Traumatic lower extremity amputation as a risk factor for venous thromboembolism.

BACKGROUND: This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS: All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS: A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p â€‹< â€‹0.001) and DVT (6.5% vs. 3.4%, p â€‹< â€‹0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p â€‹= â€‹0.015) and DVT (4.7% vs. 2.6%, p â€‹< â€‹0.001). CONCLUSIONS: In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion.

BACKGROUND: Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS: We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS: We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION: These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Hiatal hernia reporting: time to remove subjectivity?

INTRODUCTION: The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies. METHODS AND PROCEDURES: Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements. RESULTS: Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R2 = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R2 = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R2 = 0.0143, p = 0.366), endoscopic subjective size estimates (R2 = 0.0481, p = 0.0986), or the manometry measurements (R2 = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227). CONCLUSIONS: Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.

Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis.

BACKGROUND: Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS: We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS: Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (ß) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (ß = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (ß = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (ß = 0.026, p < 0.001; 95% CI, 0.020-0.032). CONCLUSION: In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Low-molecular-weight heparin is superior to unfractionated heparin in lowering the risk of venous thromboembolism after traumatic lower extremity amputation.

BACKGROUND: Patients undergoing lower extremity amputation after trauma are at high risk of venous thromboembolism. Practice variations persist regarding the optimal pharmacologic agent for venous thromboembolism prophylaxis in this patient population. We aimed to compare the efficacy of unfractionated heparin versus low-molecular-weight heparin in preventing venous thromboembolism. METHODS: Using the 2013 to 2019 American College of Surgeons Pediatric Trauma Quality Improvement Program database, all trauma patients (≥18) who underwent lower limb amputation and received venous thromboembolism thromboprophylaxis in the form of unfractionated heparin or low-molecular-weight heparin were included. We excluded patients who died within 24 hours of admission or those who received no thromboprophylaxis. The primary outcome was the rate of venous thromboembolism. Multivariable logistic regression was used to evaluate the independent relationship between the type of pharmacologic prophylaxis and the risk of venous thromboembolism. RESULTS: A total of 4,103 patients who underwent lower extremity amputation were identified. Patients were primarily young (median age 43 years) with blunt injuries (83%). The overall rate of venous thromboembolism was 8.6%. Most (77%) patients received low-molecular-weight heparin-based prophylaxis. Compared with patients without venous thromboembolism, the venous thromboembolism cohort had a greater injury severity score (19 vs 13, P < .001), had more patients undergoing above-the-knee amputation (48% vs 36%, P < .001), and less frequently received low-molecular-weight heparin (64% vs 78%, P < .001). Multivariable analysis showed that low-molecular-weight heparin was associated with a significantly lower venous thromboembolism rate than unfractionated heparin (odds ratio: 0.65 [0.51-0.83], P < .001). CONCLUSION: Thromboprophylaxis with low-molecular-weight heparin was found to be superior to unfractionated heparin in lowering the risk of venous thromboembolism among traumatic amputees and should be the preferred pharmacologic agent in this patient population prone to venous thromboembolism.

Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis.

BACKGROUND: Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS: Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS: Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION: In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality.

INTRODUCTION: Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. METHODS: The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). RESULTS: A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/µL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. CONCLUSIONS: In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.

The Not-So-Distant Future or Just Hype? Utilizing Machine Learning to Predict 30-Day Post-Operative Complications in Laparoscopic Colectomy Patients.

BACKGROUND: Complex machine learning (ML) models have revolutionized predictions in clinical care. However, for laparoscopic colectomy (LC), prediction of morbidity by ML has not been adequately analyzed nor compared against traditional logistic regression (LR) models. METHODS: All LC patients, between 2017 and 2019, in the National Surgical Quality Improvement Program (NSQIP) were identified. A composite outcome of 17 variables defined any post-operative morbidity. Seven of the most common complications were additionally analyzed. Three ML models (Random Forests, XGBoost, and L1-L2-RFE) were compared with LR. RESULTS: Random Forests, XGBoost, and L1-L2-RFE predicted 30-day post-operative morbidity with average area under the curve (AUC): .709, .712, and .712, respectively. LR predicted morbidity with AUC = .712. Septic shock was predicted with AUC ≤ .9, by ML and LR. CONCLUSION: There was negligible difference in the predictive ability of ML and LR in post-LC morbidity prediction. Possibly, the computational power of ML cannot be realized in limited datasets.

Association of Comorbidities and Functional Level With Mortality in Geriatric Bowel Perforation.

