Reportable infections following colon surgery in a large public healthcare system in New York City: The consequences of being a level 1 trauma center.

OBJECTIVES: To examine differences in risk factors and outcomes of patients undergoing colon surgery in level 1 trauma centers versus other hospitals and to investigate the potential financial impact of these reportable infections. DESIGN: Retrospective cohort study between 2015 and 2022. SETTING: Large public healthcare system in New York City. PARTICIPANTS: All patients undergoing colon surgery; comparisons were made between (1) all patients undergoing colon surgery at the level 1 trauma centers versus patients at the other hospitals and (2) the nontrauma and trauma patients at the level 1 trauma centers versus the nontrauma patients at other hospitals. RESULTS: Of 5,217 colon surgeries reported, 3,531 were at level 1 trauma centers and 1686 at other hospitals. Patients at level 1 trauma centers had significantly increased American Society of Anesthesiology (ASA) scores, durations of surgery, rates of delayed wound closure, and rates of class 4 wounds, resulting in higher SIRs (1.1 ± 0.15 vs 0.75 ± 0.18; P = .0007) compared to the other hospitals. Compared to the nontrauma patients at the other hospitals, both the nontrauma and trauma patients at the level 1 trauma centers had higher ASA scores, rates of delayed wound closure, and of class 4 wounds. The SIRs of the nontrauma patients (1.16 ± 1.29; P = .008) and trauma patients (1.26 ± 2.69; P = .066) at the level 1 trauma center were higher than the SIRs of nontrauma patients in the other hospitals (0.65 ± 1.18). CONCLUSIONS: Patients undergoing colon surgery at level 1 trauma centers had increased complexity of surgery compared to the patients in other hospitals. Until there is appropriate adjustment for these risk factors, the use of infections following colon surgery as a reportable quality measure should be re-evaluated.

Impact of Prophylactic Antibiotic Selection on the Prevention and Bacterial Flora of Surgical Site Infections After Colorectal Surgery.

Background: Deep incisional and organ/space surgical site infections (SSIs) after colorectal surgery are associated with adverse outcomes. Multiple antibiotic regimens are recommended for peri-operative prophylaxis, with no particular regimen preferred over another. We compared the prophylaxis regimens used in patients with and without SSIs, and the impact of regimens on the flora involved in SSIs. Patients and Methods: Information was extracted from the National Healthcare Safety Network databank of patients undergoing colorectal surgery from 2015 to 2022 in a large public healthcare system in New York City. Patients with SSIs were identified, and controlling for nine variables, propensity score matching was used to create a matched control group without SSIs. Prophylactic regimens were compared between the matched groups with and without SSIs. Also, for the patients with SSIs, the impact of the prophylactic regimen on the subsequent pathogens involved the infection was examined. Results: A total of 275 patients with SSIs were compared to a matched cohort without SSIs. The prophylactic regimens were extremely similar between the SSI and control groups. Among the patients who developed SSIs, more patients who received cefoxitin had emergence of select cephalosporin-resistant Enterobacterales and Bacteroides spp. when compared with those who received ß-lactam-ß-lactamase inhibitors. Conclusions: The distribution of surgical prophylaxis regimens was remarkably similar between patients developing serious SSIs and a closely matched cohort that did not develop an SSI. However, given the downstream effects of more resistant and anaerobic flora should an infection develop, use of cefoxitin should be re-evaluated as a prophylactic agent.

When New York City was the COVID-19 pandemic epicenter: The impact on trauma care.

