Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

A Technique to Minimize Aerosolization During Percutaneous Tracheostomy in COVID-19 Patients.

BACKGROUND: The SARS-CoV-2 pandemic has caused respiratory failure in many patients. With no effective treatment or vaccine, prolonged mechanical ventilation is common in survivors. Timing and performance of tracheostomy, for both patient and surgical team safety, remains a question. Here within, we report our experience with percutaneous dilatational tracheostomy with modification to minimize aerosolization. METHODS: A modified percutaneous dilatational tracheostomy technique is described. The technique was performed on 10 patients in the surgical intensive care unit. RESULTS: Ten patients underwent percutaneous dilatational tracheostomy. There were 7 males, and the average age for the group was 60.8 years. The average number of ventilator days before the operation was 26.3. All procedures were successful, and no patient had any procedure-related complications. CONCLUSIONS: The procedure described was successful in our patient population. We believe that this approach is safe for patients with coronavirus disease 2019 and limits aerosolization during the operation. LEVEL OF EVIDENCE: Level IV, case series.

An analysis of 979 patients with pelvic fractures stratified by the presence or absence of solid organ injury.

BACKGROUND: Pelvic fractures (PF) require high force mechanism and their severity have been linked with an increase in the incidence of associated injuries within the abdomen and chest. Our goal is to assess the impact of solid organ injury (SOI) on the outcome of patients with PF and to identify risk factors predictive of morbidity and mortality among these patients. STUDY DESIGN: We conducted a single-center retrospective review of medical records of patients 16 years or older admitted to our level 1 trauma center with pelvic fracture with and without OI associated from blunt trauma between 1/1/2010-7/31/2015. RESULTS: 979 patients with PF were identified. 261/979 (26.7%) had at least one associated SOI. The grade of the SOI ranged from I to III in 246 patients, grade IV in five patients and grade V in 10 patients with SOI sustained a higher pelvic AIS grade and required a statistically significant greater amount of blood products (BP). Thoracic and urogenital injuries were also more common. The mortality of patients with PF was not affected by the presence of SOI. Increasing age, Injury Severity Score, Glasgow Coma Scale, hypothermia and the amount of BP transfused were predictive of mortality. CONCLUSIONS: The presence of SOI did not affect the outcome of patients with pelvic fracture, although our results may be linked to the limited number of patients with high grade SOI. The degree of pelvic AIS is predictive of associated injuries within the abdomen and chest.

Colorectal resection in emergency general surgery: An EAST multicenter trial.

OBJECTIVE: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.