Time to Operation and Mortality Risk in Elderly Patients with Intestinal Fistula: Not Too Early and Not Too Late.

INTRODUCTION: This study aimed to ascertain the risk factors contributing to in-patient mortality in elderly patients 65 years and older who were admitted emergently, diagnosed with intestinal fistula, and underwent surgery. MATERIALS AND METHODS: Data were extracted from the National Inpatient Sample (NIS) spanning the years 2005-2014. Multivariable logistic regression and a generalized additive model (GAM) were employed to investigate predictors of mortality. Continuous variables are presented as mean values with standard deviations (SD). RESULTS: The study encompassed 34,853 patients with a mean age of 77.7 years-56.5% were female and 79.4% were White. Patients were categorized into three groups based on the time elapsed between admission and surgery: less than two days (17,761), two to three days (8,407), and more than three days (4,233). Mortality rates were 2.7%, 6%, and 6.1% for patients who underwent surgery within two to three days, within two days, and after more than three days of admission, respectively. Notably, the group that operated more than three days from admission experienced nearly double the hospital length of stay (12 days, SD: 7.2) compared to the other two groups (6.3, SD: 6 and 6.1, SD: 4.8). Furthermore, the association between mortality and time to operation, as indicated by the GAM model, revealed a significant non-linear relationship after adjusting for age, gender, race, zip code, hospital location, and comorbidities (p<0.001). CONCLUSION: Elderly patients diagnosed with intestinal fistula should undergo operative treatment as soon as possible, once they are resuscitated. Delaying the operation more than three days after admission substantially increases the risk of mortality.

Diagnosis and treatment of epiploic appendagitis in a Middle Eastern country: An observational retrospective analysis of 156 cases.

BACKGROUND: Epiploic appendagitis (EPA) is an uncommon emergency surgical condition that causes acute abdominal pain, rendering a list of differential diagnoses. Therefore, careful examination and imaging tools are required. EPA is a self-limiting condition that can be resolved in 1-2 weeks and rarely needs surgical intervention. Its low incidence makes EPA less well-known among the public and some medical professionals, and it is frequently under-diagnosed. We aimed to explore the incidence, clinical presentation, modalities of imaging to diagnose and options for treating EPA. METHODS: An observational retrospective analysis was conducted between 2016 and 2022 at a tertiary hospital in an Arab Middle Eastern country. RESULTS: There were 156 EPA cases diagnosed over six years, with a mean age of 33 years. Males represented 82% of the cohort. The entire cohort was treated non-operatively except for eight patients who had surgical intervention using open or laparoscopic surgery. The diagnosis was made by a computerized tomographic scan (CT). However, plain X-ray, abdominal ultrasound, and magnetic resonance imaging (MRI) were performed initially in a few selected cases to rule out other conditions. No specific blood test indicated EPA; however, a histopathology examination was diagnostic. No mortality was reported in the study cohort. CONCLUSION: This is the most extensive study analyzing EPA patients from the Middle East. EPA is a rare and mostly self-limiting acute abdominal disorder; however, early ultrasound and CT scan can pick it up quickly after a high index of suspicion.

Implementation of Mandatory Blood Alcohol Screening in Trauma Patients: A Retrospective Study from a Tertiary Trauma Center in a Middle Eastern Country.

