Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis.

BACKGROUND: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. METHODS: This was a retrospective (2018-2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7-9, 10-13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. RESULTS: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13-0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. CONCLUSION: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.

Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome.

BACKGROUND: Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. METHODS: In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days. RESULTS: A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups. CONCLUSION: Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Reclaiming the management of common duct stones in acute care surgery.

BACKGROUND: Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast." However, a simplified, effective LCBDE technique as part of a "surgery first" strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre-/postoperative) at a tertiary care center in the 4 years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. Laparoscopic common bile duct exploration was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance. RESULTS: One hundred eighty patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. Length of stay was significantly reduced for the LCBDE group compared with the LC + ERCP group (48.8 vs. 84.3 hours, p < 0.01). Of note, there were no intraoperative or postoperative complications in the LCBDE group. CONCLUSION: A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared with LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Blunt cerebrovascular injury: contribution of Timothy C Fabian MD and investigators from the University of Tennessee at Memphis to our understanding of the injury.

Our understanding of blunt cerebrovascular injury (BCVI) has evolved considerably over recent decades. It was once seen as a rare injury that was difficult or impossible to predict and had no useful prevention or treatment measures available. In the late 20th century, work by physicians caring for these injuries began to show that this was not the case. There were distinct risk factors for the injury and the often seen interval between injury and stroke provided an opportunity for stroke prevention. Timothy Fabian and the investigators at Memphis have been one of the groups at the forefront of this type of inquiry for >30 years. The contributions of this group has advanced the care of BCVI immensely. This review examines some of the work done by Dr Fabian and his colleagues and its importance in the care of injured patients.

Win or lose, nighttime transcystic laparoscopic common bile duct exploration is a win.

Objectives: Although controversial, recent data suggest nighttime versus daytime laparoscopic cholecystectomy (LC) have comparable outcomes. Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis decreases length of stay (LOS) as compared with LC with endoscopic retrograde cholangiopancreatography (ERCP) but increases case complexity/time. The influence of time of day on LCBDE outcomes has not been evaluated. Our aim was to examine outcomes and LOS for nighttime (PM) compared with daytime LC+LCBDE (DAY). Methods: Consecutive patients who underwent LCBDE were reviewed. Demographics, operative duration, success of LCBDE, time to postoperative ERCP (if required), LOS, and complications were compared. PM procedures were defined as beginning 19:00-07:00 hours. Results: Between 2018 and 2022, sixty patients underwent LCBDE (PM 42%). Groups had equivalent age/sex and preoperative liver function tests (LFTs). LCBDE success was 69% PM versus 71% DAY (p=0.78). Operative duration did not differ (2.8 IQR: 2.2-3.3 hours vs. 2.8 IQR: 2.3-3.2 hours, p=0.9). LOS was compared, and PM LOS was shorter (p=0.03). Time to ERCP after a failed LCBDE at night was compared with daytime (13.8 IQR: 10.6-29.5 hours vs. 19.9 IQR: 18.7-54.4 hours, p=0.07). LOS for failed PM LCBDE requiring ERCP was similar to successful DAY LCBDE (p=0.29). One complication (transient hyperbilirubinemia) was reported in the DAY group, none in PM. Conclusion: PM LCBDE cases are equivalent in safety and success rate to DAY cases but have reduced LOS. Widespread adoption of acute care surgery-driven management of choledocholithiasis via LCBDE during cholecystectomy may decrease LOS, especially in PM cases. Level of evidence: Level IV.

Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction.

INTRODUCTION: Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. MATERIALS AND METHODS: A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. RESULTS: Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission. CONCLUSIONS: Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.

Timing is everything: Early versus late palliative care consults in trauma.

