The Silent Majority of Emergency General Surgery: An Assessment of Consult and Operative Volumes.

BACKGROUND: Defining the work performed by emergency general surgery (EGS) surgeons has relied on quantifying surgical interventions, failing to include nonsurgical management performed. The purpose of this study was to identify the extent of operative and nonoperative patient management provided by an EGS service line in response to consults from other hospital providers. METHODS: This is a retrospective descriptive study of all adult patients with an EGS consult request placed from July 1, 2014 to June 30, 2016 at a 1000-bed tertiary referral center. Consult requests were classified by suspected diagnosis and linked to patient demographic and clinical information. Operative and nonoperative cases were compared. RESULTS: About 4998 EGS consults were requested during the 2-y period, of which 69.6% were placed on the first day of the patient encounter. Disposition outcomes after consultation included admission to the EGS service (27.6%) and discharge from the emergency department (25.3%). Small bowel obstruction, appendicitis, and cholecystitis decisively comprised the top three diagnoses for overall consults and those requiring admission to the EGS service. For every consult requiring an operation (n = 1400), 2.6 consults were managed without an operation (n = 3598). CONCLUSIONS: EGS surgeons are asked to evaluate and manage a variety of potentially surgical diagnoses. As most consults do not require surgical intervention, operative volume is a poor surrogate for quantifying EGS productivity. The role of this service is vital to patient triage and disposition, particularly in the emergency department setting. Institutions should consider the volume of their nonoperative consultations when evaluating EGS service line workload and in guiding staffing needs.

A Contemporary Analysis of Mental Well-being Among Living Donor Kidney Applicants.

Background: Living donation is paramount for expanding the donor pool. The aim of this study was to assess changes over time in self-reported mental health of living donor kidney applicants in efforts to inform patient-centered discussions with potential donors. Methods: Kidney donor applications from 2017 through 2021 were compiled. Data included age, gender, race, ethnicity, applicant-recipient relationship, medical history, and medications. Trends over time were analyzed and post hoc analyses were performed. Results: During the study period, 2479 applicants to the living donor kidney program were evaluated; 73% of applicants were female individuals. More than half of applicants were not related to their intended recipient; this fraction increased from 46% in 2017 to 58% in 2021 (P < 0.01). A similar decline in family relations was not present among Black and Latino applicants. Of all applicants, 18% reported depression and 18% reported anxiety; 20% reported taking antidepressants or anxiolytics. Depression and anxiety increased 170% (P < 0.001) and 136% (P < 0.001) from 2018 to 2019, respectively; antidepressant and anxiolytic use rose 138% (P < 0.001) between 2018 and 2020. Conclusions: The profile of living donor applicants has changed in recent years, with approximately 1 in 5 requiring antidepressants or anxiolytics. Predonation counseling and postdonation monitoring are imperative to decrease adverse psychological outcomes for living donors.

Liver Transplantation in Elderly Recipients: Is Age Just a Number?

BACKGROUND: The proportion of older patients on the liver transplant waitlist continues to increase. With limited existing data to guide liver transplant evaluation of elderly patients, we aimed to study selection practices and outcomes of patients ≥70 years old. We hypothesized that 1-year patient and graft survival would not differ between appropriately selected elderly patients and those who are younger. METHODS: All patients referred for liver transplantation between 2018 and 2020 were stratified into elderly (age ≥70) and young (age <70) cohorts. Evaluation data pertaining to medical, surgical, and psychosocial risk assessment were reviewed. Recipient characteristics and post-operative outcomes, primarily 1-year graft and patient survival, were compared, with a median follow-up of 16.4 months. RESULTS: 322 patients underwent transplant out of 2331 referred. Elderly patients represented 230 of these referrals and 20 underwent transplant. The most common reasons for denial of elderly patients were multiple medical comorbidities (49%), cardiac risk (15%) and psychosocial barriers (13%). The median MELD of elderly recipients was lower (19 vs 24, P = .02), and proportion of hepatocellular carcinoma was higher (60% vs 23%, P < .001). There was no difference in 1-year graft (elderly 90.9% vs young 93.3%, P = .72) or patient survival (elderly 90.9% vs young 94.7%, P = .88). DISCUSSION: Liver transplant outcomes and survival are not affected by advanced age in carefully evaluated and selected recipients. Age should not be considered an absolute contraindication for liver transplant referral. Efforts should be made to develop guidelines for risk stratification and donor-recipient matching that optimize outcomes in elderly patients.

Change in Total Body Water as a Metric for Predicting Need for Outpatient Intravenous Fluids in Postoperative Bariatric Patients.

BACKGROUND: Dehydration drives a significant proportion of readmissions following bariatric surgery. Routinely performed body composition testing and total body water (TBW) calculations may present a novel method for diagnosing dehydration for outpatient intervention. We sought to determine if a change in TBW from preoperative baseline could help identify bariatric patients requiring outpatient intravenous fluid (IVF) administration for dehydration. METHODS: The VUMC Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was retroactively queried for all patients undergoing bariatric surgery at an accredited bariatric surgery center from January 1, 2017 to May 31, 2018. Body composition test results presurgery and postsurgery were extracted from the electronic health record. Change in TBW was compared between patients requiring outpatient IVF and those who did not use multivariable logistic regression. RESULTS: 583 patients underwent surgery over the study period (388 laparoscopic Roux-en-Y gastric bypass, 195 sleeve). 62 (10.6%) required outpatient fluid administration for dehydration. After multivariable analysis, patients with an increased hospital length of stay at index operation were more likely to require outpatient IVF (odds ratio [OR] 1.65, 95% CI 1.22-2.2). Preexisting diabetes diagnosis was protective (OR 0.35, 95% CI 0.16-0.74). Neither 1-week nor 1-month change in TBW from preoperative baseline was significantly different between patients receiving outpatient IVF and those who did not. CONCLUSION: Increased hospital length of stay predicts patients at risk of postoperative dehydration requiring IVF administration. Body composition testing and TBW were not useful in distinguishing between populations. Further research is needed to examine the efficacy of outpatient IVF in preventing hospital readmissions for dehydration.

Comparison of American Association for the Surgery of Trauma grading scale with modified Hinchey classification in acute colonic diverticulitis: A pilot study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. METHODS: This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. RESULTS: One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. CONCLUSION: The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Peer-led Surgical Clerkship Programming Support Through the General Surgery Interest Group at the Vanderbilt University School of Medicine.

OBJECTIVE: We present a systematic, sustainable, student-led model for supporting the Surgical Clerkship experience. DESIGN: Our model includes student-led suturing and knot-tying classes, operating room tours, skills sessions, and shelf review sessions provided systematically for each of 5 Surgical Clerkship blocks in the 2017 to 2018 academic year. SETTING: Vanderbilt University School of Medicine. PARTICIPANTS: Vanderbilt University School of Medicine Surgical Clerkship students and senior medical student instructors. RESULTS: Successful implementation of a peer-led support program for the Surgical Clerkship with a majority of students rating the helpfulness of both the operating room tours and the skills sessions a 4 or 5 on a Likert scale. CONCLUSION: Our student-led model for a Surgical Clerkship support program can be successfully implemented and demonstrates positive initial indicators of effectiveness.