Impact of catastrophic brain injury guidelines on organ donation rates: Results of an EAST multicenter trial.

BACKGROUND: One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. METHODS: This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. RESULTS: A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. CONCLUSION: There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. LEVEL OF EVIDENCE: Prognostic; Level III.

Scanning the aged to minimize missed injury: An EAST multicenter study.

BACKGROUND: Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a Pan-Scan (Head/C-spine/Torso) or a Selective Scan (Head/C-spine ± Torso). We hypothesized that a patient's initial history and exam could be used to guide imaging. METHODS: We prospectively studied blunt trauma patients aged 65+ at 18 Level I/II trauma centers. Patients presenting >24 h after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of Head/C-spine or Torso (chest, abdomen/pelvis, and T/L spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our dataset. Our priority was to identify a simple rule which could be applied at the bedside, maximizing sensitivity (Sens) and negative predictive value (NPV) to minimize missed injuries. RESULTS: We enrolled 5,498 patients with 3,082 injuries. Nearly half (47.1%, n = 2,587) had an injury within the defined CT body regions. No rule to guide a Pan-Scan could be identified with suitable Sens/NPV for clinical use. A clinical algorithm to identify patients for Pan-Scan, using a combination of physical exam findings and specific high-risk criteria, was identified and had a Sens of 0.94 and NPV of 0.86 This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. CONCLUSIONS: Our findings advocate for Head/Cspine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. LEVEL OF EVIDENCE: Level 2, Diagnostic Tests or Criteria.

Evaluation of Gender Bias Through Autonomy During Laparoscopic Cholecystectomy at a Rural Community General Surgery Residency Program.

OBJECTIVE: Gender bias not only continues to exist in surgical specialties, but in the medical field overall. Despite females graduating from medical schools at the same rate as men, a discrepancy still exists in the number of females pursuing surgical specialties compared to their male counterparts. We hypothesized that surgical training occurring in smaller institutions with close-knit relationships between faculty and residents should decrease the likelihood of gender bias towards females, as measured by perceived autonomy during laparoscopic cholecystectomy. DESIGN: All 17 surgery residents at a community surgery residency program were asked to voluntarily and anonymously complete an investigator-created questionnaire after every laparoscopic cholecystectomy from October 2020 to May 2022. The questionnaire included details regarding overall resident operative experience, case complexity, patient diagnosis, resident autonomy throughout the case, and perceived autonomy compared to their peers. Each respondent estimated their percent autonomy from 0% to 100% during 5 distinct portions of the case, from which, a mean overall percent autonomy was calculated. RESULTS: A total of 233 questionnaires (98 female, 135 male) were completed during the study period, with 8 females and 9 males in the first study year and 7 females and 10 males in the second. Mean overall autonomy was statistically similar between males and females, 71% and 72% respectively (p = 0.967). Case difficulty was not statistically different between males and females (p = 0.445). There was a significant difference in autonomy of all residents with male and female attendings, 67.5% and 80.3%, respectively (p = 0.001), however this did not differ between male and female residents. Eighty-three percent of respondents felt that their level of autonomy was acceptable for their postgraduate year (PGY) level. Over 90 percent of respondents felt their autonomy was not affected by their gender. CONCLUSIONS: There was no significant difference in perceived autonomy between male and female residents during laparoscopic cholecystectomy at our small general surgery residency program. Gender bias did not appear to be a prohibiting factor in the amount of autonomy given to male and female residents.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Round Ligament Varicocele Masquerading as an Inguinal Hernia During Pregnancy.

Hernia is an exceedingly common pathology, to which inguinal hernias are frequently diagnosed. Though this entity is regularly seen, in pregnancy a different diagnosis must be excluded: round ligament varicocele (RLV). Round ligament varicocele has a similar presentation to inguinal hernia, and therefore is often misdiagnosed. Though misdiagnosis potentially occurs from a lack of knowledge of the disease, RLV has shown that it's at least as common as inguinal hernia in pregnancy. The issue with misdiagnosis occurs as there is significant difference in management; hernia may require operative intervention, while RLV follows a conservative course. Therefore, an accurate diagnosis is essential, and an incorrect diagnosis can be associated with an unnecessary operation and consequence. We present the case of a patient in her second trimester who was referred for surgery due to suspicion of an inguinal hernia, and review the literature for evaluation recommendations, appropriate diagnostic strategies, and management tactics for RLV.

Sarcomatoid Carcinoma of the Ascending Colon: A Case Report and Literature Review.