BACKGROUND: During early spring 2020, New York City (NYC) rapidly became the first US epicenter of the COVID-19 pandemic. With an unparalleled strain on health care resources, we sought to investigate the impact of the pandemic on trauma visits and mortality in the United States' largest municipal hospital system. METHODS: We conducted a retrospective multicenter cohort study of the five level 1 trauma centers in NYC's public health care system, New York City's Health and Hospitals Corporation. Clinical characteristics, mechanism of injury, and mortality of trauma patients presenting during the early pandemic (March 1, 2020, to May 31, 2020) were compared with a similar period in the previous 2 years. To account for important patient and hospital-level confounding variables, we created a propensity score for treatment and applied inverse probability weighting. RESULTS: In March to May 2020, there was a 25% decrease in median number of monthly trauma visits (693 vs. 528; p = 0.02) but a 50% increase (15% vs. 22%; p = <0.001) in patients presenting for penetrating injuries, compared with the same period for 2018 and 2019. Injured patients with COVID were significantly more likely to die compared with those without COVID-19 (10.5% vs. 3.6%; p < 0.001). Overall, there was no significant difference in mortality for non-COVID-injured New Yorkers cared for in 2020 compared with 2018 and 2019. Less severely injured non-COVID patients (Injury Severity Score, <15), however, were significantly more likely to die compared with this same subgroup in 2018 and 2019 (adjusted relative risk, 2.7 [95% confidence interval, 1.5-4.7]). CONCLUSION: Despite a decline in overall trauma visits during the early part of the COVID pandemic in NYC, there was a significant increase in the proportion of penetrating mechanisms. Less-injured non-COVID patients experienced an increase in mortality in the early pandemic, possibly from a depletion of human and hospital resources from the large influx of COVID patients. These data lend support to the safeguarding of trauma system resources in the event of a future pandemic. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation.

INTRODUCTION: Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes. STUDY DESIGN: We conducted a retrospective cohort study using our level-1 trauma center's trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test. RESULTS: We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001). CONCLUSION: TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.

Improving SCD compliance in trauma patients at Kings County Hospital Center: a quality improvement report.

Venous thromboembolism (VTE) is the fourth most commonly reported complication in trauma patients. For these patients, thromboprophylaxis is a standard of care. Patient compliance with sequential compression devices (SCDs), a form of mechanical VTE prophylaxis, has been a focus of efforts to improve patient safety. At our institution, a baseline audit in July 2020 revealed that patients admitted to the trauma floors have poor compliance with the use of SCDs. In this quality improvement project, we developed a patient education intervention to improve SCD compliance. We distributed an informational flyer to patients and led short educational sessions on VTE risk factors and proper SCD use. Our aim was to increase our SCD compliance rate by 30% in 4 weeks. We used three plan-do-study-act (PDSA) cycles to implement and refine our intervention. We measured SCD compliance during morning and afternoon patient observations and generated run charts to understand how our cycles were leading to change. After a 4-week period, we did not achieve our aim, but increased our overall compliance from 45% to 60% and sustained this improvement throughout our PDSA cycles. Morning compliance was lower than afternoon compliance both at baseline (45% vs 48.5%) and at the end the project (45% vs 53%). Our results suggest that patient education should be coupled with interventions that address other barriers to SCD compliance.

Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis.

BACKGROUND: We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality. METHODS: The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach. RESULTS: We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0). CONCLUSION: The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.

Superior gluteal artery pseudoaneurysm after a gunshot wound to the buttock: A case.

INTRODUCTION: Penetrating trauma to the buttock can rarely result into the development of a gluteal artery pseudoaneurysm. Here we present the case of a patient with a superior gluteal pseudoaneurysm after a gunshot wound to the left buttock. PRESENTATION OF CASE: A 48-year-old male presented with fullness and tenderness at the left gluteal wound that resulted from a gunshot 18 days prior. At the time of initial trauma, imaging showed minimal extravasation of contrast at the left superior gluteal artery, but the bleeding stopped and patient was discharged. On his return, examination showed palpable fluctuance but no bleeding. A superior gluteal artery pseudoaneurysm was identified on CT scan. Patient also complained of intermittent subjective fever and new onset of SOB. CT chest demonstrated a pulmonary embolism at the right basilar segmental artery. Coil embolization was performed to treat the pseudoaneurysm and patient was subsequently started on anticoagulation therapy. DISCUSSION: Penetrating wounds to the buttock can result in associated vascular or visceral injuries. Pseudoaneurysms can develop days to years after the initial injury. On exam, presence of pain, swelling, tenderness, bleeding from wound, thrill, bruit or a pulsating mass should raise suspicion for pseudoaneurysm, which can be diagnosed on CT scan and treated with embolization. CONCLUSION: Proper management of traumatic wounds to the buttock with associated vascular injuries, with follow up protocols and patient education is necessary to prevent life-threatening complications such as hemorrhage from pseudoaneurysm.

Case report of an intussusception presenting after a trauma jejunorrhaphy.

