Inferior Vena Cava Ligation and Pancreaticoduodenectomy in a Patient With Penetrating Abdominal Trauma.

INTRODUCTION: Injury to the inferior vena cava (IVC) is often fatal. Pancreaticoduodenectomy for trauma is also rare. This case describes a patient who underwent both procedures. CASE PRESENTATION: A 30-year-old male presented status post gunshot to the abdomen. He was taken to the operating room and found to have 6 cm defect in the IVC, which was ligated. Despite resuscitation, the patient required emergent return to the OR where bleeding from the pancreaticoduodenal artery was noted in addition to injuries in the stomach, duodenum, and pancreas. He subsequently underwent a pancreaticoduodenectomy. He was discharged after a month-long hospital stay. CONCLUSIONS: This case demonstrates that IVC ligation is a form of damage of control surgery. Pancreaticoduodenectomy is rarely performed during the index operation for trauma patients. Patient with injuries to the pancreaticoduodenal complex can be life-threatening if not rapidly controlled. This patient is a rare example of someone who survived two morbid trauma surgery interventions.

Estimated vs measured energy expenditure in ventilated surgical-trauma critically ill patients.

BACKGROUND: The American and European guidelines recommend measuring resting energy expenditure (REE) using indirect calorimetry (IC). Predictive equations (PEs) are used to estimate REE, but there is limited evidence for their use in critically ill patients. The aim of this study is to evaluate the degree of agreement and accuracy between IC-measured REE (REE-IC) and 10 different PEs in mechanically ventilated critically ill patients with surgical trauma who met their estimated energy requirement. METHODS: REE-IC was retrospectively compared with REE-PE by 10 PEs. The degree of agreement between REE-PE and REE-IC was analyzed by the Bland-Altman test (BAt) and the concordance correlation coefficient (CCC). The accuracy was calculated by the percentage of patients whose REE-PE values differ by up to ±10% in relation to REE-IC. All analyses were stratified by gender and body mass index (BMI; <25 vs ≥25). RESULTS: We analyzed 104 patients and the closest estimate to REE-IC was the modified Harris-Benedict equation (mHB) by the BAt with a mean difference of 49.2 overall (61.6 for males, 28.5 for females, 67.5 for BMI <25, and 42.5 for BMI ≥25). The overall CCC between the REE-IC and mHB was 0.652 (0.560 for males, 0.496 for females, 0.570 for BMI <25, and 0.598 for BMI ≥25). The mHB equation was the most accurate with an overall accuracy of 44.2%. CONCLUSION: The effectiveness of PEs for estimating the REE of mechanically ventilated surgical-trauma critically ill patients is limited. [Correction added on 17 February 2022, after first online publication: The word "with" was deleted before "is limited" in the preceding sentence.] Nonetheless, of the 10 equations examined, the closest to REE-IC was the mHB equation.

Clinical Impact of a Dedicated Trauma Hybrid Operating Room.

BACKGROUND: Early hemorrhage control is essential to optimal trauma care. Hybrid operating rooms offer early, concomitant performance of advanced angiographic and operative hemostasis techniques, but their clinical impact is unclear. Herein, we present our initial experience with a dedicated, trauma hybrid operating room. STUDY DESIGN: This retrospective cohort analysis of 292 adult trauma patients undergoing immediate surgery at a Level I trauma center compared patients managed after implementation of a dedicated, trauma hybrid operating room (n = 186) with historic controls (n = 106). The primary outcomes were time to hemorrhage control (systolic blood pressure ≥ 100 mmHg without ongoing vasopressor or transfusion requirements), early blood product administration, and complication. RESULTS: Patient characteristics were similar between cohorts (age 41 years, 25% female, 38% penetrating trauma). The hybrid cohort had lower initial hemoglobin (10.2 vs 11.1 g/dL, p = 0.001) and a greater proportion of patients undergoing resuscitative endovascular balloon occlusion of the aorta (9% vs 1%, p = 0.007). Cohorts had similar case mixes and intraoperative consultation with cardiothoracic or vascular surgery (13%). Twenty-one percent of all hybrid cases included angiography. The interval between operating room arrival and hemorrhage control was shorter in the hybrid cohort (49 vs 60 minutes, p = 0.005). From 4 to 24 hours after arrival, the hybrid cohort had fewer red cell (0.0 vs 1.0, p = 0.001) and plasma transfusions (0.0 vs 1.0, p < 0.001). The hybrid cohort had fewer infectious complications (15% vs 27%, p = 0.009) and ventilator days (2.0 vs 3.0, p = 0.011), and similar in-hospital mortality (13% vs 10%, p = 0.579). CONCLUSIONS: Implementation of a dedicated, trauma hybrid operating room was associated with earlier hemorrhage control and fewer early blood transfusions, infectious complications, and ventilator days.