INTRODUCTION: Spontaneous bowel perforation is associated with high morbidity and mortality. This entity remains understudied in the geriatric patient. We sought to use a national surgical sample to uncover independent predictors of mortality in elderly patients undergoing emergent operation for perforated bowel. METHODS: Using the American College of Surgeons National Surgical Quality Improvement database, years 2007 to 2017, all geriatric patients (age ≥65 y) who underwent emergency surgery and who had a postoperative diagnosis of bowel perforation were included. Univariate and multivariable analyses were used to identify independent predictors of 30-d mortality. RESULTS: A total of 8981 patients were included. The median (interquartile range) age was 75 y (69, 82), and 59.0% were female. Twenty-one percent of patients were partially or totally dependent, and 25.2% were admitted from sources other than home. Overall, 30-d mortality rate was 22.1%. Independent predictors of mortality included the following: age 70-79 y (odds ratio [OR]: 1.59, P < 0.001), age ≥80 y (OR: 3.23, P < 0.001), American Society of Anesthesiologists ≥3 (OR: 4.74, P < 0.001), admission from chronic care facility (OR: 1.61, P < 0.001), being partially or totally dependent (OR: 1.50, P < 0.001), chronic steroid use (OR: 1.36, P < 0.001), and preoperative septic shock (OR: 3.74, P < 0.001). Having immediate fascial closure was protective against mortality (immediate fascial closure only, OR: 0.55, P < 0.001; -immediate closure of all surgical site layers, OR: 0.44, P < 0.001). CONCLUSIONS: In geriatric patients, functional status and chronic steroid therapy play an important role in determining survival following surgery for bowel perforation. These factors should be considered during preoperative counseling and decision-making.

Complicated Abdominal Wall Hernias in the Elderly: Time Is Life and Comorbidities Matter.

BACKGROUND: Abdominal wall hernias represent a common problem that can present as surgical emergencies with increased morbidity and mortality. The data examining outcomes in elderly patients with hernia emergencies is scant. METHODS: The 2007-2017 ACS-NSQIP database was queried. Patients ≥65 years old with a diagnosis of acute complicated abdominal wall hernia were included. Univariable and multivariable analyses were used to identify independent predictors of 30-day mortality and surgical site infection (SSI). RESULTS: Main predictors of 30-day mortality were admission from nursing home or chronic care facility (OR = 1.62, 95% CI: 1.10-2.38, P = .014), transfer from outside ED (OR = 1.81, 95% CI: 1.31-2.51, P < .001), days from admission to operation (OR = 1.05, 95% CI: 1.02-1.08, P = .002), recent significant weight loss (OR = 1.95, 95% CI: 1.12-3.37, P = .018), pre-operative septic shock (OR = 4.13, 95% CI: 2.44-6.99, P < .001), ventilator dependence (OR = 2.50, 95% CI: 1.29-4.81, P = .006), and ASA status. When compared to open repair, laparoscopic repair emerged as protective against SSI (OR = .34, 95% CI: .17-.66, P = .001). Bowel resection (OR = 2.15, 95% CI: 1.63-2.84, P < .001) and increasing wound class were risk factors for SSI. CONCLUSION: In the elderly patient presenting with an acute complicated abdominal wall hernia, time to surgery is crucial for survival, and comorbidities influence outcome. Laparoscopy is an option in management due to its decreased risk of surgical site infection without increased mortality, whenever patient factors are favorable for this approach.

Revisiting abdominal closure in mesenteric ischemia: is there an association with outcome?

PURPOSE: Current guidelines advocate liberal use of delayed abdominal closure in patients with acute mesenteric ischemia (AMI) undergoing laparotomy. Few studies have systematically examined this practice. The goal of this study was to evaluate the effect of delayed abdominal closure on postoperative morbidity and mortality in patients with AMI. METHODS: We performed a retrospective cohort study of the ACS-NSQIP 2013-2017 registry. We included patients with a diagnosis of AMI undergoing emergency laparotomy. Patients were divided into two groups based on the type of abdominal closure: (1) delayed fascial closure (DFC) when no layers of the abdominal wall were closed and (2) immediate fascial closure (IFC) if deep layers or all layers of the abdominal wall were closed. Propensity score matching was performed based on comorbidities, pre-operative, and operative characteristics. Univariable analysis was performed on the matched sample. RESULTS: The propensity-matched cohort consisted of 1520 patients equally divided into the DFC and IFC groups. The median (IQR) age was 68 (59-77), and 836 (55.0%) were female. Compared to IFC, the DFC group showed increased in-hospital mortality (38.9% vs. 31.6%, p = 0.002), 30-day mortality (42.4% vs. 36.3%, p = 0.012), and increased risk of respiratory failure (59.5% vs. 31.2%, p < 0.001). CONCLUSIONS: The delayed fascial closure technique was associated with increased mortality compared to immediate fascial closure. These findings do not support the blanket incorporation of delayed closure in mesenteric ischemia care or its previously advocated liberal use.

