatic. CONCLUSION: Posttraumatic visceral artery aneurysms are rare with an incidence of 0.01-0.2%, however they have a potential for high mortality if undiagnosed or untreated. An aggressive operative approach can lead to favorable outcomes.

Do acute care surgeons need bariatric surgical training to ensure optimal outcomes in obese patients with nonbariatric emergencies?

INTRODUCTION: Acute care surgeons care for the entire breadth of the American adult population, including obese patients. As the population gets heavier, more patients will present to acute case surgeons with nonbariatric surgical emergencies. Do these surgeons need bariatric training to properly care for obese population? OBJECTIVES: To evaluate our experience in obese population requiring acute surgery and compare outcomes based on surgeon expertise in bariatric surgery. SETTING: Community teaching hospital, United States. METHODS: Retrospective review of obese patients requiring acute surgical intervention. Surgeons were classified as bariatric surgeons (B, n = 2) versus nonbariatric surgeons (NB, n = 4). Demographic characteristics, co-morbidities, and outcomes based on surgeon training were compared. RESULTS: Two hundred three patients comprised the cohort. The mean body mass index was 37 ±6 kg/m2. The majority of procedures were laparoscopic (cholecystectomies n = 75, appendectomies n = 45). The remaining nonroutine laparoscopic cases were intestinal obstructions (n = 9), incarcerated hernias (n = 17), traumatic injuries (n = 48), and intestinal ischemia or perforation (n = 9). Bariatric surgeons performed 35% of cases, and risk profiles were similar between groups. Operative times were similar for cholecystectomies and appendectomies. Bariatric surgeons performed more nonroutine cases laparoscopically (7% B versus 2% NB, P = .001). Surgical site infections were low (2% B versus 4% NB, P = .4). Hospital length of stay was higher in the NB group at 9 ± 9 days versus 5 ± 4 days for B (P = .05). Mortality was 5%. CONCLUSIONS: Acute surgical procedures were performed in obese patients. Bariatric expertise favorably affected length of stay and the application of laparoscopy. Bariatric expertise may improve outcomes in nonbariatric emergencies, but further study is warranted.

Results from a Quality Improvement Project to Decrease Infection-Related Ventilator Events in Trauma Patients at a Community Teaching Hospital.

Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. A VAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009-2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 + 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE: Prognostic, level III.

Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction.

INTRODUCTION: Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications. METHODS: A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG. RESULTS: Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2-7 vs. 5 days IQR 2-12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management. CONCLUSION: Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality. LEVEL OF EVIDENCE: Therapeutic, level III.

High-Risk Prehospital Mechanisms in Tier II Trauma Codes: An Analysis of Under-Triage at a Level II Trauma Center.

Under-triage is used as a surrogate for trauma quality. We sought to analyze factors that may impact under-triage at our institution by a detailed analysis of prehospital mechanisms and patient factors that were associated with the need for invasive intervention, intensive care unit monitoring, or death. Patients admitted to our Level II trauma center who met the criteria for under-triage using the Cribari method were studied, n = 160, and prominent mechanisms were motor vehicle collisions (MVCs). Patient demographics, detailed mechanism characteristics, ED vital signs, operative intervention, and outcomes were studied. The age of the study group and injury severity score were 42 ± 20 and 22 ± 6, respectively. Alcohol or drug use was common as were high-speed frontal collisions. Overall, 38 per cent of patients required surgery, and a monitored bed was required in 60 per cent of patients. Logistic regression identified drug use as predictive of mortality and MVC speeds ≥40 mph as predictive of intensive care unit admission. Patients requiring surgery had a high incidence of frontal collisions, 40 per cent. MVCs were predominant in under-triaged trauma patients. Operative intervention, intensive care unit monitoring, and deaths were associated with frontal impacts, high speeds, and drug use. Further study is warranted to assess the incorporation of high-risk injury patterns in triage algorithms aimed at enhancing trauma quality.

Application of a Geriatric Injury Protocol Demonstrates High Survival Rates for Geriatric Trauma Patients with High Injury Acuity.

Geriatric trauma has historically been associated with poor outcomes, particularly in the setting of severe polytrauma. Although geriatric trauma protocols are common, there are limited data on their impact in patients with high injury severity. In this study, we sought to investigate the impact of a geriatric injury protocol on outcomes in patients with severe trauma acuity. Ninety-eight geriatric patients (age ≥65) admitted to our trauma center with injury severity scores (ISS) ≥15 comprised the study cohort. The mean age was 75 ± 7.7 yrs. The mean ISS was 25 ± 9.2, and the mean geriatric trauma outcome score was 150 ± 3. Mortality was 17 per cent and 70 per cent were due to central nervous system injury. When patients with nonsurvivable injuries or advanced directives resulting in early care withdrawal were excluded, the mortality was 6 per cent. Extremes of age did not impact mortality[ (>80 years, 21%) vs (65-79, 16%, P = 0.5)]. Most patients (53%) were discharged home. The application of our geriatric trauma protocol led to favorable results despite high injury acuity. These data suggest that even at the extremes of age, a large percentage of patients can be expected to survive. A prospective validation of these findings is warranted.