BACKGROUND: The incorporation of dedicated palliative care (PC) services in the care of the critically injured trauma patient is not yet universal. Preexisting data demonstrate both economic and clinical value of PC consults, yet patient selection and optimal timing of these consults are poorly defined, possibly leading to underutilization of PC services. Prior studies in geriatric patients have shown benefits of PC when PC clinicians are engaged earlier during hospitalization. We aim to compare hospitalization metrics of early versus late PC consultation in trauma patients. METHODS: All patients 18 years or older admitted to the trauma service between January 1, 2019, and March 31, 2021, who received a PC consult were included. Patients were assigned to EARLY (PC consult ≤3 days after admission) and LATE (PC consult >3 days after admission) cohorts. Demographics, injury and underlying disease characteristics, outcomes, and financial data were compared. Length of stay (LOS) in the EARLY group is compared with LOS-3 in the LATE group. RESULTS: A total of 154 patient records met the inclusion criteria (60 EARLY and 94 LATE). Injury Severity Score, head Abbreviated Injury Scale score, and medical comorbidities (congestive heart failure, dementia, previous stroke, chronic obstructive pulmonary disease, malignancy) were similar between the groups. The LATE group was younger (69.9 vs. 75.3, p = 0.04). Patients in the LATE group had significantly longer LOS (17.5 vs. 7.0 days, p < 0.01) and higher median hospital costs ($53,165 vs. $17,654, p < 0.01). Patients in the EARLY group had reduced ventilator days (2.4 vs. 7.0, p < 0.01) and reduced rates of tracheostomies and surgical feeding tubes (1.7% vs. 11.7%, p = 0.03). CONCLUSION: Trauma patients with early PC consultation had shorter LOS, reduced ventilator days, reduced rates of invasive procedures, and lower costs even after correcting for delay to consult in the late group. These findings suggest the need for mechanisms leading to earlier PC consult in critically injured patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The value of compassion: Healthcare savings of palliative care consults in trauma.

BACKGROUND: The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. STUDY DESIGN: We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. RESULTS: 140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). CONCLUSION: Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.

Diagnostic Inaccuracies Using Extended Focused Assessment With Sonography in Trauma for Traumatic Pneumothorax.

BACKGROUND: Traumatic pneumothorax (PTX) can be deadly, and rapid diagnosis is vital. Ultrasound (US) is rapidly gaining acceptance as an accurate bedside diagnostic tool. While making the diagnosis is important, not all PTX require tube thoracostomy. Our goal was to evaluate the predictive ability of ultrasound in identifying clinically significant PTX. METHODS: Over 13 months, data was collected on patients undergoing evaluation for trauma. Patients were included if they underwent US, radiograph chest X-ray (CXR), and computed tomography of the chest. Predictive ability of ultrasound was evaluated in identifying clinically significant PTX. RESULTS: Ninety-four patients received evaluation by all 3 modalities. Of these, 32% were diagnosed with PTX. Sixteen patients (17%) had a clinically significant PTX. Chest X-ray and US both had a sensitivity of 75%; however, US had more than twice as many false positives, resulting in a much lower positive predictive value (63% vs 80%). CONCLUSIONS: While US can reliably rule out PTX, it may be overly sensitive diagnosing clinically significant PTX. Ultrasound alone should not be used in determining the need for tube thoracostomy as many patients will not require acute intervention.

Above the Clavicle: A Simplified Screening Method for Asymptomatic Blunt Cerebral Vascular Injury.

INTRODUCTION: Blunt cerebrovascular injury (BCVI) is an increasingly detected pattern in trauma with significant morbidity, putting patients at risk for subsequent stoke. Complex screening protocols exist to determine who should undergo CT angiography of the neck (CTAN) to evaluate for BCVI. Once identified, stroke incidence may be reduced with appropriate treatment across grades. We hypothesize that an expanded and simplified method for identifying patients with clinical suspicion for BCVI based upon injury above the clavicle (ATC) will illustrate a previously undiagnosed cohort of patients. METHODS: A single-institution retrospective review of adult (age ≥18 years) blunt trauma patients with BCVI from January 1, 2010 to December 31, 2019 was conducted at a tertiary academic medical center. Patients undergoing CTAN were divided into 2 groups based upon qualification by either the expanded Denver criteria or clinical evidence of any injury ATC. RESULTS: A total of 219 patients were diagnosed with BCVI (25 566 blunt trauma admissions, .9% incidence). Seventeen patients (8%) who did not satisfy expanded Denver were diagnosed with BCVI by ATC, most commonly undergoing CTAN due to facial trauma (n = 8). There were no differences in distribution of carotid artery injuries (CAI) and vertebral artery injuries (VAI) in the expanded Denver criteria group compared to the ATC group. CONCLUSIONS: CTAN for blunt trauma with any injury ATC is an easy-to-use screening tool and may be seamlessly included with initial whole-body imaging.

Successful Non-Operative Management of Adhesive Small Bowel Obstruction: Is it Really a Success?