Timing and choice of systemic anticoagulation in the setting of extremity arterial injury repair.

PURPOSE: The role of perioperative anticoagulation in the setting of peripheral arterial injury remains unclear. We hypothesized that early initiation of anticoagulation is associated with a reduced amputation rate without increasing bleeding complications. METHODS: Using the 2016-2019 ACS-TQIP database, adult patients with upper and lower extremity vascular injuries who underwent open arterial repair and received anticoagulation were included. Patients were divided into two groups: (1) early venous thromboembolism prophylaxis (≤ 24 h) and (2) late prophylaxis (> 24 h) following arterial repair. The primary outcomes were the rates of limb amputation and bleeding complications. Multivariable logistic regression was used to estimate the impact of timing and type of anticoagulation on the rates of limb amputation and bleeding complications. RESULTS: 4379 patients were included, and 83.9% were males. 68.1% of patients received early anticoagulation, whereas 31.9% received late thromboprophylaxis. Low-molecular-weight heparin (LMWH) was used in 62.0% of patients, and unfractionated heparin (UFH) was administered in 34.3% of patients. Multivariable analysis showed that late initiation of thromboprophylaxis (OR = 1.69 [1.16-2.45], p = 0.006) and use of UFH (OR = 2.61 [1.80-3.79], p < 0.001) were associated with increased rate of amputation. Early initiation of anticoagulation (OR = 2.16 [1.63-2.85], p < 0.001) was associated with increased risk of bleeding complications requiring blood transfusions. Similarly, the use of UFH was associated with a higher rate of bleeding events compared to LWMH (OR = 2.61, [1.80-3.79], p < 0.001). CONCLUSION: Patients with the operative repair of arterial injuries receiving early perioperative anticoagulation demonstrated an improved limb salvage outcome than those who received late thromboprophylaxis. Our data also suggest that early initiation of prophylaxis may be associated with increased bleeding risk, which may be attenuated using LMWH compared to UFH.

Bowel Ischemia in COVID-19 Infection: One-Year Surgical Experience.

BACKGROUND: COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. METHODS: All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. RESULTS: Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. CONCLUSION: Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.

Multisystem outcomes and predictors of mortality in critically ill patients with COVID-19: Demographics and disease acuity matter more than comorbidities or treatment modalities.

BACKGROUND: We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts. METHODS: This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality. RESULTS: A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality. CONCLUSION: We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities. LEVEL OF EVIDENCE: Prognostic, level III.

Preventable Morbidity and Mortality Among Non-trauma Emergency Surgery Patients: The Role of Personal Performance and System Flaws in Adverse Events.

BACKGROUND: Preventable morbidity and mortality among emergency surgery patients is not adequately analyzed. We aim to describe and classify preventable complications and deaths in this population. METHODS: The medical records and quality control documents of patients with emergency, non-trauma, surgical disease admitted between September 1, 2006, and August 31, 2018, and recorded to have a preventable or potentially preventable morbidity and mortality were reviewed. The primary outcome was a classification of the complications and deaths by a panel of experts, as attributable to issues of personal performance or system deficiencies. RESULTS: One hundred and fifty patients were identified (127 complications and 23 deaths). The most commonly encountered preventable complications were surgical-site infection (17%), bleeding (13%), injury to adjacent structures (12%), and anastomotic leak (8%). The majority of complications seemed to stem from personal performance (97%), due to either technical or judgment issues, and only 3% were linked with system flaws, either in the form of communication or inadequate protocols. Alcohol use disorder and duration of operation were different between patients with preventable adverse events related to technical issues and patients related to judgment issues; furthermore, more patients who experienced judgment issues died during hospital stay (p <0.05). CONCLUSION: Among emergency surgery patients, who suffer preventable complications and deaths, issues related to personal performance are more frequent than system flaws. Whereas the effort to improve systems should be unwavering, the emphasis on the surgeon's personal responsibility to avoid preventable complications should not be derailed.

Single-port Laparoscopic Appendectomy: Beyond the Learning Curve: A Retrospective Comparison With Multi-port Laparoscopic Appendectomy.

