Bridging the Gap: Comparison of Outpatient Clinic and Emergency Department Patients Undergoing Cholecystectomy.

INTRODUCTION: Literature shows failure of the outpatient clinic (OC) pathway after emergency department (ED) ultrasound diagnosis of symptomatic cholelithiasis (SC). We hypothesized SC to be more prevalent on final surgical pathology (FSP) in patients who successfully completed OC pathway. METHODS: This retrospective single-institution chart review compared OC and ED patients with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. Clinical evaluation was considered positive if RUQ pain >4 h, or + Murphy's sign. Ultrasound was positive if two of these three were present: sonographic Murphy's, wall thickness > 4 mm, or pericholecystic fluid. Results were compared with FSP. RESULTS: Six hundred-seven patients underwent cholecystectomy, 299 OC and 308 ED. OC was more likely to SC (23% versus 4.6%) (P < 0.0001) and ED acute cholecystitis (39.3% versus 4.7%). Chronic cholecystitis was the most common FSP in both OC (72%) and ED (56%) populations, of these, 73% of OC denied pain >4 h versus only 10% of ED (P < 0.001). Median time from evaluation to cholecystectomy was 14 d versus 14 h in the OC and ED respectively (P < 0.0001). CONCLUSIONS: While chronic cholecystitis was the most common FSP in both OC and ED, the majority of OC reported RUQ pain <4 h delineating these presentations. Duration of pain should be utilized as algorithm triage. We recommend patients with pain episode <4 h should complete OC algorithm with expedited cholecystectomy within 14 d.

Association of Age and Overall Survival in Surgically Resected Colorectal Cancer Patients.

INTRODUCTION: Incidence of colorectal cancer (CRC) among young patients has increased in the last 20 y often with more aggressive tumor biology. It is unclear if age < 50 y is an independent factor for shorter overall survival in CRC patients. Our objective was to determine if younger age at diagnosis was associated with worse overall survival. METHODS: This study used the National Cancer Data Base (2004-2016), retrospectively reviewing patients who underwent surgical resection for CRC. Patients were limited to only those without comorbidities and primary outcome was overall survival for all patients. RESULTS: Older patients have worse overall survival as compared to younger patients at a lower stage of disease (I and II) after adjusting for tumor location, gender, histology, stage, and systemic chemotherapy (< 36 y old versus 36-55 y old hazard ratio [HR] 1.16, confidence interval [CI] 1.03-1.29). This survival benefit is eliminated at a higher stage of disease, stage III in 36-55 y old versus < 36 y old (HR 0.96 [CI 0.90-1.03.99]) and stage IV (HR 0.94 [CI 0.89-0.99]). CONCLUSIONS: Older patients (aged > 36 y) have worse overall survival at a lower stage of disease, but the survival among all age groups was similar for stage III or IV disease in CRC.

Predictors of Success When Implementing an Electromagnetic Navigational Bronchoscopy Program.

INTRODUCTION: With the advent of lung cancer screening, lung nodules are being discovered at an increasing rate. With improvements in transbronchial biopsy technology, it is important for thoracic surgeons to be involved with diagnostic procedures. The aim of this project is to relate the thoracic surgeon experience in implementing an electromagnetic navigational bronchoscopy (ENB) program at our institution and describe the factors that led to successful navigation (the ability to position a biopsy instrument in range for biopsy) and diagnostic biopsy of nodules. METHODS: The thoracic surgery ENB program was initiated in 2014. A retrospective analysis of patients referred to thoracic surgery from 2014 to 2019 for lung nodule evaluation was performed. Patients who underwent ENB and biopsy were included. Recursive partitioning (CART) and multivariable regression analyses were used to identify predictors of successful navigation and biopsy. RESULTS: There were 73 patients who underwent ENB evaluation of 91 nodules from 2014 to 2019. There was successful navigation in 75.8% of nodules, and on multivariable analysis, bronchus sign, lesion size, and pleural distance were significant predictors of successful navigation. Of the lesions that had successful navigation, 65.2% had a diagnostic biopsy. Based on CART analysis, positive bronchus sign and lesion size ≥ 1.3 cm were most predictive of obtaining a diagnostic biopsy with a probability of 0.75. CONCLUSIONS: Nodule size, distance to the pleura, and bronchus size are independent variables of successful navigation when using ENB. However, of the lesions that were successfully reached, combined lesion size >1.3 cm and a positive bronchus sign were most predictive of obtaining a diagnostic biopsy. These factors should be considered when implementing an ENB program in a thoracic surgery practice.