Audiovisual Modules to Enhance Informed Consent in the ICU: A Pilot Study.

Obtaining informed consent for commonly performed ICU procedures is often compromised by variability in communication styles and inadequate verbal descriptions of anatomic concepts. The objective of this study was to evaluate the efficacy of an audiovisual module in improving the baseline knowledge of ICU procedures among patients and their caregivers. DESIGN: Prospective, observational study. SETTING: Forty-eight-bed adult surgical ICU at a tertiary care center. SUBJECTS: Critically ill surgical patients and their legally authorized representatives. INTERVENTIONS: An audiovisual module describing eight commonly performed ICU procedures. MEASUREMENTS AND MAIN RESULTS: Fifty-nine subjects were enrolled and completed an 11-question pre- and postvideo test of knowledge regarding commonly performed ICU procedures and a brief satisfaction survey. Twenty-nine percent had a healthcare background. High school was the highest level of education for 37% percent of all subjects. Out of 11 questions on the ICU procedure knowledge test, subjects scored an average 8.0 ± 1.9 correct on the pretest and 8.4 ± 2.0 correct on the posttest (p = 0.055). On univariate logistic regression, having a healthcare background was a negative predictor of improved knowledge (odds ratio, 0.185; 95% CI, 0.045-0.765), indicating that those with a health background had a lower probability of improving their score on the posttest. Among subjects who did not have a healthcare background, scores increased from 7.7 ± 1.9 to 8.3 ± 2.1 (p = 0.019). Seventy-five percent of all subjects indicated that the video was easy to understand, and 70% believed that the video improved their understanding of ICU procedures. CONCLUSIONS: Audiovisual modules may improve knowledge and comprehension of commonly performed ICU procedures among critically ill patients and caregivers who have no healthcare background.

Occult bowel injury after blunt abdominal trauma.

BACKGROUND: Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan. METHODS: Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%). RESULTS: The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37-10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03-5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52-13.13). CONCLUSIONS: Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.

The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma.

BACKGROUND: Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma. METHODS: We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury. RESULTS: There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88). CONCLUSIONS: Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy.

BACKGROUND: To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN: We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS: Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS: Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Adhesive Closed-loop Small Bowel Obstruction.

Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands that form following iatrogenic peritoneal injury. Rarely, adhesive SBO may arise without previous intra-abdominal surgery through other modes of peritoneal trauma. We present the case of a male evaluated in the emergency department for a closed-loop small bowel obstruction due to an adhesive band that likely formed after blunt abdominal trauma over two decades earlier. We review the epidemiology, pathophysiology, and treatment options for similar cases of adhesive SBO.

A protocol for non-operative management of uncomplicated appendicitis.