BACKGROUND: In adhesive small bowel obstructions (ASBOs), literature has shown that passage of a water-soluble contrast challenge at either 8 hours or 24 hours is predictive of successful non-operative management (NOM) for an ASBO, but the long-term outcomes between these two groups are unknown. We hypothesized that patients who require longer transit times to the colon have a higher one-year recidivism of ASBO. METHODS: This was a 4-year review of patients with presumed ASBO undergoing successful NOM. Those requiring operation or those with an SBO due to something other than adhesions were excluded. Patients were divided into two groups (8 hour and 24 hour) based on when contrast reached their right colon. Patients were followed for one year to determine ASBO recurrence. RESULTS: 137 patients underwent NOM; 112 in the 8-hour group and 25 in the 24-hour group. One-year recurrence rate was 21.4% in the 8-hour group and 40% in the 24-hour group (P = 0.05). The median time to recurrence was 113 days in the 8-hour group and 13 days in the 24-hour group (P = 0.02). Of those who recurred in the 24-hour group, 60% recurred within 30 days (P = 0.01). On univariable analysis, first-time ASBO and 24-hour transit time were risk factors for recurrence. CONCLUSIONS: Adhesive small bowel obstruction patients undergoing NOM in the 24-hour group had a recurrence rate nearly twice that of patients in the 8-hour group and may benefit from an operative exploration during the index hospitalization at the 8-hour mark of a water-soluble contrast challenge, especially if experiencing a first-time ASBO.

Duration of Antibiotic Therapy in Necrotizing Soft Tissue Infections: Shorter is Safe.

Background: Early debridement improves outcome in necrotizing soft tissue infection (NSTI), but there is no consensus on duration of antimicrobial therapy. We recently changed practice to discontinue antibiotic agents early with a goal of 48 hours after adequate source control. We hypothesized that discontinuing antibiotic agents after a short course is safe in the treatment of NSTI. Patients and Methods: This was a prospective study of patients with NSTI comparing short duration of antibiotic agents to a control population after a change in practice. In 2018 we began discontinuing antibiotic agents within 48 hours of source control (absence of cellulitis and no evidence of active infection). Previously, antibiotic duration was at the discretion of the attending surgeon (generally 7-10 days). Patients were excluded from analysis if they were initially debrided at a referring facility, immune compromised, or died prior to source control. Patient characteristics and outcomes were evaluated. The primary outcome was treatment failure requiring antibiotic agents to be restarted with or without further debridement of infected tissue. Secondary outcomes included the duration of antibiotic therapy after source control. Results: We evaluated 151 patients; 119 admitted between January 1, 2011 and January 31, 2018 (PRE) and 32 admitted after January 31, 2018 (POST). Patients were not statistically different regarding characteristics, admission physiologic variables, and comorbidities. The median duration of antibiotic agents after source control in the PRE group was 180.3 hours (interquartile range [IQR], 100.7-318.8) versus 48 hours (IQR, 32.3-100.8) in the POST group (p < 0.01). Patients in each group were treated as described above, and treatment failure occurred in seven (5.9%) PRE patients and two (6.3%) POST (99.3% post hoc power at non-inferiority limit 20%, significance p < 0.05). Thirty-day all-cause mortality was not different between groups (6.7% vs. 6.3%; p = 0.94). Conclusions: Short-duration (48 hours) antibiotic agents after NSTI source control is as safe and effective as a longer course.

Equivalent Operative Outcomes for Emergency Colon Cancer Resections Among Acute Care Surgeons and Specialists in Colorectal Surgery.

OBJECTIVES: Improved screening has decreased but not eliminated the need for emergent surgery for colon cancer (CC), many of which are performed by acute care surgery (ACS) surgeons. This retrospective review compares outcomes for CC resections on the ACS service to the surgical oncology and colorectal services (SO/CRS). METHODS: Retrospective review was performed for CC operations between 2014 and 2019. Data for margin status, cancer stage, number of lymph nodes dissected, time to medical oncology follow-up, and time to initiation of chemotherapy were collected. Patients with curative resection, who chose comfort care, presented on alternative services or with non-CC indications as well as those were lost to follow-up were excluded. RESULTS: 36 ACS patients and 269 SO/CRS patients underwent CC resections. Most ACS patients presented emergently compared to the SO/CC group (83.3% vs 1%, P < .05) as well as with more advanced tumor stage. There were no statistically significant differences for presence of metastatic disease, number of lymph nodes obtained, or time to post-surgical care (in days) and chemotherapy initiation (in days). 3 (8%) EGS patients had positive margins compared to 6 (2%) CRS/SO patients due to the presence of perforated tumors in the ACS group (p < .05). There were no statistically significant differences in 30- day or 1-year mortality despite the emergent presentation of the ACS patients. DISCUSSION: These findings suggest that despite emergent presentation and advanced disease burden, ACS surgeons provide quality care to CC patients, both in the operating room and in coordination of care.