Acute Kidney Injury in the Critically Ill Patient: A Current Review of the Literature.

PURPOSE: A comprehensive review of the literature to provide a focused and thorough update on the issue of acute kidney injury (AKI) in the surgical patient. METHODS: A PubMed and Medline search was performed and keywords included AKI, renal failure, critically ill, and renal replacement therapy (RRT). PRINCIPAL FINDINGS: A common clinical problem encountered in critically ill patients is AKI. The recent consensus definitions for the diagnosis and classification of AKI (ie, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease/Acute Kidney Injury Network) have enabled us to standardize the severity of AKI and facilitate strategies for prevention. These strategies as well as treatment modalities of AKI are discussed. We provide a concise overview of the issue of renal failure. We describe strategies for prevention including types of fluids used for resuscitation, timing of initiation of RRT, and different treatment modalities currently available for clinical practice. CONCLUSIONS: Acute kidney injury is a common problem in the critically ill patient and is associated with worse clinical outcomes. A standardized definition and staging system has led to improved diagnosis and understanding of the pathophysiology of AKI. There are many trials leading to improved prevention and management of the disease.

A rare case of chronic traumatic diaphragmatic hernia requiring complex abdominal wall reconstruction.

INTRODUCTION: Traumatic diaphragmatic hernia is a rare and often under recognized complication of penetrating and blunt trauma. These injuries are often missed or there is a delay in diagnosis which can lead to enlargement of the defect and the development of abdominal or respiratory symptoms. PRESENTATION OF CASE: We report a case of an otherwise healthy 37 year old male who was involved in a motor vehicle accident at age twelve. He presented 25 years later with vague lower abdominal symptoms and was found to have a large chronic left sided diaphragmatic hernia involving the majority of his intra-abdominal contents. Repair of the defect with a biologic mesh was undertaken and the patient also required complex abdominal wall reconstruction due to loss of intra-abdominal domain from the chronicity of the hernia. A staged closure of the abdomen was performed first with placement of a Wittmann patch. Medical management of intra-abdominal hypertension was successful and the midline fascia was sequentially approximated at the bedside for three days. The final closure was performed with a component separation and implantation of a fenestrated biologic fetal bovine mesh to reinforce the closure. In addition, a lightweight Ultrapro mesh was placed for additional lateral reinforcement. The patient recovered well and was discharged home. DISCUSSION: These injuries are rare and diagnosis is challenging. Mechanism and CT scan characteristics can aid clinicians. CONCLUSION: Blunt diaphragmatic injury is rare and remains a diagnostic challenge. Depending on the chronicity of the injury, repair may require complex surgical decision making.

Role of drains in laparoscopic appendectomy for complicated appendicitis at a busy county hospital.

Laparoscopic appendectomy (LA) has become the treatment of choice for acute appendicitis with equal or better outcomes than traditional open appendectomy (OA). LA in patients with a gangrenous or perforated appendicitis carries increased rate of pelvic abscess formation when compared with OA. We hypothesized routine placement of pelvic drains in gangrenous or perforated appendicitis decreases pelvic abscess formation after LA. Three hundred thirty-one patients undergoing LA between January 2007 and June 2011 were reviewed. Patients with perforated or gangrenous appendicitis were included. Group I had a Jackson-Pratt (JP) drain(s) placed and Group II had no JP drain. Data included patient demographics, emergency department laboratory values and vital signs, and computed axial tomography scan findings, intra-abdominal or pelvic abscess postoperatively, interventional radiology drainage, and length of stay. Clinic follow-up notes were reviewed. One hundred forty-eight patients were identified. Forty-three patients had placement of JP drains (Group I) and 105 patients had no JP drain (Group II). Three patients (three of 43 [6%]) in Group I developed pelvic abscess and 21 of 105 (20%) patients in Group II developed pelvic abscesses requiring subsequent drainage. This was statistically significant. Patient demographics, temperature, and mean white blood count before surgery were similar. Presurgery computed tomography (CT) with appendicolith and CT with abscess were more prevalent in Group I. The use of JP drainage in patients with perforated or gangrenous appendicitis during LA has decreased rates of pelvic abscess. This was demonstrated despite the drain group having appendicolith or abscess on preoperative CT.