Patient outcomes and cost in robotic emergency general surgery.

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

COVID, the Gut, and Nutritional Implications.

Purpose of Review: The purpose of this review is to provide an overview of the current literature, recommendations, and practice guidelines on the nutritional management of and implications associated with COVID-19 infection. Recent Findings: Particular attention should be paid to the screening, prevention, and treatment of malnutrition in critically ill individuals with COVID-19 infection given the significant risk for complications and poor outcomes. Extrapolation of existing literature for the nutritional support in the critically ill patient has demonstrated early enteral nutrition is safe and well-tolerated in patients with severe COVID-19 infection. Summary: Futures studies should focus on the long-term nutritional outcomes for patients who have suffered COVID-19 infection, nutritional outcomes/recommendations for special populations with COVID-19, nutritional outcomes based on the current recommendations and guidelines for nutrition therapy, and the role for micronutrient supplementation in COVID-19 infection.

Cecal Perforation Secondary to Large Bowel Obstruction From a Tubo-Ovarian Abscess.

With the continued specialization of medicine, we as physicians often fall into the trap of placing pathologies into silos, focusing on what we are most practiced in caring for. When managing acute patients, it is important that we consider complications that can arise across systems and specialties which could place our patients at increased risk for morbidity and mortality. Tubo-ovarian abscesses (TOAs) are complex infections often arising in the setting of pelvic inflammatory disease. The resultant reactive inflammation is frequently the culprit of potentially fatal sequelae. This article looks to highlight a case of TOA that resulted in inflammation and obstruction of the adjacent large bowel which subsequently led to large bowel obstructions (LBOs) and perforation. Although LBO management is well described in the literature, perforation secondary to inflammatory compression from a TOA is rarely documented. We present the case of a middle-aged female with significant comorbid conditions and recent prolonged retention of a tampon which likely acted as the nidus for the infection that led to her presenting pathology and need for admission, a left-sided TOA measuring 8.1 × 4.7 × 3.4 cm. Consultation by obstetrics-gynecology and interventional radiology determined that admission for observation and intravenous antibiotics alone was appropriate. The patient's hospital course was complicated by enlarging TOA with peri-colonic abscess and acute decompensation in the setting of LBO and cecal perforation. Emergency laparotomy and right hemicolectomy by the acute care surgical team were performed. Postoperative management was complicated by septic shock which prolonged her hospital stay. Following inpatient optimization of nutrition and management of comorbid conditions, the patient was able to make a full recovery. In patients with suspected TOA, special consideration should be given to surrounding structures, and potentially fatal complications should be kept in the forefront of the primary team's minds. This case report aims to urge physicians caring for patients with TOA to maintain a high level of suspicion and consider how the benefits of aggressive management may outweigh those of conservative options.