BACKGROUND: We developed a protocol to identify candidates for non-operative management (NOM) of uncomplicated appendicitis. Our objective was to evaluate protocol efficacy with the null hypothesis that clinical outcomes, hospital readmission rates, and hospital charges would be unchanged after protocol implementation. METHODS: We performed a single-center 4-year propensity score matched retrospective cohort analysis of 406 patients with acute uncomplicated appendicitis. The protocol recommended NOM for patients with modified Alvarado score ≤6 and no appendicolith. Patients admitted before (n = 203) and after (n = 203) protocol implementation were matched by Charlson comorbidity index, duration of symptoms, and modified Alvarado score. Outcomes included operative management, days on antibiotic therapy, length of stay, and hospital charges, as well as readmissions, complications, and mortality within 180 days. RESULTS: Baseline characteristics were similar between groups (age 31 years, ASA class 2.0, Charlson comorbidity index 0.0). Protocol compliance was higher when the protocol recommended appendectomy (97%) rather than NOM (73%, p < 0.001). The incidence of operative management decreased from 99% to 82% after protocol implementation (p < 0.001). In the protocol group, there was a lower incidence of open surgery (4% vs. 10%, p = 0.044) despite a longer interval between admission and surgery (8.6 vs. 7.1 hours, p < 0.001). After protocol implementation, 51 patients had NOM: 18 failed NOM during admission and 6 failed NOM after discharge. Compared to the pre-protocol group, the protocol group had similar length of stay, antibiotic days, and overall complication rates, but more readmissions (6% vs. 1%, p = 0.019) and lower hospital charges for the index admission ($5,630 vs. $6,878, p < 0.001). CONCLUSIONS: Implementation of a protocol to identify candidates for NOM of acute uncomplicated appendicitis was associated with lower rates of open surgery, fewer appendectomies, decreased hospital charges, and no difference in overall complications despite high rates of readmission and failure of NOM. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Effect of Time to Operation on Value of Care in Acute Care Surgery.

BACKGROUND: As reimbursement models evolve, there is increasing emphasis on maximizing value-based care for inpatient conditions. We hypothesized that longer intervals between admission and surgery would be associated with worse outcomes and increased costs for acute care surgery patients, and that these associations would be strongest among patients with high-risk conditions. METHODS: We performed a 5-year retrospective analysis of three risk cohorts: appendectomy (low-risk for morbidity and mortality, n = 618), urgent hernia repair (intermediate-risk, n = 80), and laparotomy for intra-abdominal sepsis with temporary abdominal closure (sTAC; high-risk, n = 102). Associations between the interval from admission to surgery and outcomes including infectious complications, mortality, length of stay, and hospital charges were assessed by regression modeling. RESULTS: Median intervals between admission and surgery for appendectomy, hernia repair, and sTAC were 9.3, 13.5, and 8.1 h, respectively, and did not significantly impact infectious complications or mortality. For appendectomy, each 1 h increase from admission to surgery was associated with increased hospital LOS by 1.1 h (p = 0.002) and increased intensive care unit (ICU) LOS by 0.3 h (p = 0.011). For hernia repair, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 1.6 h (p = 0.007), increased hospital LOS by 3.3 h (p = 0.002), increased ICU LOS by 1.5 h (p = 0.001), and increased hospital charges by $1918 (p < 0.001). For sTAC, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 5.0 h (p = 0.006), increased hospital LOS by 3.9 h (p = 0.046), increased ICU LOS by 3.5 h (p = 0.040), and increased hospital charges by $3919 (p = 0.002). CONCLUSIONS: Longer intervals from admission to surgery were associated with prolonged antibiotic administration, longer hospital and ICU length of stay, and increased hospital charges, with strongest effects among high-risk patients. To improve value of care for acute care surgery patients, operations should proceed as soon as resuscitation is complete.

Hypertonic saline resuscitation after emergent laparotomy and temporary abdominal closure.

BACKGROUND: Our objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function. METHODS: We performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury. RESULTS: The HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003). CONCLUSION: Hypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury. LEVEL OF EVIDENCE: Prognostic study, level II.

Characterization of hypoalbuminemia following temporary abdominal closure.