Development of a Risk Score to Predict Post-Discharge Rehabilitation Care After Liver Metastasectomy.

INTRODUCTION: Need for discharge to intermediate care (DCIC) can increase length of stay and be a source of stress to patients. Estimating risk of DCIC would allow earlier involvement of case managers, improve length of stay and patient satisfaction by setting realistic expectations. The aim was to use National Surgical Quality Improvement Program dataset to develop a prediction model for DCIC after undergoing liver metastasectomy. METHODS: Data were obtained from National Surgical Quality Improvement Program 2011-2018 covering liver metastasectomy. Recursive partitioning narrowed potential predictors and identified thresholds for categorization of continuous variables. Logistic regression identified a predictive model, internally validated by using 200 bootstrap samples with replacement. A risk score was derived using Framingham Study methodology by dividing all regression coefficients by the smallest model coefficient. Receiver operating characteristic analysis identified the score that maximized sensitivity/specificity, defining low/high risk. Finally, recursive partitioning identified categories low/medium/high. RESULTS: The most parsimonious model predicting DCIC area under the curve (, 0.722, 95%CI: 0.705-0.739) identified five independent predictors including age >60, procedure type, hypertension requiring medication, albumin <3.5 mg/dL and hematocrit <30%. Internal validation resulted in expected bias-corrected area under the curve of 0.717, 95% CI: 0.698-0.732. The maximum score was 17.9 and 5.8 maximized sensitivity (sn) and specificity (sp) [sn = 81%, sp = 51%) predicting DCIC. Stratified into three groups, a score ≥9.5 identified highest risk (12.8%), ≥4.3 medium (6.1%) and <4.3 lowest risk (1.5%). CONCLUSIONS: Determining risk of DCIC benefits shared decision making and patient care. This evidence may enhance discharge planning after liver metastasectomy expediting the process. Age >60 contributed the most weight to the score, but the use of additional variables in three groups allowed further discrimination between patients.

Traumatic Pediatric Fatalities: Are They Preventable?

INTRODUCTION: Trauma related injury remains the leading cause of mortality in pediatric patients, many of which are preventable. The goal of our study was to identify the mechanism of injury (MOI) in pediatric trauma-related fatalities and determine if these injuries were preventable to direct future injury prevention efforts within trauma programs. METHODS: After IRB approval, a retrospective, single-institution review of pediatric (age ≤18) trauma fatalities from 2010 to 2019 was performed. MOI, use of protective devices, demographics, and whether the injury was preventable were collected. Patients were divided into five age cohorts, and frequencies and proportions were used to summarize data. Bivariate testing was done using Fisher's exact and Monte Carlo estimates for the exact test. RESULTS: MOI was found to vary by age with non-accidental trauma found to be the most common cause of trauma related deaths in children <1 (88.5%) and 1-4 (33.3%). MVC was the most common MOI in children >5 y, with 68.4% in the 5-9, 34.4% in the 10-14, and 45.8% in the 15-18 age group. The majority of fatalities resulted from a preventable injury (P < 0.0001) in the younger children with a negative association as age increased: 92.3% <1, 53.3% in 1-4, 36.8% in 5-9, 46.9% in 10-14 and 48.6% in 15-18. Of the preventable injuries, non-accidental trauma was the most common MOI in children <5, while GSW was the most common MOI in children >10. CONCLUSIONS: This study demonstrates many pediatric fatalities are the result of a preventable traumatic injury. This data can guide focused traumatic injury prevention efforts.

Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients.