BACKGROUND: Alcohol consumption is a significant risk factor for several types of injuries and trauma recidivism and remains an important public health concern worldwide. We aimed to describe the implementation of mandatory alcohol screening and the AUDIT tool among trauma patients admitted to a level 1 trauma center in a country with a partial ban on alcohol consumption. METHODS: This was a retrospective analysis of trauma patients (>12 years old) who required hospital admission and underwent blood alcohol concentration (BAC) screening between 2014 and 2019. This was achieved via an enzymatic method using alcohol dehydrogenase for ethanol detection in the plasma and serum samples. Trauma patient with a BAC < 2.2 mmol/L was referred to as "negative," and BAC > 2.2 mmol/L was referred to as "BAC positive." A comparative analysis was performed between the two BAC groups. Alcohol Screening, Brief Intervention, Referral for Treatment [ASBIRT] program, and AUDIT were applied. RESULTS: A total of 7,326 BAC screening tests were performed in 7,284 patients during the study period. With slight variation over the years, the compliance rate was 77% (70.4%-85.3%), and the test-positivity rate was 10% (8.6%-12.5%). There were 42 repeated admissions, of which seven patients were BAC positive at every admission. Young age and non-Arab patients were more likely to test positive, and the main mechanism of injury (MOI) was road traffic-related trauma (p<0.05). Assault and self-inflicted injuries were significantly higher in BAC-positive patients than in BAC-negative patients (18% vs 4% and 2.7% vs 1.3%, respectively; p=0.001). The injury severity score (ISS) and mortality rate were comparable between the study groups. Patients with a positive BAC were significantly more likely to undergo pan-CT scan in the emergency department, intubation, and exploratory laparotomy than those with a negative BAC. In patients who sustained injuries due to assault, all-terrain vehicles, or motorcycle crashes, there was a significant association between the positivity of BAC tests and the patient' ISS. CONCLUSION: Despite improvements in BAC screening in trauma admissions over the years, almost 20% of cases were missed. Although the mortality rates were comparable, alcohol consumption burdens resources in terms of excess imaging, intubation, open abdominal surgery, and possible disability. Further studies are needed to understand the key obstacles and challenges to achieving optimum compliance for screening in trauma settings.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma.

BACKGROUND: Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma. METHODS: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement. RESULTS: A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma. CONCLUSIONS: The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review.

BACKGROUND: The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS: A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS: The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION: Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.

Complex Abdominal Wall Reconstruction with Biologic Mesh for Ventral/Umbilical Hernias in Patients with Cirrhosis: Technique and Outcomes.

INTRODUCTION: Patients with cirrhosis undergoing non-liver transplant surgery have a higher risk or adverse events than those without cirrhosis. The main objectives of this study were to describe characteristics, outcomes, and outcome predictors of cirrhotic patients undergoing complex abdominal wall reconstruction (CAWR) with biologic mesh. MATERIALS AND METHODS: This study had retrospective and prospective components, including all cirrhotic patients at our center with CAWR for ventral/umbilical hernia repair with biologic mesh between December 2016 and November 2021. RESULTS: We studied 37 patients with cirrhosis. Their mean age was 57.2 years, and 64.9% were male. The median body mass index (BMI) was 28.1kg/m2. Ascites was present in 83.3% of patients. The other most common comorbidities were alcohol abuse (67.6%), hypertension (37.8%), and diabetes (24.3%). All complications in aggregate occurred in 11 patients (29.7%). Six patients (16.2%) underwent reoperation. Surgical site infections (SSIs) occurred in five patients (13.5%). Four deaths occurred within 90 days (11.2% cumulative mortality). By 120 days, there were five deaths (14.2% mortality, but none due to the operation). Seven predictor variables achieved an area under the receiver operating characteristic curve (AUROC) for SSI of 0.963, and two predictors yielded an AUROC of 0.825 for 120-day mortality. CONCLUSIONS: Our results suggest that CAWR for ventral/umbilical hernias among cirrhotic patients is feasible given a dedicated CAWR team in collaboration with transplant surgeons and a transplant hepatologist. The rates of adverse outcomes were low or at the midpoint of the range of the study-specific estimates.

When Should We Operate on the Elderly with Acute Pancreatitis Requiring Emergency Surgery? A 10-Year Study of a National Inpatient Sample Using a Generalized Additive Model of 110,289 Patients.