BACKGROUND: The purpose of this study was to characterize associations among serum proteins, negative-pressure wound therapy (NPWT) fluid loss, and primary fascial closure (PFC) following emergent laparotomy and temporary abdominal closure (TAC). We hypothesized that high levels of C-reactive protein (CRP) and NPWT output would be associated with hypoalbuminemia and failure to achieve PFC. METHODS: We performed a retrospective analysis of 233 patients managed with NPWT TAC. Serum proteins and resuscitation indices were assessed on admission, initial laparotomy, and then at 48 hours, 96 hours, 7 days, and discharge. Correlations were assessed by Pearson coefficient. Multivariable regression was performed to identify predictors of PFC with cutoff values for continuous variables determined by Youden index. RESULTS: Patients who failed to achieve PFC (n = 55) had significantly higher CRP at admission (249 vs. 148 mg/L, p = 0.003), initial laparotomy (237 vs. 154, p = 0.002), and discharge (124 vs. 72, p = 0.003), as well as significantly lower serum albumin at 7 days (2.3 vs. 2.5 g/dL, p = 0.028) and discharge (2.5 vs. 2.8, p = 0.004). Prealbumin (in milligrams per deciliter) was similar between groups at each time point. There was an inverse correlation between nadir serum albumin and total milliliters of NPWT output (r = -0.33, p < 0.001). Exogenous albumin administration (in grams per day) correlated with higher serum albumin levels at each time point: 48 hours: r = 0.26 (p = 0.002), 96 hours: r = 0.29 (p = 0.002), 7 days: r = 0.40 (p < 0.001). Albumin of less than 2.6 g/dL was an independent predictor of failure to achieve PFC (odds ratio, 2.59; 95% confidence interval, 1.02-6.61) in a multivariate model including abdominal sepsis, body mass index of greater than 40 kg/m, and CRP of greater than 250 mg/L. CONCLUSIONS: Early and persistent systemic inflammation and high NPWT output were associated with hypoalbuminemia, which was an independent predictor of failure to achieve PFC. The utility of exogenous albumin following TAC requires further study. LEVEL OF EVIDENCE: Prognostic study, level III; Therapeutic study, level IV.

Neural network prediction of severe lower intestinal bleeding and the need for surgical intervention.

BACKGROUND: The prognosis for patients with severe acute lower intestinal bleeding (ALIB) may be assessed by complex artificial neural networks (ANNs) or user-friendly regression-based models. Comparisons between these modalities are limited, and predicting the need for surgical intervention remains elusive. We hypothesized that ANNs would outperform the Strate rule to predict severe bleeding and would also predict the need for surgical intervention. METHODS: We performed a 4-y retrospective analysis of 147 adult patients who underwent endoscopy, angiography, or surgery for ALIB. Baseline characteristics, Strate risk factors, management parameters, and outcomes were analyzed. The primary outcomes were severe bleeding and surgical intervention. ANNs were created in SPSS. Models were compared by area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals. RESULTS: The number of Strate risk factors for each patient correlated significantly with the outcome of severe bleeding (r = 0.29, P < 0.001). However, the Strate model was less accurate than an ANN (AUROC 0.66 [0.57-0.75] versus 0.98 [0.95-1.00], respectively) which incorporated six variables present on admission: hemoglobin, systolic blood pressure, outpatient prescription for Aspirin 325 mg daily, Charlson comorbidity index, base deficit ≥5 mEq/L, and international normalized ratio ≥1.5. A similar ANN including hemoglobin nadir and the occurrence of a 20% decrease in hematocrit was effective in predicting the need for surgery (AUROC 0.95 [0.90-1.00]). CONCLUSIONS: The Strate prediction rule effectively stratified risk for severe ALIB, but was less accurate than an ANN. A separate ANN accurately predicted the need for surgery by combining risk factors for severe bleeding with parameters quantifying blood loss. Optimal prognostication may be achieved by integrating pragmatic regression-based calculators for quick decisions at the bedside and highly accurate ANNs when time and resources permit.

Emergent laparotomy and temporary abdominal closure for the cirrhotic patient.

BACKGROUND: Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients. METHODS: We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals. RESULTS: At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients. CONCLUSIONS: Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.

Computed tomography evidence of fluid in the hernia sac predicts surgical site infection following mesh repair of acutely incarcerated ventral and groin hernias.