BACKGROUND: Relatively few studies have compared outcomes between helicopter transport (HT) and ground transport (GT) for the inter-facility transfer of trauma patients to tertiary trauma centers (TTC). Mixed results have been reported from these studies ranging from a slight increase in odds of survival for the severely injured to no evident benefit for HT patients. We hypothesized there was no adjusted difference in mortality between patients transported interfacility by HT or GT taking into account distance from TTC. METHODS: Data from an inclusive statewide trauma registry was used to conduct a retrospective cohort study of adult (18+ years old) trauma patients who initially presented to a non-tertiary trauma center (NTC) before subsequent transfer by HT or GT to a TTC. Records from the NTC and TTC were linked (N = 9880). We used propensity adjusted, multivariable Cox proportional hazards models to assess the association of HT on mortality at 72-hour and within the first 2 weeks of arrival at a TTC; these multivariable analyses were stratified by distance (miles) between NTC and TTC: 21-90, and greater than 90. RESULTS: Mean distance between NTC and TTC was greater for HT patients, 96.7 miles versus 69.9 miles for GT. A higher proportion of patients among the HT group had an ISS of 16 or higher (24.6% vs 10.9%), an initial SBP < 90 mmHg (7.3% vs 2.8%), and GCS < 10 (12.5% vs 3.7%) than the GT group. HT was associated with significantly decreased 72-hour mortality (HR 0.65, 95%CI 0.48-0.90) for patients transferred from a NTC <90 miles from the TTC. No association was seen for patients transferred more than 90 miles to the TTC. No significant association of HT and 2-week mortality was seen at any distance from the TTC. CONCLUSIONS: Only for patients transferred from an NTC <90 miles from the receiving TTC was HT associated with a significantly decreased hazard of mortality in the first 72 hours. Many HT patients, especially from the most distant NTCs, had minor injuries and normal vital signs at both the NTC and TTC suggesting the decision to use HT for these patients was resource-driven rather than clinical.

Obesity is an Independent Risk Factor for Mortality in Otherwise Healthy Patients After Hepatectomy.

BACKGROUND: Obesity is often associated with comorbidities that limit remnant liver recovery after hepatectomy. The extent to which obesity, in the absence of comorbidities, impacts surgical risk after hepatectomy is unknown. We hypothesized that an obese population without major comorbidities would not be at increased risk of adverse outcomes after hepatectomies. METHODS: We performed a retrospective analysis identifying patients who underwent hepatectomies from the American College of Surgeons National Surgical Quality Improvement Program data set 2005-2017. Outcomes of interest included the following: mortality, any morbidity, critical care complications, and failure to discharge home. Body mass index (BMI) was the primary variable of interest, grouped as ≥35 and <35 based on bivariate tests of associations with candidate cut-off points. In attempt to isolate the effect of obesity on outcomes among patients "without major comorbidities" (WOC), we included patients without diabetes, chronic obstructive pulmonary disease, renal insufficiency, and nonsmokers; remaining patients were grouped as "with major comorbidities" (WC). Multivariable logistic regression was used to test whether obesity is independently associated with the outcomes of interest after adjustment for other covariates. RESULTS: A total of 36,396 patients were included. There were 13,754 patients in the WOC group and 22,642 in the WC group. Among patients in the WOC group, the adjusted odds of mortality were 2.2 times higher for patients with a BMI ≥35 versus a BMI <35. Among the patients in the WC group, a BMI ≥35 was not a statistically significant predictor of mortality after adjustment for other covariates. Obese patients had increased odds of each outcome among the WOC group. CONCLUSIONS: Our hypothesis was refuted by these data. In fact, the adverse effect of obesity was more evident among healthy patients.

Propofol administration for induction is associated with peri-intubation instability in trauma critical care unit patients.

INTRODUCTION: Peri-intubation hypotension is associated with increased hospital length of stay and morbidity. Propofol is associated with alterations in hemodynamics. We hypothesize that using propofol for induction leads to peri-intubation hypotension in trauma critical care patients. METHODS: Patients that underwent unplanned intubation in the trauma intensive care unit (TICU) were prospectively enrolled. Peri-intubation vitals and medications were recorded to assess hypotension within 10 â€‹min of intubation. Patients were divided into propofol (PROP) or other medication (OTR) groups. RESULTS: Data was complete for 69 patients; 31 PROP and 38 OTR. In OTR there was an 8.8-point (-21.1, 3.6) SBP decrease (p â€‹= â€‹0.159) and in PROP there was a 30.8-point (-45.6, -16.0) SBP decrease (p â€‹= â€‹0.0002) with significant increases in heart rate (HR) and shock index (SI) (HR p â€‹= â€‹0.001, SI p â€‹< â€‹0.0001). CONCLUSION: In patients without hypotension prior to intubation, we observed a statistically significant drop in the patients' SBP with use of propofol. In trauma critical care unit patients, we recommend considering an induction medication for unplanned intubation other than propofol.

Learning Curve of a Laparoscopic Pancreaticoduodenectomy Program at a Second Institution.