INTRODUCTION: Elderly patients with acute pancreatitis have longer hospital length of stay (HLOS) and higher mortality compared to adult patients. We aimed to assess the optimal timing to operate for acute pancreatitis and to evaluate the relationship between HLOS and mortality. MATERIALS AND METHODS: This was a retrospective cohort study of 110,289 elderly patients diagnosed with acute pancreatitis requiring emergency admission using the National Inpatient Sample (NIS) between 2005-2014. The ICD9 code 577.0 was used to select patients with a diagnosis of acute pancreatitis. Stratified analysis was performed to compare male versus female, survived versus deceased, and no operation versus operation. Multivariable logistic regression models were created to assess independent risk factors of mortality. Generalized additive models (GAM) were created to assess the linearity of the relationship between HLOS and in-hospital mortality. RESULTS: The mean age of the cohort was 76 years old, and 56.3% were female. The mean frailty index was 1.65. Twenty-five percent of patients underwent an operation, with a mean time to operation being 3.44 days for females and 3.77 days for males. Overall mortality was 2.3%. For patients who had an operation, each additional day of delay until operation increased the odds of mortality by 8.8%. Each additional point for the modified frailty index increased the odds of mortality by 30.2%. HLOS had a non-linear relationship with mortality, with an estimated degree of freedom of 22.05 and a nadir at three to seven days. Each additional day in hospital after day seven increased the odds of mortality by 6.7%. CONCLUSIONS: In those who required an operation, every day of delay in operation increased the odds of mortality by almost 9%. The lowest mortality for elderly patients with acute pancreatitis occurred with a hospital length of stay of three to seven days. After seven days, each additional day increased the odds of mortality by 6.7%.

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005-2014.

Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18−64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005−2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.

Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients.

INTRODUCTION: Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation. MATERIALS AND METHODS: We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated. RESULTS: 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home. CONCLUSION: DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.

Improving Liver Transplant Outcomes for Hepatitis C Virus Hepatocellular Carcinoma in the Direct-Acting Antiviral Therapy Era.

BACKGROUND: Direct-acting antiviral (DAA) therapy has transformed the outcomes of liver transplant (LT) with hepatitis C virus (HCV). This study aimed to analyze the effects of DAA treatment for HCV-associated hepatocellular carcinoma (HCC) in LT. METHODS: We included patients confirmed with HCC on explant, analyzed data from United Network for Organ Sharing, and defined the pre-DAA era (2012-2013) and DAA era (2014-2016). RESULTS: HCV-associated HCC cases totaled 4778 (62%) during the study period. In the DAA era, the median recipient age was older and the median days on the waiting list were longer. For the donor, median age, body mass index, and the rate of HCV significantly increased in the DAA era. In pathology, the median largest tumor size was significantly higher; however, the rate of completed tumor necrosis was significant higher in the DAA era. The 3-year graft/patient survival had significantly improved in the DAA era. In multivariable analysis, the DAA era (hazard ratio, 0.79; 95% confidence interval, 0.68-0.91) had significantly affected the 3-year graft survival. CONCLUSIONS: DAA has a significant beneficial effect on LT. In the DAA era, graft survival for HCV-associated HCC has been significantly improving.

Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients.

The goal of this study was to identify risk factors that are associated with mortality in adult and elderly patients who were hospitalized for umbilical hernia. A total of 14,752 adult patients (ages 18−64 years) and 6490 elderly patients (ages 65+), who were admitted emergently for umbilical hernia, were included in this retrospective cohort study. The data were gathered from the National Inpatient Sample (NIS) 2005−2014 database. Predictors of mortality were identified via a multivariable logistic regression, in patients who underwent surgery and those who did not for adult and elderly age groups. The mean (SD) ages for adult males and females were 48.95 (9.61) and 46.59 (11.35) years, respectively. The mean (SD) ages for elderly males and females were 73.62 (6.83) and 77.31 (7.98) years, respectively. The overall mortality was low (113 or 0.8%) in the adult group and in the elderly group (179 or 2.8%). In adult patients who underwent operation, age (OR = 1.066, 95% CI: 1.040−1.093, p < 0.001) and gangrene (OR = 5.635, 95% CI: 2.288−13.874, p < 0.001) were the main risk factors associated with mortality. Within the same population, female sex was found to be a protective factor (OR = 0.547, 95% CI: 0.351−0.854, p = 0.008). Of the total adult sample, 43% used private insurance, while only 18% of patients in the deceased population used private insurance. Conversely, within the entire adult population, only about 48% of patients used Medicare, Medicaid, or self-pay, while these patients made up 75% of the deceased group. In the elderly surgical group, the main risk factors significantly associated with mortality were frailty (OR = 1.284, 95% CI: 1.105−1.491, p = 0.001), gangrene (OR = 13.914, 95% CI: 5.074−38.154, p < 0.001), and age (OR = 1.034, 95% CI: 1.011−1.057, p = 0.003). In the adult non-operation group, hospital length of stay (HLOS) was a significant risk factor associated with mortality (OR = 1.077, 95% CI: 1.004−1.155, p = 0.038). In the elderly non-operation group, obstruction was the main risk factor (OR = 4.534, 95% CI: 1.387−14.819, p = 0.012). Elderly patients experienced a 3.5-fold higher mortality than adult patients who were emergently admitted with umbilical hernia. Increasing age was a significant risk factor of mortality within all patient populations. In the adult surgical group, gangrene, Medicare, Medicaid, and self-pay were significant risk factors of mortality and female sex was a significant protective factor. In the adult non-surgical group, HLOS was the main risk factor of mortality. In the elderly population, frailty and gangrene were the main risk factors of mortality within the surgical group, and obstruction was the main risk factor for the non-surgical group.