BACKGROUND Sarcomatoid carcinoma is a rare tumor that can occur in different organs and anatomical locations. Colonic sarcomatoid carcinoma, also known as carcinosarcoma, is an extremely rare tumor, with only 32 cases reported world-wide. The pathogenesis and guidelines for treatment are poorly understood due to the rarity and invasiveness of the disease. CASE REPORT A 77-year-old woman presented with worsening lower abdominal pain and associated fever after having initially been diagnosed with stump appendicitis and associated phlegmon 3 weeks prior, which was treated with antibiotics. Repeat imaging revealed an extraluminal versus perforated colonic mass with associated phlegmon. The patient's condition continued to worsen, with development of obstructive-like symptoms, resulting in operative intervention involving a R2 right hemicolectomy, stapled ileo-colostomy, and partial omentectomy. The patient had an uneventful remainder of her hospitalization other than continued lower abdominal pain. After initial discharge, the patient presented to an outside hospital due to continued deterioration of health, with findings of an additional mass, likely secondary to the previous lymphadenopathy. Ultimately, goals of care were discussed, and the decision was made to provide palliative care, and the patient died due to her illness 32 days after the initial procedure. CONCLUSIONS Carcinosarcoma is an extremely rare tumor with scant research guiding treatment guidelines. Current guidelines gathered from previous case reports suggest treating colorectal carcinosarcoma as adenocarcinoma. Additional research and studies are needed to establish appropriate therapeutic guidelines for carcinosarcoma.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Choose Your Patients Wisely: A Preoperative Protocol to Reduce Surgical Site Infection Rates in Elective Neurosurgical Procedures.

OBJECTIVE: Surgical site infections (SSIs) are the most common and costly of all hospital-acquired infections, occurring in 5 percent of patients and accounting for 20% of all hospital-acquired infections. Preoperatively, we developed a protocol where patients were screened using hemoglobin A 1c (HbA1c) and nasal swabs. If HbA1c was greater than 9, patients were rescheduled for surgery when their HbA1c was less than 9. All patients then underwent nasal swabs to identify methicillin-sensitive Staphylococcus aureus/methicillin-resistant S. aureus in addition to standard chlorhexidine gluconate bathing. If positive, mupirocin ointment was used to treat the patients 5 days prior to surgery. We sought to measure the effectiveness of this protocol in reducing SSI in elective neurosurgical patients who were undergoing hardware implantation or had a procedure anticipated to last greater than 2 hours. METHODS: This was a retrospective review of patients undergoing elective neurosurgical procedures at Conemaugh Memorial Medical Center from 1/1/2014 to 06/30/2016. The intervention period was from 7/1/2016 to 12/20/2018, which included the patients undergoing the protocol. RESULTS: The preintervention group consisted of 817 cases with a 2.7% infection rate (22 SSIs). The intervention group consisted of 822 cases with a 0.1% infection rate (1 SSI). This observed difference was statistically significant (P = 0.003). CONCLUSIONS: This retrospective review of a presurgical protocol with measuring of HbA1c and nasal swabs revealed a significant decrease in the infection rate of patients undergoing elective neurosurgical procedures. Additional investigations are necessary; however, we recommend its use.

Bronchoscopy Decreases Ventilator-Associated Pneumonia in Trauma Patients.

Health care-associated pneumonias (HAPs) are a significant comorbidity seen in hospitalized patients. Traumatic injury is a known independent risk factor for the development of HAP. Trauma-related injuries also contribute to an increase in the rate of pneumonia in mechanically ventilated patients requiring intensive care unit (ICU) treatment. In 2011, the ventilator-associated pneumonia (VAP) rate among ICU patients at our institution (CMMC) increased dramatically. As a result, our infection control specialists performed a focused review of these patients and found a likely association between these infections and patients requiring pre-hospital intubation. Their determination prompted a July 2012 revision of the CMMC Trauma/Surgery Admission ICU protocol for ventilated patients to include bronchoscopy for all patients who have been intubated pre-hospital providing no contraindications were present. Our aim was to ascertain any influence of the protocol change on the rate of VAP. We conducted a retrospective medical record review of trauma patients who were intubated in the field or ED and seen at our institution (an accredited Level 1 trauma center) from 2012 to 2018. Applying the current definition of VAP from the Centers for Disease Control and Prevention (CDC) to data collected from the CMMC trauma registry, we observed a 13% lower VAP rate in the bronchoscopy group (YB) as compared to the group that did not receive bronchoscopy (NB) (P < .025). Based on our results, we determined that bronchoscopy performed in this setting does support a statistically significant decrease in the rate of ventilator-associated pneumonia.