INTRODUCTION: Intussusception in pediatric cases are predominantly idiopathic, while intussusception in adult cases are predominantly associated with a lesion. The differential diagnosis for the lesion includes Meckel's diverticulum, lipoma, adenoma, and metastatic disease. PRESENTATION OF CASE: We report a case of intussusception in which the lead point was the site of a jejunorrhaphy for a jejunal perforation secondary to blunt abdominal trauma. The intussusception presented as a postoperative bowel obstruction requiring a re-laparotomy and a segmental bowel resection. The postoperative course after the re-laparotomy was unremarkable. DISCUSSION: Postoperative intussusception with a bowel anastomosis acting as the lead point is a rare but described complication of anastomotic procedures. Our report is the first in the trauma literature to describe an intussusception led by a jejunorrhaphy rather than a circumferential suture or stapled anastomosis. While rare, this complication is a critical constituent in the differential diagnosis of bowel obstruction after laparotomy for trauma. Currently, no standardized technique or prophylactic maneuver exists to prevent intussusception after an intestinal repair.

Challenge of uncontrolled enteroatmospheric fistulas.

INTRODUCTION: With the popularization of damage control surgery and the use of the open abdomen, a new permutation of fistula arose; the enteroatmospheric fistula (EAF), an opening of exposed intestine spilling uncontrollably into the peritoneal cavity. EAF is the most devastating complication of the open abdomen. We describe and analyze a single institution's experience in controlling high-output EAFs in patients with peritonitis. METHODS: We analyzed 189 consecutive procedures to achieve and maintain definitive control of 24 EAFs in 13 patients between 2006 and 2017. EAFs followed surgery for either trauma (seven patients) or non-traumatic abdominal conditions (six patients). All procedures were mapped onto an operative timeline and analyzed for: success in achieving definitive control, number of reoperations, and feasibility of bedside procedures in the surgical intensive care unit. The end point was controlled enteric drainage through a healed abdominal wound. RESULTS: There was a mean delay of 8.5 days (range 2-46 days) from the index operation until the EAF was identified. Most EAFs required several attempts (mean: 2.7 per patient, range 1-7) until definitive control was achieved. Multiple reoperations were then required to maintain control (mean: 13). While the most effective techniques were endoscopic (1) and proximal diversion (1), these were applicable only in select circumstances. A 'floating stoma' where the fistula edges are sutured to an opening in a temporary closure device, while technically effective, required multiple reoperations. Tube drainage through a negative pressure dressing (tube vac) required the most maintenance usually through bedside procedures. Primary closure almost always failed. Twelve of the 13 patients survived. CONCLUSION: An EAF is a highly complex surgical challenge. Successful source control of the potentially lethal ongoing peritonitis requires tenacity and tactical flexibility. The appropriate control technique is often found by trial and error and must be creatively tailored to the individual circumstances of the patient.

A rare case of splenic pseudoaneurysm in pediatric splenic blunt trauma patient: Review of diagnosis and management.

INTRODUCTION: Splenic pseudoaneurysms (SPA) are a rare but serious sequela of blunt traumatic injury to the spleen. Management of adult blunt splenic trauma is well-studied, however, in children, the management is much less well-defined. PRESENTATION OF CASE: A 15 year-old male presented with severe abdominal pain of acute onset after sustaining injury to his left side while playing football. FAST was positive for free fluid in the abdomen. Initial abdomen CT demonstrated a grade III/IV left splenic laceration with moderate to large hemoperitoneum with no active extravasation or injury to the splenic vessels noted. A follow-up CT angiography of the abdomen demonstrated a splenic hypervascular structure suspicious for a small pseudoaneurysm. Splenic arteriogram which demonstrated multiple pseudoaneurysms arising from the second order splenic artery branches which was angioembolized and treated. DISCUSSION & CONCLUSION: Questions still remain regarding the timing of repeat imaging for diagnosis of SPA following non-operative blunt splenic trauma, which patients should be imaged, and how to manage SPA upon diagnosis. More clinical study and basic science research is warranted to study the disease process of SPA in pediatric patient. We believe that our proposed management algorithm timely detect formation of delayed SPA formation and addresses the possible fatal disease course of pediatric SPA.