OBJECTIVES: Previous comparisons between single-port laparoscopic appendectomy (SPLA) and multi-port laparoscopic appendectomy have been conflicting and limited. We compare our single-surgeon, SPLA experience with multi-port cases performed during the same time. METHODS: A retrospective chart review of 128 single-surgeon single-port and 941 multi-port laparoscopic appendectomy cases from April 2009 to December 2014 was conducted. RESULTS: Patient demographics and preoperative laboratory values were comparable. SPLA was associated with shorter operative time (P=0.0001). There was no statistically significant difference in length of hospitalization, postoperative pain medication use, cost, postoperative complication rates (ileus, urinary retention, deep space infection), or readmission between the 2 groups. There were no postoperative incisional hernias in the single-port group. The single-port group had more postoperative oxycodone use (P=0.0110). CONCLUSIONS: Our study supports recently published metaanalyses that fail to support older studies demonstrating longer operative times, and higher hernia rates with SPLA.

Patience is a virtue: an argument for delayed surgical intervention in fulminant Clostridium difficile colitis.

Recently, the incidence and severity of Clostridium difficile infection (CDI) has increased. In cases of fulminant infection, surgery is a viable therapeutic option but associated with high mortality. We sought to examine factors associated with mortality in a large sample of patients with severe CDI that underwent surgery. A retrospective study was conducted in patients with severe CDI undergoing colectomy. Demographics, risk factors, comorbidities, clinical and laboratory data, and time between admission/diagnosis of CDI and colectomy were collected. Conventional markers of severity were evaluated as predictors of mortality. Sixty-four cases were included for analysis. The overall observed mortality rate was 45.3 per cent. Few conventional markers of severity were significantly associated with mortality. Risk factors that correlated with postsurgical mortality were vasopressor use (odds ratio, 3.08; 95% confidence interval, 1.00 to 9.92) and shorter time between diagnosis and surgery (median time, 2 vs 3 days, P = 0.009). This study suggests that a delay in surgery after diagnosis of severe CDI may improve overall outcomes. The finding regarding timing of surgery is contrary to traditional teaching and may be the result of improved medical treatment and stabilization before surgery. Consideration should be given to the importance of timing of colectomy in fulminant CDI, whereas prospective studies should be conducted to elucidate causal relationships.

Single-incision laparoscopic total colectomy.

BACKGROUND AND OBJECTIVES: To present our experience with a single-incision laparoscopic total colectomy, along with a literature review of all published cases on single-incision laparoscopic total colectomy. METHODS: A total of 22 cases were published between 2010 and 2011, with our patient being case 23. These procedures were performed in the United States and United Kingdom. Surgical procedures included total colectomy with end ileostomy, proctocolectomy with ileorectal anastomosis, and total proctocolectomy with ileopouch-anal anastomosis. Intraoperative and postoperative data are analyzed. RESULTS: Twenty-two of the 23 cases were performed for benign cases including Crohns, ulcerative colitis, and familial adenomatous polyposis. One case was performed for adenocarcinoma of the cecum. The mean age was 35.3 years (range, 13 to 64), the mean body mass index was 20.1 (range, 19 to 25), mean operative time was 175.9 minutes (range, 139 to 216), mean blood loss was 95.3mL (range, 59 to 200), mean incision length was 2.61cm (range, 2 to 3). Average follow-up was 4.6 months with 2 reported complications. CONCLUSIONS: Single-incision laparoscopic total colectomy is feasible and safe in the hands of an experienced surgeon. It has been performed for both benign and malignant cases. It is comparable to the conventional multi-port laparoscopic total colectomy.

Clinical characteristics, treatment, and outcome of pancreatic Schwannomas.

This article involves the study of a patient with a rare benign schwannoma in the body of the pancreas. After reviewing 39 patient cases previously reported in the literature, a discussion of the schwannoma with regard to clinical presentation, diagnosis, and treatment is examined. A review of the patient's chart was performed along with a review of the literature using a Medline search. Translations were performed whenever necessary. There are 23 reports of 29 patient cases of pancreatic schwannomas in English and European literature and one report of 10 patient cases in the Japanese literature. The mean age was 57.75 years (range 32-89) and the male-to-female (M:F) ratio was 17:23. The mean reported size was 8.79 cm. The lesion was located in the head in 16 patients (40%), the body in 8 patients (20%), the body and tail in 8 patients (20%), the tail in 6 patients (15%), the head and body in 1 patient (2.5%), and the location was not specified in 1 patient (2.5%). Of the English and European patients, 11 out of 30 patients (36.7%) exhibited solid tumors and 14 out of 30 patients (46.7%) exhibited cystic tumors. The majority of the tumors (35 out of 40) were benign, but there were five reported malignancies. There were no deaths or recurrences reported with a follow-up of 18.68 months +/- 24.09 (range 3-108 months). Pancreatic schwannomas are rare, and the preoperative diagnosis is difficult. Intraoperative frozen section can confirm the diagnosis of a benign schwannoma. Enucleation of the tumor from the surrounding parenchyma is recommended, if possible. Patients undergoing resection indicate an excellent long-term prognosis.