BACKGROUND: Historically, pancreaticoduodenectomy (PD) has been performed via a laparotomy, but increasingly, laparoscopic and robotic platforms are being employed for PD. Laparoscopic PD has a steep surgeon specific learning curve and programmatic elements that must be optimized. These factors may limit a surgeon who is proficient at laparoscopic PD to develop a program at another institution. We hypothesize that the learning curve for a surgeon transferring a program to a second institution is shorter than the initial laparoscopic PD learning curve for the same surgeon. METHODS: A retrospective review of patients who underwent laparoscopic PD for any indication at the first institution (FI) from 2012 to 2017 and the second institution (SI) from 2018 to 2021 was conducted. Standard statistical analysis was performed. The learning curve was identified using one-sided CUSUM analysis of operative times. RESULT: We identified 110 participants, 90 from the FI and 20 from the SI. More patients at the FI were diagnosed with periampullary adenocarcinoma on final pathology compared to the SI (65.6% vs 40.0%, P = .0132). FI operative times stabilized after the 25th laparoscopic PD and SI operative times stabilized after the 5th operation. No statistically significant difference was identified in postoperative complications. CONCLUSIONS: The learning curve and average operative time of an SI laparoscopic PD program was shorter than the initial learning curve for a single surgeon with comparable outcomes. This suggests that complex minimally invasive surgical programs can be safely transferred to another high-volume institution without significant loss of progress.

Association of Cardiovascular Disease Risk Factors with Exclusive Smokeless Tobacco Use among US Males: Cross-Sectional Analysis of NHANES Data 2003-2018.

PURPOSE: To evaluate cardiovascular disease (CVD) risk factors among smokeless tobacco (ST) users. Exclusive ST users were compared to exclusive cigarette smokers and non-tobacco users. DESIGN: Cross-sectional study. SAMPLE: Data were used from 16,336 adult males who participated in one of the National Health and Nutrition Examination Surveys (NHANES) from 2003 to 2018. MEASURES: Biochemically verified tobacco use, CVD risk factors (hypertension, cholesterol levels, BMI categories), physical activity, cotinine concentration, and sociodemographic variables. ANALYSIS: Weighted analysis of the aggregate data was performed. ST users were compared with cigarette smokers and nontobacco users for their association with CVD risk factors. Associations were examined using univariate and multiple logistic regression with odds ratios (OR) and 95% confidence intervals (CI) reported. RESULTS: Prevalence of exclusive ST use was 4.4% whereas, exclusive smoking was 22.2%. Among ST users, 36.2% were hypertensive, 24.5% had high cholesterol levels, and most of them were overweight (31.1%) or obese (52.6%). ST users were more likely to have hypertension compared to smokers (aOR = 1.48, 95%CI: 1.12, 1.95) and nontobacco users (aOR = 1.41, 95%CI: 1.09, 1.83) adjusted for other covariates. ST users were twice more likely to be obese than nontobacco users (aOR = 2.18, 95%CI: 1.52, 3.11). ST users had significantly higher cotinine concentration than smokers. CONCLUSION: Study findings indicate substantial association of ST use among males with hypertension and obesity which are independent risk factors of CVD.

Bidirectionality of smoking and depression in adolescents: a systematic review.

INTRODUCTION: Recently, evidence has been accumulating that both smoking and mental health disorders are continuously increasing among adolescents. This systematic review elucidates the research into evidence of the direction of the association and risk factors influencing the relationship between smoking and depression. We also highlight recent studies on the effects of electronic cigarettes and developments on the association between depression and smoking. METHODS: A literature search was conducted on databases including PubMed, Ovid Medline, EMBASE, and PsycINFO and in relevant neurology and psychiatry journals. Terms used for electronic searches included smoking, tobacco, cigarettes; depression; adolescent, youth; direction. Relevant information was then utilized to synthesize findings on the association between smoking and depression among adolescent population. RESULTS: The initial database searches yielded 2,738 related articles. After screening and cross-referencing, duplicate articles, articles published in languages other than English, and studies on animals, social and lifestyle factors, mood disorders, and substance use were excluded. Of these, a total of 122 publications only focusing on smoking and depression in the adolescent population were selected for synthesis in this qualitative systemic review. These include 110 original research articles, eight meta-analyses and reviews, and four reports and websites. CONCLUSION: The relationship between smoking and depression in the literature does not reflect the cause-effect relationship. The lack of evidence on the direction of the association may reflect futile study designs, confounding factors and/or use of indirect measures of depression and quantification of smoking. Future prospective randomized studies should target elucidation of the causal association.