Adult and Elderly Risk Factors of Mortality in 23,614 Emergently Admitted Patients with Rectal or Rectosigmoid Junction Malignancy.

Background: Colorectal cancer, among which are malignant neoplasms of the rectum and rectosigmoid junction, is the fourth most common cancer cause of death globally. The goal of this study was to evaluate independent predictors of in-hospital mortality in adult and elderly patients undergoing emergency admission for malignant neoplasm of the rectum and rectosigmoid junction. Methods: Demographic and clinical data were obtained from the National Inpatient Sample (NIS), 2005−2014, to evaluate adult (age 18−64 years) and elderly (65+ years) patients with malignant neoplasm of the rectum and rectosigmoid junction who underwent emergency surgery. A multivariable logistic regression model with backward elimination process was used to identify the association of predictors and in-hospital mortality. Results: A total of 10,918 non-elderly adult and 12,696 elderly patients were included in this study. Their mean (standard deviation (SD)) age was 53 (8.5) and 77.5 (8) years, respectively. The odds ratios (95% confidence interval, P-value) of some of the pertinent risk factors for mortality for operated adults were 1.04 for time to operation (95%CI: 1.02−1.07, p < 0.001), 2.83 for respiratory diseases (95%CI: 2.02−3.98), and 1.93 for cardiac disease (95%CI: 1.39−2.70), among others. Hospital length of stay was a significant risk factor as well for elderly patients­OR: 1.02 (95%CI: 1.01−1.03, p = 0.002). Conclusions: In adult patients who underwent an operation, time to operation, respiratory diseases, and cardiac disease were some of the main risk factors of mortality. In patients who did not undergo a surgical procedure, malignant neoplasm of the rectosigmoid junction, respiratory disease, and fluid and electrolyte disorders were risk factors of mortality. In this patient group, hospital length of stay was only significant for elderly patients.

Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention.

BACKGROUND: Older trauma patients present with poor preinjury functional status and more comorbidities. Advances in care have increased the chance of survival from previously fatal injuries with many left debilitated with chronic critical illness and severe disability. Palliative care (PC) is ideally suited to address the goals of care and symptom management in this critically ill population. A retrospective chart review was done to identify the impact of PC consults on hospital length of stay (LOS), ICU LOS, and surgical decisions. STUDY DESIGN: A Level 1 Trauma Center Registry was used to identify adult patients who were provided PC consultation in a selected 3-year time period. These PC patients were matched with non-PC trauma patients on the basis of age, sex, race, Glasgow Coma Scale, and Injury Severity Score. Chi-square tests and Student's t-tests were used to analyze categorical and continuous variables, respectively. Any p value >0.05 was considered statistically significant. RESULTS: PC patients were less likely to receive a percutaneous endoscopic gastric tube or tracheostomy. PC patients spent less time on ventilator support, spent less time in the ICU, and had a shorter hospital stay. PC consultation was requested 16.48 days into the patient's hospital stay. Approximately 82% of consults were to assist with goals of care. CONCLUSION: Specialist PC team involvement in the care of the trauma ICU patients may have a beneficial impact on hospital LOS, ICU LOS, and surgical care rendered. Earlier consultation during hospitalization may lead to higher rates of goal-directed care and improved patient satisfaction.