BACKGROUND: Mesh placement during repair of acutely incarcerated ventral and groin hernias is associated with high rates of surgical site infection (SSI). The utility of preoperative computed tomography (CT) in this setting is unclear. We hypothesized that CT evidence of bowel wall compromise would predict SSI while accounting for physiologic parameters. METHODS: We performed a 4-year retrospective cohort analysis of 50 consecutive patients who underwent mesh repair of acutely incarcerated ventral or groin hernias. We analyzed chronic disease burden, acute illness severity, CT findings, operative management, and herniorrhaphy-specific outcomes within 180 days. The primary outcome was SSI by the Centers for Disease Control and Prevention criteria. Multiple logistic regression was performed to identify independent predictors of SSI. RESULTS: Eighty-four percent of all patients were American Society of Anesthesiologists class III or IV, 28% were active smokers, and mean body mass index (BMI) was 35 kg/m. Fifty-four percent had ventral hernias, 40% had inguinal hernias, and 6% had femoral or combined inguinal/ femoral hernias. Seventy percent of preoperative CT scans had features suggesting bowel compromise, abdominal free fluid, or fluid in the hernia sac. Surgical site infection occurred in 32% of all patients (8% superficial, 24% deep or organ/space). The strongest predictors of SSI were CT evidence of fluid in the hernia sac (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.7-41), initial heart rate 90 beats/min or greater (OR, 6.3; 95% CI, 1.1-34), and BMI 35 kg/m or greater (OR, 5.8; 95% CI, 1.2-28). Surgical site infection rates were significantly higher among patients who had CT evidence of fluid in the hernia sac (56% vs. 19%, p = 0.012). CONCLUSIONS: More than half of all patients with CT scan evidence of fluid in the hernia sac developed an SSI. Computed tomography evidence of fluid in the hernia sac was the strongest predictor of SSI, followed by heart rate and BMI. Together, these parameters identify high-risk patients for whom better strategies are needed to avoid SSI without sacrificing durability. LEVEL OF EVIDENCE: Prognostic study, level III; Therapeutic, level IV.

Early bronchoalveolar lavage for intubated trauma patients with TBI or chest trauma.

PURPOSE: To evaluate the efficacy of an early bronchoalveolar lavage (E-BAL) protocol. BAL was performed within 48 h for intubated patients with traumatic brain injury or chest trauma. We hypothesized that E-BAL would decrease antibiotic use and improve outcomes compared to late BAL (L-BAL) triggered by clinical signs of pneumonia. METHODS: Retrospective cohort analysis of 132 patients with quantitative BAL and ≥1 risk factor: head Abbreviated Injury Score ≥2, ≥3 rib fractures, or radiographic signs of aspiration or pulmonary contusion. E-BAL (n=71) was compared to L-BAL (n=61). Pneumonia was defined as ≥104 organisms on BAL or Clinical Pulmonary Infection Score >6. RESULTS: There were no significant differences in age, injury severity, initial Pao2:Fio2, or smoking status between E-BAL and L-BAL groups. 52% and 61% of the E-BAL and L-BAL cultures were positive, respectively. E-BAL patients had fewer antibiotic days (7.3 vs 9.2, P=.034), ventilator days (11 vs 15, P=.002), tracheostomies (49% vs 75%, P=.002), and shorter intensive care unit and hospital length of stay (13 vs 17 days (P=.007), 18 vs 22 days (P=.041)). CONCLUSIONS: More than half of all E-BAL patients had pneumonia present early after admission. E-BAL was associated with fewer days on antibiotics and better outcomes than L-BAL.

Antibiotics May be Safely Discontinued Within One Week of Percutaneous Cholecystostomy.

BACKGROUND: For patients with acute cholecystitis managed with percutaneous cholecystostomy (PC), the optimal duration of post-procedural antibiotic therapy is unknown. Our objective was to compare short versus long courses of antibiotics with the hypothesis that patients with persistent signs of systemic inflammation 72 h following PC would receive prolonged antibiotic therapy and that antibiotic duration would not affect outcomes. METHODS: We performed a retrospective cohort analysis of 81 patients who underwent PC for acute cholecystitis at two hospitals during a 41-month period ending November 2014. Patients who received short (≤7 day) courses of post-procedural antibiotics were compared to patients who received long (>7 day) courses. Treatment response to PC was evaluated by systemic inflammatory response syndrome (SIRS) criteria. Logistic and linear regressions were used to evaluate associations between antibiotic duration and outcomes. RESULTS: Patients who received short (n = 30) and long courses (n = 51) of antibiotics had similar age, comorbidities, severity of cholecystitis, pre-procedural vital signs, treatment response, and culture results. There were no differences in recurrent cholecystitis (13 vs. 12%), requirement for open/converted to open cholecystectomy (23 vs. 22%), or 1-year mortality (20 vs. 18%). On logistic and linear regressions, antibiotic duration as a continuous variable was not predictive of any salient outcomes. CONCLUSIONS: Patients who received short and long courses of post-PC antibiotics had similar baseline characteristics and outcomes. Antibiotic duration did not predict recurrent cholecystitis, interval open cholecystectomy, or mortality. These findings suggest that antibiotics may be safely discontinued within one week of uncomplicated PC.