Lurking Under the Surface: Dercum's Disease.

Adiposis dolorosa, also known as Dercum's disease, is a rare disorder characterized by debilitating painful lipomas throughout the body. The prevalence and etiology of Dercum's disease are unknown as mentioned in the National Organization of Rare Disorders. We present an interesting case of Dercum's disease in a 53-year-old female who initially presented with a six-week history of painful subcutaneous masses. Ultrasound findings were suggestive of lipomas, however, her symptoms were debilitating beyond that of benign lipomas. She then represented with a rapidly increasing number of soft tissue masses manifesting throughout her body, as well as significant diffuse pain concentrating around these lesions within a short period of time following her initial presentation. The patient underwent surgical excision of a select number of these masses, with histopathology consistent with lipomas. Most cases of Dercum's disease are sporadic, and no guidelines exist regarding the treatment of the disease. Due to the rarity of this condition, in conjunction with simple lipomas typically presenting as painless masses, many patients may be misdiagnosed and neglected due to being falsely labeled as pain seeking or having their symptoms attributed to psychological disorders. Management, therefore, is complex and currently consists of a multidisciplinary approach employing multimodal treatments, including pain control, surgical excision, and psychotherapy. Although this condition has been described in the literature for over 100 years, there have been minimal advancements towards alleviating the suffering of these patients. We aimed to unearth and bring to light the reality and the suffering experienced by patients with Decrum's disease.

Benefit of continued noninvasive cardiac monitoring in geriatric trauma: A retrospective review of geriatric pelvis, hip, and femur fractures and analysis of cardiac events during immediate post-traumatic course.

OBJECTIVE: The geriatric population suffers from a predisposition to cardiac events due to physiologic changes commonly associated with aging. The majority of the trauma population seen at our facility is within the geriatric population (greater than 65 years old). Therefore, this study was aimed to determine which of those preexisting factors were associated with an increased risk for developing cardiac event. By assessing those risks, we hoped to determine a timeline for the highest risk of cardiac event occurrence, in order to identify a safe period of when cardiac monitoring was indicated. METHODS: A retrospective study performed over 6 months reviewing geriatric trauma patients with hip, pelvis, or femur fractures, n = 125. A list of predetermined risk factors including comorbidities, pathologies, laboratory values, electrocardiogram findings, and surgery was crossed with the patient's records in order to identify factors for increased risk of cardiac event. Once patients who had documented cardiac events were identified, a temporal pattern of cardiac event occurrence was analyzed in order to determine a period when noninvasive cardiac monitoring should remain in place. RESULTS: In 125 patients, 40 cardiac events occurred in 30 patients. The analyzed variables with statistically significant associations for having a cardiac event were comorbidities (p = 0.019), elevated body mass index (p = 0.001), abnormal initial phosphorus (p = 0.002), and an electrocardiogram finding of other than normal sinus rhythm (p = 0.020). Of the identified cardiac events, we found that by hospital day 3 68% of cardiac event had occurred, with 85% by hospital day 4, 95% by day 5, and 100% within the first 7 days of admission. CONCLUSION: Patient history of cardiac comorbidities, elevated body mass index, abnormal phosphorus, and abnormal electrocardiogram findings were found to be significant risk factors for cardiac event development in geriatric trauma. All recorded events in our study occurred within 7 days of the initial trauma.

Too Big, Too Small or Just Right? Why the 28 French Chest Tube Is the Best Size.

BACKGROUND: Tube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen-Poiseuille equation. MATERIALS AND METHODS: A model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at -20 cm H2O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen-Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark. RESULTS: All tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F-36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F). CONCLUSIONS: The 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications.

Extraskeletal Osteosarcoma Recognized following Acute Traumatic Injury.

Extraskeletal Osteosarcoma (ESOS), a rare entity accounting for less than 2% of all soft tissue sarcomas. Known risk factors for development include: middle aged and elderly patients, a history of radiation, and a controversial link to trauma. The typical presenting symptoms, if any, are tenderness and swelling. In trauma patients, these symptoms often mask the ESOS diagnosis and are assumed to be hematoma or other traumatic diagnosis. Easy misinterpretation of what appears to be obvious traumatic injury, can lead to delays in accurate diagnosis and appropriate treatments.

Preoperative decolonization to reduce infections in urgent lower extremity repairs.