A core outcome set for damage control laparotomy via modified Delphi method.

OBJECTIVES: Damage control laparotomy (DCL) remains an important tool in the trauma surgeon's armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias. METHODS: A modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) 'landmark' DCL papers and EAST ad hoc COS task force consensus. RESULTS: Of 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus. CONCLUSIONS: Through an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes. LEVEL OF EVIDENCE: V, criteria.

Screening for Bacteremia in Trauma Patients: Traditional Markers Fall Short.

BACKGROUND: Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. MATERIALS AND METHODS: Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. RESULTS: Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. CONCLUSION: Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.

Evaluation of the Performance of ACS NSQIP Surgical Risk Calculator in Emergency General Surgery Patients.

The ACS NSQIP Surgical Risk Calculator is designed to estimate the chance of an unfavorable outcome after surgery. Our goal was to evaluate the accuracy of the calculator in our emergency general surgery population. Surgical outcomes were compared to predicted risk. The risk was calculated with surgeon adjustment scores (SASs) of 1 (no adjustment), 2 (risk somewhat higher), and 3 (risk significantly higher than estimate). Two hundred and twenty-seven patients met the inclusion criteria. An SAS of 1 or 2 accurately predicted risk of mortality (5.7% and 8.5% predicted versus 7.9% actual), whereas a risk adjustment of 3 indicated significant overestimation of mortality rate (14.8% predicted). There was good overall prediction performance for most variables with no clear preference for SAS 1, 2, or 3. Poor correlation was seen with SSI, urinary tract infection, and length of stay variables. The ACS NSQIP Surgical Risk Calculator yields valid predictions in the emergency general surgery population, and the data support its use to inform conversations about outcome expectations.

Use of posterior component separation and transversus abdominis release in trauma and emergency general surgery patients: a case report and review of the literature.

Posterior component separation with transversus abdominis release and implantation of synthetic mesh in the retromuscular space is a durable type of repair for many large incisional hernias with recurrence rates consistently less than 10%. The purported advantage of biologic prostheses in contaminated fields has recently been challenged, and the concern for placing synthetic mesh in contaminated fields may be overstated. There are almost no data specifically addressing the use of this type of repair for chronic incisional hernias in trauma and emergency general surgery patients, so research is needed on this patient population. In this review, a case of a trauma patient receiving posterior component separation with transversus abdominis release and implantation of synthetic mesh for a chronic incisional hernia resulting from a gunshot wound to the abdomen is presented, the technique is explained, and relevant literature is reviewed.

The spleen not taken: Differences in management and outcomes of blunt splenic injuries in teenagers cared for by adult and pediatric trauma teams in a single institution.

BACKGROUND: Nonoperative management (NOM) of blunt splenic injury, initially touted for the care of pediatric patients, has become the standard of care for stable trauma patients of all ages. In our institution, trauma patients younger than 16 years are managed by the pediatric surgery service and patients 16 years or older are managed by the adult trauma service. Angioembolization is routinely used for adults with blunt splenic injury but rarely used for pediatric patients. A retrospective chart review was performed to determine if more liberal use of angioembolization increases the success rate of NOM of blunt splenic injury in adolescents. METHODS: Using our institutional trauma registry, we performed a retrospective chart review of 13- to 18-year-olds admitted with blunt splenic injury from 2007 to 2015. One hundred thirty-three patients were identified; 59 were 13- to 15-year-olds and cared for by the Pediatric Trauma service, whereas 74 were 16- to 18-year-olds and cared for by the Adult Trauma service. The cohorts were compared with respect to imaging performed, grade of injury, Injury Severity Score, presence of active extravasation or pseudoaneurysm, interventions performed, blood transfused, intensive care unit days, length of stay, complications, and 30-day mortality rates. RESULTS: There were no significant differences in Injury Severity Score, incidence of active extravasation or pseudoaneurysm identified on computed tomography, or grade of injury between the two cohorts. More patients underwent angioembolization in the "adult" group (p = 0.001) with no difference in the success rate of NOM (p = 0.117). The overall failure rate of NOM of high-grade injuries was only 4.1%. CONCLUSION: Failure of NOM in high-grade injuries is rare; as a result, the number needed to treat with prophylactic angioembolization would be around 37 patients, resulting in undue risk to many patients with no therapeutic benefit. No improvement in failure rate was seen with aggressive angioembolization, though a larger sample size is needed to rule out type 2 error. LEVEL OF EVIDENCE: Therapeutic, level IV.