Disparate access to breast cancer screening and treatment.

BACKGROUND: Barriers to breast cancer screening remain despite Medicaid expansion for preventive screening tests and implementation of patient navigation programs under the Affordable Care Act. Women from underserved communities experience disproportionately low rates of screening mammography. This study compares barriers to breast cancer screening among women at an inner-city safety-net center (City) and those at a suburban county medical center (County). Inner city and suburban county medical centers' initiatives were studied to compare outcomes of breast cancer screening and factors that influence access to care. METHODS: Women 40 years of age or older delinquent in breast cancer screening were offered patient navigation services between October 2014 and September 2019. Four different screening time-to-event intervals were investigated: time from patient navigation acceptance to screening mammography, to diagnostic mammography, to biopsy, and overall screening completion time. Barriers to complete breast cancer screening between the two centers were compared. RESULTS: Women from lowest income quartiles took significantly longer to complete breast cancer screening when compared to women from higher income quartiles when a barrier was present, regardless of barrier type and center. Transportation was a major barrier to screening mammography completion, while fear was the major barrier to abnormal screening work up. CONCLUSION: Disparity in breast cancer screening and management persists despite implementation of a patient navigation program. In the presence of a barrier, women from the lowest income quartiles have prolonged breast cancer screening completion time regardless of center or barrier type. Women who experience fear have longest screening time completion. Future directions aim to increase resource allocation to ameliorate wait times in overburdened safety-net hospitals as well as advanced training for patient navigators to alleviate women's fears.

Liver transplantation does not increase morbidity or mortality in women undergoing surgery for breast cancer.

PURPOSE: The incidence of breast cancer following solid organ transplantation is comparable to the age-matched general population. The rate of de novo breast cancer following liver transplantation varies. Furthermore, there is limited information on the management and outcomes of breast cancer in liver transplant recipients. We aim to evaluate the impact of liver transplantation on breast cancer surgery outcomes and compare the outcomes after breast cancer surgery in liver transplant recipient in transplant versus non-transplant centers. METHODS: National Inpatient Sample database was accessed to identify liver transplant recipient with breast cancer. Mortality, complications, hospital charges, and total length of stay were evaluated with multivariate logistic regression testing. Weighted multivariate regression models were employed to compare outcomes at transplant and non-transplant centers. RESULTS: Ninety-nine women met inclusion criteria for liver transplantation + breast cancer and were compared against women with breast cancer without liver transplantation (n = 736,527). Liver transplantation + breast cancer had lower performance status as confirmed via higher Elixhauser Comorbidity Index (20.5% vs 10.2%, p < 0001). There were significantly more complications in the liver transplantation cohort when compared to the non-liver transplant recipient (15.0% vs 8.2%, p = 0.012). However, on multivariate analysis, liver transplantation was not an independent risk factor for post-operative complications following breast cancer surgery (odd ratio, 1.223, p = 0.480). Cost associated with breast cancer care was significantly higher in those with liver transplantation (2.621, p < 0.001). Breast conservation surgery in liver transplantation had shorter length of stay as compared to breast cancer alone (odds ratio, 0.568, p = 0.027) in all hospitals. CONCLUSION: Liver transplantation does not increase short-term mortality when undergoing breast cancer surgery. Although there were significantly more complications in the liver transplantation cohort when compared to the non-liver transplant recipient (15.0% vs 8.2%, p = 0.012), on multivariate analysis, liver transplantation was not an independent risk factor for postoperative complications following breast cancer surgery. Breast cancer management in liver transplant recipient at non-transplant centers incurred higher charges but no difference in complication rate or length of stay when compared to transplant centers.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment.

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.

Surgery for Complex Abdominal Wall Defects: Update of a Nine-Step Treatment Strategy.