Not all cholecystitis is created equal: Disparities contributing to ED presentation and failure of the outpatient algorithm.

BACKGROUND: The majority of final surgical pathology (FSP) from both emergency department (ED) and outpatient clinic (OC) patients is chronic cholecystitis. We aimed to differentiate these presentations and identify disparities associated with ED utilization and OC failure. METHODS: Retrospective chart review of single institution ED and OC cholecystectomies for cholelithiasis. Clinical presentation, FSP, demographics, and zip code poverty (ZCP) levels were evaluated. Data analysis by summary statistics, bivariate comparisons, and logistic regression. RESULTS: Of 299 OC and 308 ED patients, OC was more likely to be Caucasian (78% vs 46%, p < 0.0001) and insured (89% vs. 32%, p < 0.0001). 71.8% of OC with ZCP <10% had insurance versus only 32.5% in ZCP >20%. Uninsured ED OR was 13.1 (95% CI 8.7-22.9). CONCLUSION: Uninsured ED patients are vulnerable to fail the outpatient algorithm, especially when misdiagnosed by US. Clinical diagnosis of cholecystitis in this population should warrant offering of urgent cholecystectomy.

A Retrospective Case Control Study Examining Procalcitonin as a Biomarker for Necrotizing Enterocolitis.

Background: Procalcitonin (PCT) is a biomarker for sepsis, but its utility has not been investigated in necrotizing enterocolitis (NEC). Necrotizing enterocolitis is a devastating multisystem disease of infants that in severe cases requires surgical intervention. We hypothesize that an elevated PCT will be associated with surgical NEC. Patients and Methods: After obtaining Institutional Review Board (IRB) approval (#12655), we performed a single institution retrospective case control study between 2010 and 2021 of infants up to three months of age. Inclusion criteria was PCT drawn within 72 hours of NEC or sepsis diagnosis. Control infants had a PCT drawn in the absence of infectious symptoms. Recursive partitioning (RP) identified PCT cutoffs. Categorical variable associations were tested using Fisher exact or χ2 tests. Continuous variables were tested using Wilcoxon rank sum test, Student t-test, and Kruskal-Wallis test. Adjusted associations of PCT and other covariables with NEC or sepsis versus controls were obtained via multinomial logistic regression analysis. Results: We identified 49 patients with NEC, 71 with sepsis, and 523 control patients. Based on RP, we selected two PCT cutoffs: 1.4 ng/mL and 3.19 ng/ml. A PCT of ≥1.4 ng/mL was associated with surgical (n = 16) compared with medical (n = 33) NEC (87.5% vs. 39.4%; p = 0.0015). A PCT of ≥1.4 ng/mL was associated with NEC versus control (p < 0.0001) even when adjusting for prematurity and excluding stage IA/IB NEC (odds ratio [OR], 28.46; 95% confidence interval [CI], 11.27-71.88). A PCT of 1.4-3.19 ng/mL was associated with both NEC (adjusted odds ratio [aOR], 11.43; 95% CI, 2.57-50.78) and sepsis (aOR, 6.63; 95% CI, 2.66-16.55) compared with controls. Conclusions: A PCT of ≥1.4 ng/mL is associated with surgical NEC and may be a potential indicator for risk of disease progression.

Blunt Cerebrovascular Injury in Pediatric Hanging Victims.

INTRODUCTION: Incidence of blunt cerebrovascular injury (BCVI) following hanging in the pediatric population is ill-defined. Current guidelines recommend screening imaging during the initial trauma evaluation. Necessity of screening is questioned given BCVI is considered rare after hanging, especially when asymptomatic. This study aims to elucidate the incidence of BCVI in pediatric hangings and determine the value of radiographic work-up. METHODS: A retrospective cohort study was performed of pediatric hangings reported to the National Trauma Data Bank (NTDB), 2017-2019. Imaging, diagnoses, and findings suggestive of BCVI, such as Glasgow Coma Scale (GCS) ≤8, presence of cervical injury, and soft tissue injury were considered. Statistical analysis was carried out to compare incidence. RESULTS: 197 patients met study criteria, with 179 arriving in the trauma bay with signs of life. BCVI incidence was 5.6% (10 of 179). Computed Tomography Angiography (CTA) of the neck was the only reported screening modality in this data set. A CTA was completed in 46% of the cases. DISCUSSION: BCVI incidence following pediatric hanging is more common than previously thought. Less than half of patients had a CTA reported in this cohort. This may result in an underestimate. Given the potentially devastating consequences of a missed BCVI, the addition of CTA to initial work-up may be worthwhile to evaluate for cervical vascular injury, but further studies into the outcomes of children who do receive prophylactic therapy are needed.