PURPOSE: Medical implants and surgical site infections (SSIs) can be a burden on both patients and healthcare systems with a significant rise in morbidity, mortality and costs. Preoperatively, our practice of a chlorohexidine gluconate (CHG) washcloth bath or solution shower was supplemented with nasal painting using povidone-iodine skin and nasal antiseptic (PI-SNA). We sought to measure the effectiveness in reducing SSIs in patients undergoing repair of lower extremity fractures. METHODS: A retrospective review of trauma patients undergoing orthopedic operations conducted at Conemaugh Memorial Medical Center from 10/1/2012 through 9/30/2016. The intervention period was 10/1/2014 to 9/30/2016 which included the addition of nasal painting with PI-SNA preoperatively. All patients were followed for 1 year prior to January 2013 and 30 or 90 days thereafter for the development of a SSI. RESULTS: The pre-intervention group consisted of 930 cases with a 1.1% infection rate (10 SSIs). The intervention group consisted of 962 cases with a 0.2% infection rate (2 SSIs). This observed difference was statistically significant (P = 0.020). CONCLUSIONS: This retrospective review of a methicillin-resistant Staphylococcus aureus decolonization protocol using CHG bath/shower and PI-SNA nasal painting revealed a significant decrease in the infection rate of patients undergoing lower extremity fracture repairs. We recommend its use without contraindications, but recognize that additional investigations are necessary.

Evaluating the traditional day and night shift in an acute care surgery fellowship: Is the swing shift a better choice?

BACKGROUND: Fellowship trainees in acute care surgery require experience in the management of complex and operative trauma cases. Trauma center staffing usually follows standard 12-hour or 24-hour shifts, with resident and fellow trainees following a similar schedule. Although trauma admissions can be generally unpredictable, we analyzed temporal trends of trauma patient arrival times to determine the best time frame to maximize trainee experience during each day. METHODS: We reviewed 10 years (2007-2016) of trauma registry data for blunt and penetrating trauma activations. Hourly volumetric trends were observed, and three specific events were chosen for detailed analysis: (1) trauma activation with Injury Severity Score (ISS) greater than 15, (2) laparotomy for trauma, and (3) thoracotomy for trauma. A retrospective shift log was created, which included day (7:00 AM to 7:00 PM), night (7:00 PM to 7:00 AM), and swing (noon to midnight) shifts. A swing shift was chosen because it captures the peak volume for all three events. Means and 95% confidence intervals were calculated, and comparisons were made between shifts using the Wilcoxon matched-pairs signed rank test with Bonferroni correction, and p less than 0.05 considered significant. RESULTS: During the 10-year study period, 28,287 patients were treated at our trauma center. This included the evaluation and management of 7,874 patients with ISS greater than 15, performance of 1,766 laparotomies, and 392 thoracotomies for trauma. Swing shift was superior to both day and night shifts for ISS greater than 15 (p < 0.001). Both swing and night shifts were superior to day shift for laparotomies (p < 0.001). Swing shift was superior to both day shift (p < 0.001) and night shift (p = 0.031). Shifts with the highest yield of ISS greater than 15, laparotomies, and thoracotomies include night and swing shifts on Fridays and Saturdays. CONCLUSION: Projected experience of acute care surgery fellows in managing complex trauma patients increases with the integration of swing shifts into the schedule. Daily trauma volume follows a temporal pattern which, when used correctly, can increase trainee exposure to complex and operative trauma cases. We encourage other centers to analyze their volume and adjust trainee schedules accordingly to maximize their educational experience. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries.

BACKGROUND: Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries. METHODS: We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries. RESULTS: A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p < 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p < 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018). CONCLUSION: Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Feasibility of and barriers to continuity of care in US general surgery residencies with an 80-hour duty week.

BACKGROUND: The current level of continuity of care for following up a single patient through preoperative evaluation, surgery, and postoperative care is unknown. METHODS: A survey of residents was performed, asking for their best guess regarding the number of patients seen for 6 common and 4 uncommon surgeries, and ranking barriers to continuity of care. The length of time to achieve single-patient continuity of care in 5 patients was derived as well as the creation of odds ratios for the barriers. RESULTS: A total of 274 residents (56 programs) completed surveys. Residency length was 7 years for common surgeries and 9 for complex surgeries. The 30-hour work restrictions, inability to attend clinic, and floor/ward duties were the barriers to continuity of care. These data were unaffected by type of program, the presence of a night float system, or residency year. CONCLUSIONS: Achieving the level of continuity of care used in this article will require a radical change in the length or structure of general surgery residency programs.