Complex abdominal wall defects (CAWDs) are a new surgical entity that require a dedicated and multidisciplinary approach. The spectra of CAWDs and complex abdominal wall reconstruction (CAWR) are poorly defined, and may include any of these elements: large or multiple recurrent hernia, presence of previously placed mesh (open or laparoscopic), loss of abdominal wall domain due to trauma, infection or tumor resection, hernia in the presence of enterocutaneous or enteroatmospheric fistulae (ECF/EAF), hernia in the presence of infected sinus tract, large debilitating parastomal hernia, hernias in the presence of synthetic erosion into the bowel or causing intestinal obstruction, eroded hernias post open abdomen management with skin graft in the presence of intraabdominal catastrophe or massive trauma, and hernias (umbilical or ventral/incisional) in patients with cirrhosis in the presence of massive ascites. The relevance of abdominal wall reconstruction with reinforcement using synthetic or biological mesh has never been as high as it is now. In particular, the use of biological mesh is rising exponentially due to its inherent properties. We previously described a nine-step approach to the management of difficult abdomen with enterocutaneous fistula. In this paper, we update this strategy based on our recent experience with almost 300 patients at our institution who underwent CAWR. Special attention is paid to the management of contaminated fields and the rationale of using biological mesh.

Serial rotational thromboelastography (ROTEM) in mechanically ventilated patients with COVID-19 demonstrates hypercoagulopathy despite therapeutic heparinization.

Background: Clinical hypercoagulopathy in patients with COVID-19 has been anecdotally described, but there is lack of evidence due to the novelty of this disease. Our study reports the results of rotational thromboelastography (ROTEM) in relation to traditional laboratory coagulation tests and acute phase markers among a cohort of severely ill, mechanically ventilated patients with COVID-19. Methods: Patients with COVID-19 (N=21) with respiratory failure requiring mechanical ventilation were included in this prospective case series. ROTEM was serially obtained for all patients on three different days during their intensive care unit (ICU) stay and analyzed using repeated measures analysis. Demographic variables, symptoms at the time of presentation, ROTEM values, laboratory values for traditionally measured coagulation profiles, and acute phase reactants were analyzed, in addition to the use of anticoagulation and clinical hypercoagulopathic complications. Results: The average age of our cohort was 57.9 years old (SD=14.4) and 76.2% were male. The mortality rate was 14.3% (3 of 21). Two patients (12.5%) were identified to have new-onset deep vein thrombosis, two patients (12.5%) were found to have ≥3 episodes of central venous catheter thrombosis, and three patients (18.7%) had confirmed stroke. ROTEM demonstrated elevated EXTEM and INTEM clotting times, including elevated FIBTEM maximum clot firmness (MCFFIB). All patients treated with therapeutic anticoagulation still demonstrated hypercoagulopathy within the MCFFIB tests. Discussion: Repeated measure ROTEMs were able to detect hypercoagulopathy in ICU patients with COVID-19 despite therapeutic anticoagulation with heparin. Level of evidence: III.

Firearms: the leading cause of years of potential life lost.

OBJECTIVES: Data from the Centers for Disease Control and Prevention (CDC) show that firearm deaths are increasing in the USA. The aims of this study were to determine the magnitude of potential years of life lost due to firearms and to examine the evolution of firearm deaths on the basis of sex, race, and geographical location within the USA. METHODS: Data was extracted (2009-2018) from the National Vital Statistics Reports from the CDC and the Web-based Injury Statistics Query and Reporting System database. Years of potential life lost was calculated by the CDC standard of subtracting the age at death from the standard year of 80, and then summing the individual years of potential life lost (YPLL) across each cause of death. RESULTS: The YPLL in 2017 and 2018 was higher for firearms than motor vehicle crashes (MVCs). In 2018, the YPLL for firearms was 1.42 million and 1.34 million for MVC. Males comprised the majority (85.4%) of the 38 929 firearm deaths. White males had the most YPLL due to suicide, with 4.95 million YPLL during the course of the 10-year period; black males had the most YPLL due to homicide with 3.2 million YPLL during the same time period. The largest number of suicides by firearms was in older white males. Firearm-related injury deaths were highest in the South, followed by the West, Midwest, and Northeast, respectively. CONCLUSION: Firearms are now the leading cause of YPLL in trauma. Firearm deaths have overtaken MVC as the mechanism for the main cause of potential years of life lost since 2017. Suicide in white males accounts for more YPLL than homicides. Deaths related to firearms are potentially preventable causes of death and prevention efforts should be redirected. LEVEL OF EVIDENCE: Level III-Descriptive Study.