The Effect of Body Mass Index on the Creation of an End-Colostomy in Rectal Cancer Patients.

With the increasing prevalence of obesity, there has been a parallel increase in the incidence of rectal cancer. The association of body mass index (BMI) and end-colostomy creation versus primary anastomosis in patients undergoing proctectomy for rectal cancer has not been described. This is a retrospective study of patients with rectal cancer from 2012 to 2018 using data from the National Surgical Quality Improvement Project. 16,446 (92.1%) underwent primary anastomosis and 1,418 (7.9%) underwent creation of an end-colostomy. Patients with a BMI of 25-29.9 (overweight) comprised the most frequent group to have a proctectomy (reference group), but the least likely to have an end-colostomy. Patients with severe obesity (BMI 50+) had an adjusted odds ratio for end-colostomy of 2.7 (95% CI 1.5-4.7) compared to the reference group. Patients who have severe obesity should be counseled regarding the likelihood of an end-colostomy and may benefit from medical weight management or weight-loss surgery.

Simultaneous Detection of Multiple Tumor-targeted Gold Nanoparticles in HER2-Positive Breast Tumors Using Optoacoustic Imaging.

Purpose To develop optoacoustic, spectrally distinct, actively targeted gold nanoparticle-based near-infrared probes (trastuzumab [TRA], TRA-Aurelia-1, and TRA-Aurelia-2) that can be individually identifiable at multispectral optoacoustic tomography (MSOT) of human epidermal growth factor receptor 2 (HER2)-positive breast tumors. Materials and Methods Gold nanoparticle-based near-infrared probes (Aurelia-1 and 2) that are optoacoustically active and spectrally distinct for simultaneous MSOT imaging were synthesized and conjugated to TRA to produce TRA-Aurelia-1 and 2. Freshly resected human HER2-positive (n = 6) and HER2-negative (n = 6) triple-negative breast cancer tumors were treated with TRA-Aurelia-1 and TRA-Aurelia-2 for 2 hours and imaged with MSOT. HER2-expressing DY36T2Q cells and HER2-negative MDA-MB-231 cells were implanted orthotopically into mice (n = 5). MSOT imaging was performed 6 hours following the injection, and the Friedman test was used for analysis. Results TRA-Aurelia-1 (absorption peak, 780 nm) and TRA-Aurelia-2 (absorption peak, 720 nm) were spectrally distinct. HER2-positive human breast tumors exhibited a significant increase in optoacoustic signal following TRA-Aurelia-1 (28.8-fold) or 2 (29.5-fold) (P = .002) treatment relative to HER2-negative tumors. Treatment with TRA-Aurelia-1 and 2 increased optoacoustic signals in DY36T2Q tumors relative to those in MDA-MB-231 controls (14.8-fold, P < .001; 20.8-fold, P < .001, respectively). Conclusion The study demonstrates that TRA-Aurelia 1 and 2 nanoparticles operate as a spectrally distinct HER2 breast tumor-targeted in vivo optoacoustic agent. Keywords: Molecular Imaging, Nanoparticles, Photoacoustic Imaging, Breast Cancer Supplemental material is available for this article. © RSNA, 2023.

Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is indication for urgent cholecystectomy: A comparison of clinical, ultrasound, and pathologic diagnosis.

