Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status.

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013-2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88-6.69) (OR: 11.24; 95% CI: 8.53-13.95), more time spent in ICU (2.73; 1.70-3.76) (7.98; 6.10-9.87), and increased risk for surgical site infection (1.32; 1.03-1.68) (2.54; 1.71-3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Reducing the incidence of parastomal hernia with a simple surgical technique.

The incidence of parastomal hernia is reported at between 10% and 50%. The development of a hernia after stoma surgery can lead to both physical and psychological problems and may reduce the individual's quality of life. Many garments and appliances are aimed at managing a stoma and a peri-stomal hernia. From a surgical perspective, to date there has been no real success in achieving a reduction in parastomal hernia incidence. The cost of managing a parastomal hernia is reported as being in excess of £1 million a year in England for non-surgical management alone. Surgical repair of parastomal hernia carries not only a financial burden but an increased risk of mortality and morbidity.

In vivo assessment of absorbable knotless barbed suture for single layer gastrotomy and enterotomy closure.

OBJECTIVE: To compare the performance of an absorbable barbed suture device to absorbable monofilament suture after single layer, appositional gastrotomy and enterotomy closure. STUDY DESIGN: Experimental comparative study. ANIMALS: Purpose-bred adult mongrel hounds (n = 14). METHODS: Bursting strengths up to 250 mmHg of incisional closure with either monofilament or barbed suture in a simple continuous, appositional pattern at sites in the stomach (2), jejunum (4), and colon (4) were compared at postoperative Days 3, 7, and 14. Time for incisional closure was compared between materials. RESULTS: Bursting strength was not significantly different between gastrotomies/enterotomies closed with the monofilament suture or the barbed device. Closure time was significantly reduced with the barbed device in jejunal enterotomy closure. CONCLUSION: The barbed device compared favorably with monofilament suture for gastrotomy and enterotomy (small intestine, colon) closure. Results demonstrate comparable burst strengths between monofilament suture and the barbed device. Closure time was significantly reduced in jejunum closure using the barbed device.

Late vs early ostomy closure for necrotizing enterocolitis: analysis of adhesion formation, resource consumption, and costs.

BACKGROUND: Surgeons prefer to close ostomies at least 6 weeks after the primary operation because of the anticipated postoperative abdominal adhesions. Limited data support this habit. Our aim was to evaluate adhesion formation-together with an analysis of resource consumption and costs-in patients with necrotizing enterocolitis who underwent early closure (EC), compared with a group of patients who underwent late closure (LC). METHODS: Chart reviews and cost analyses were performed on all patients with necrotizing enterocolitis undergoing ostomy closure from 1997 to 2009. Operative reports were independently scored for adhesions by 2 surgeons. RESULTS: Thirteen patients underwent EC (median, 39 days; range, 32-40), whereas 62 patients underwent LC (median, 94 days; range, 54-150). Adhesion formation in the EC group (10/13 patients, or 77%) was not significantly different (P = 1.000) from the LC group (47/59 patients, or 80%). No differences were found in the costs of hospital stay, surgical interventions, and outpatient clinic visits. CONCLUSIONS: Ostomy closure within 6 weeks of the initial procedure was not associated with more adhesions or with changes in direct medical costs. Therefore, after stabilization of the patient, ostomy closure can be considered within 6 weeks during the same admission as the initial laparotomy.

Outcomes using a bioprosthetic mesh at the time of permanent stoma creation in preventing a parastomal hernia: a value analysis.

PURPOSE/METHODS: A retrospective review of the medical records of all patients who had a prosthetic placed at the time of stoma creation for the prevention of a parastomal hernia was performed. The purpose of this study was to evaluate the safety, efficacy, and cost-effectiveness of bioprosthetics. RESULTS: A bioprosthetic was used in 16 patients to prevent the occurrence of a parastomal hernia. The median follow-up was 38 months. There were no mesh-related complications, and no parastomal hernias occurred. On value analysis, to be cost-effective, the percentage of patients who would have subsequently needed surgical repair of a parastomal hernia would have to be in excess of 39% or the bioprosthetic would have to cost less than $2,267 to $4,312. CONCLUSIONS: These data show the safety and efficacy of using a bioprosthetic at the time of permanent stoma creation in preventing a parastomal hernia and defines the parameters for this approach to be cost-effective.

[Surgical strategy in acute or elective sigmoid resection in The Netherlands; survey based on a marketing model]. / Operatieve strategie bij de acute of electieve sigmoïdresectie in Nederland; enquête op basis van een marketingmodel.

OBJECTIVE: To gain insight into the operative strategies used by Dutch surgeons for complicated diverticulitis and sigmoid carcinoma, and into the influence of patient risk factors and surgeon's experience on the preferred operative strategy. DESIGN: Descriptive. METHOD: A questionnaire was sent to all 148 members of the Dutch Society of Gastrointestinal Surgery, concerning 32 fictitious patients with sigmoid pathology. It was based on conjoint-analysis, a model used in marketing research. This model analyses qualities that make a product preferable to another product of the same product group. The operative choices were: resection with Hartmann's procedure, resection with primary anastomosis after on-table lavage, or with primary anastomosis only, or no primary resection but diverting stoma only, or some personal technique. The survey focused on experience of the surgeons with the operative procedures, and on treatment choices in four fictitious cases frequently encountered in general surgery. RESULTS: There was little agreement concerning the preferred surgical option for treatment of complicated diverticular disease or sigmoid carcinoma. With the exception of one fictitious young, electively operated 'ideal' patient (resection with primary anastomosis) there is hardly any consensus among the surgeons with respect to preferred treatment. CONCLUSIONS: Reasons to depart from the conceptually optimal treatment (resection and anastomosis) in complicated cases (from the point of view of the surgeon or the patient), and absence of agreement on responsible other treatment could be differences in appraisal of the importance of several risk factors, or differences in acquired decision making strategies. The literature offers no answer to the question which techniques should be preferred under various circumstances.