Predicting appendiceal tumors among patients with appendicitis.

BACKGROUND: As nonoperative management of appendicitis gains popularity, vigilance for appendiceal tumors becomes increasingly important. We hypothesized that, among patients presenting with acute appendicitis, those with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis would be more likely to have underlying appendiceal tumors. METHODS: We performed a 4-year retrospective cohort analysis of 677 consecutive adult patients who underwent appendectomy for appendicitis at our tertiary care center. Patients with an appendiceal tumor on their final pathology report were compared to patients with no tumor. Conditions present on admission were used to create a multivariate logistic regression model to predict appendiceal tumor. Risk factors were reported as odds ratio (OR) [95% CI]. Model strength was assessed by area under the receiver operating characteristic curve. RESULTS: Seventeen patients (2.5%) had an appendiceal tumor. Within this group. 14 underwent immediate appendectomy, two initially had nonoperative management but failed to improve on antibiotics and underwent appendectomy during the initial admission, and one had successful nonoperative management and elective appendectomy 19 days after discharge. Four variables contributed to the multivariate model to predict the presence appendiceal tumor: age ≥ 50 (OR 3.6 [1.1-11.4]), outpatient steroid/immunosuppressant use (OR 12.1 [2.0-72.5]), the absence of migratory right lower quadrant pain (OR 4.7 [1.2-18.1]), and the appearance of a phlegmon on CT scan (OR 7.0 [1.6-30.2]); model area under the receiver operating characteristic curve: 0.860 [0.705-0.969]. CONCLUSION: For patients presenting with acute appendicitis, conditions present on admission may predict underlying appendiceal tumor. Patients with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis should be considered for appendectomy during the index admission or at earliest convenience if nonoperative management is necessary. LEVEL OF EVIDENCE: Prognostic study, level III.

Routine surveillance cholangiography after percutaneous cholecystostomy delays drain removal and cholecystectomy.

INTRODUCTION: Percutaneous cholecystostomy (PC) is often performed for patients with acute cholecystitis who are at high risk for operative morbidity and mortality. However, the necessity for routine cholangiography after PC remains unclear. We hypothesized that routine surveillance cholangiography (RSC) after PC would provide no benefit compared to on-demand cholangiography (ODC) triggered by signs or symptoms of biliary pathology. METHODS: We performed a 3-year retrospective cohort analysis of patients managed with PC for acute cholecystitis at two tertiary care hospitals. Patients who had routine surveillance cholangiography (RSC, n = 43) were compared to patients who had on-demand cholangiography (ODC, n = 41) triggered by recurrent biliary disease. RESULTS: RSC and ODC groups were similar by severity of acute cholecystitis, presence of gallstones, systemic inflammatory response syndrome (SIRS) criteria at the time of PC, SIRS criteria 72 hours after PC, and hospital length of stay. Two patients in the ODC group developed clinical indications for cholangiography. All 44 RSC patients had cholangiography, and 67 total cholangiograms were performed in this group. Surveillance cholangiography identified six patients (14%) with cystic duct filling defect and seven patients (16%) with a common bile duct filling defect, all of whom were asymptomatic. Fifteen patients (35%) in the RSC group had 32 ERCP procedures; five patients (12%) in the ODC group had 7 ERCPs (p = 0.021). The ODC group had fewer days to drain removal (35 vs. 61, p < 0.001) and days to cholecystectomy (39 vs. 81, p = 0.005). Rates of recurrent cholecystitis, cholangitis, gallstone pancreatitis, drain removal, and cholecystectomy were similar between groups. CONCLUSION: RSC after PC for acute cholecystitis identified biliary pathology in asymptomatic patients and propagated further testing, but did not provide clinical benefit. ODC was associated with earlier drain removal, earlier cholecystectomy, and decreased resource utilization. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.