BACKGROUND: Biliary pathology is a common reason for emergency department visits with discharge and outpatient follow up if sonographic evaluation does not reveal evidence of cholecystitis. This retrospective review was conducted to assess the sensitivity of clinical versus sonographic evaluation for indication of urgent cholecystectomy. METHODS: Retrospective chart review of 308 patients who presented to the emergency department (ED) with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. The history and physical exam, laboratory values, ultrasound (US), and final surgical pathology were compared for accuracy of clinical to pathologic diagnosis. RESULTS: 95.5% of our patients that presented to the ED secondary to RUQ pain with cholelithiasis had pathologic cholecystitis. Sensitivity of clinical diagnosis was superior to US findings as compared to pathologic diagnosis of cholecystitis at 96% vs 44% and 87% vs 18% for acute (AC) and chronic cholecystitis (CC) respectively. CONCLUSION: RUQ pain with known cholelithiasis lasting longer than 4 hours is sensitive for pathologic cholecystitis. This finding, even with the absence of sonographic evidence of cholecystitis, is indication for index encounter urgent cholecystectomy.

Risk Factors Associated With Readmission After Pancreatectomy: A Single-Institution Retrospective Cohort Study.

BACKGROUND: Pancreatectomy has a significant rate of procedure-specific morbidity which can result in readmission. Readmission has been proposed as a measure of quality. The goal of this study is to determine what factors are associated with readmission after pancreatectomy and whether readmission can be prevented. METHODS: A retrospective review of a single institution's pancreatectomies between January 2011 and April 2015 was performed. Demographic, perioperative, and outpatient data were collected from the medical record. Primary outcome was 90-day readmission. Univariate and multivariable analyses were performed to determine which factors were associated with increased risk for readmission. RESULTS: A total of 257 patients met inclusion criteria; the 90-day readmission rate was 32.7%. The median time to readmission was 13 days. Readmitted patients were more likely to have a postoperative pancreatic fistula (POPF) on univariate analysis. Surgical site infections were more common in readmitted patients (18% vs 6.4%, P = .0138). Upon multivariable adjustment, only POPF (P = .0005) remained significant. A positive dose-response relationship was noted between POPF grade and the odds of readmission with odds ratios (ORs) ranging from 1.6 (95% Confidence Interval (CI): .6-4.1) for grade A to 16.7 (95% CI: 1.8-156.8) for grade C, albeit with limited precision. CONCLUSIONS: Readmission after pancreatectomy is a common occurrence despite the many advancements in perioperative care. Our data suggest that POPF is a risk factor for readmission after pancreatectomy. Presently, this factor is not clearly preventable. This suggests that readmission may not be the best measure of quality to utilize in the evaluation of pancreatic surgery.

Retrospective Cohort Analysis of the Effect of Age on Lymph Node Harvest, Positivity, and Ratio in Colorectal Cancer.

Introduction: Colon cancer among young patients has increased in incidence and mortality over the past decade. Our objective was to determine if age-related differences exist for total positive nodes (TPN), total lymph node harvest (TLH), and lymph node ratio (LNR). Material and Methods: A retrospective review of stage III surgically resected colorectal cancer patient data in the National Cancer Database (2004−2016) was performed, reviewing TPN, TLH, and LNR (TPN/TLH). Results: Unadjusted analyses suggested significantly higher levels of TLH and TPN (p < 0.0001) in younger patients, while LNR did not differ by age group. On adjusted analysis, TLH remained higher in younger patients (<35 years 1.56 (CI 95 1.54, 1.59)). The age-related effect was less pronounced for LNR (<35 years 1.16 (CI 95 1.13, 1.2)). Conclusion: Younger patients have increased TLH, even after adjusting for known confounders, while age does not have a strong independent impact on LNR.

Retrospective review of intervention for traumatic blunt spleen injuries in adolescents by trauma center type.

BACKGROUND: Management guidelines for pediatric blunt spleen injuries (BSI) include adolescent patients but few studies have compared current management of adolescents with respect to other age groups by center type. METHODS: A retrospective review of 2017-2018 National Trauma Quality Improvement (TQIP) data of children (6-12), adolescents (13-17) and young adults (18-24) with BSI presenting to an adult, pediatric only, or adult/pediatric trauma center, comparing the rate of splenic intervention for adolescents by trauma center was performed. RESULTS: Children had lower odds of spleen intervention than adolescents at both adult (OR 0.61 95%CI 0.39, 0.95) and adult/pediatric (OR 0.55 95%CI 0.35, 0.87) centers but did not differ at pediatric centers (OR 0.94 95%CI 0.39, 2.2) (n = 10,494). Adolescents adjusted odds of intervention was equal to adults at adult trauma centers (OR 1.2 95%CI 0.95, 1.4). CONCLUSION: Adolescents are more likely to undergo interventions for BSI as compared to children at both adult and adult/pediatric trauma centers.