Extracorporeal Membrane Oxygenation-Associated Compartment Syndrome: Review of a National Database.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy. METHODS: Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders. RESULTS: A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330). CONCLUSIONS: ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.

Return to Play Guidelines in Pediatric Concussion: A Systematic Review of Current Literature.

INTRODUCTION: Pediatric concussions, particularly in youth sports, are a significant public health concern, with up to 18% of children experiencing one by age 17. Return-to-play (RTP) guidelines aim to protect athletes from the adverse effects of repeated injuries, but these protocols vary widely based on factors such as age, sport, and geography. This review synthesizes current literature on RTP guidelines for pediatric concussions to provide evidence-based recommendations. METHODS: A systematic search of PubMed was conducted using Medical Subject Headings (MeSH) terms "return to play," "pediatric concussion," and "mild traumatic brain injury." Studies published between January 2000 and December 2023 were included if they focused on RTP protocols for children aged 5 to 17. After screening 60 articles, 45 were selected for review. Study quality was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. RESULTS: RTP protocols showed significant variability influenced by age, gender, and sport type. Common themes included initial rest followed by a gradual return to activity. Female athletes generally required longer recovery periods. Multidisciplinary care and early therapeutic interventions, such as vestibular therapy, were associated with better outcomes and faster recovery. CONCLUSIONS: There is a need for standardized, evidence-based RTP guidelines to address inconsistencies in concussion management. Future research should focus on creating universally applicable protocols, with attention to gender, sport-specific factors, and early intervention to improve recovery outcomes for young athletes.

Evaluating the Efficacy of Large Language Models in CPT Coding for Craniofacial Surgery: A Comparative Analysis.

BACKGROUND: The advent of Large Language Models (LLMs) like ChatGPT has introduced significant advancements in various surgical disciplines. These developments have led to an increased interest in the utilization of LLMs for Current Procedural Terminology (CPT) coding in surgery. With CPT coding being a complex and time-consuming process, often exacerbated by the scarcity of professional coders, there is a pressing need for innovative solutions to enhance coding efficiency and accuracy. METHODS: This observational study evaluated the effectiveness of 5 publicly available large language models-Perplexity.AI, Bard, BingAI, ChatGPT 3.5, and ChatGPT 4.0-in accurately identifying CPT codes for craniofacial procedures. A consistent query format was employed to test each model, ensuring the inclusion of detailed procedure components where necessary. The responses were classified as correct, partially correct, or incorrect based on their alignment with established CPT coding for the specified procedures. RESULTS: The results indicate that while there is no overall significant association between the type of AI model and the correctness of CPT code identification, there are notable differences in performance for simple and complex CPT codes among the models. Specifically, ChatGPT 4.0 showed higher accuracy for complex codes, whereas Perplexity.AI and Bard were more consistent with simple codes. DISCUSSION: The use of AI chatbots for CPT coding in craniofacial surgery presents a promising avenue for reducing the administrative burden and associated costs of manual coding. Despite the lower accuracy rates compared with specialized, trained algorithms, the accessibility and minimal training requirements of the AI chatbots make them attractive alternatives. The study also suggests that priming AI models with operative notes may enhance their accuracy, offering a resource-efficient strategy for improving CPT coding in clinical practice. CONCLUSIONS: This study highlights the feasibility and potential benefits of integrating LLMs into the CPT coding process for craniofacial surgery. The findings advocate for further refinement and training of AI models to improve their accuracy and practicality, suggesting a future where AI-assisted coding could become a standard component of surgical workflows, aligning with the ongoing digital transformation in health care.

Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases.

BACKGROUND: Autologous breast reconstruction (ABR) after mastectomy is increasing due to benefits over implant-based reconstruction. However, free flap reconstruction is not universally offered to patients of advanced age due to perceived increased perioperative risk. METHODS: Patients undergoing free flap breast reconstruction at our institution from 2005 to 2018 were included. Risk-adjusted logistic regression models were fit while controlling for demographic and comorbid characteristics to determine the association of age with the probability of venous thromboembolism (VTE), delayed healing, skin necrosis, surgical site infection (SSI), seroma, hematoma, hernia, and flap loss. Linear predictions from risk-adjusted logistic regression models were used to create spline curves and determine the risk of outcomes associated with age. RESULTS: A cohort of 2,598 patients underwent free flap breast reconstruction in the period examined. The median age was 51 with approximately 9% of patients being 65 or older. Increased age was associated with a greater risk of delayed healing, skin necrosis, and hematoma after surgery. There was no increased risk of medical complications such as VTE or complications such as flap loss, seroma, or SSI. CONCLUSION: A set age cutoff for patients undergoing free flap breast reconstruction does not appear warranted. There is no difference in major surgical complications such as flap loss with increasing age. However, older age does predispose patients to specific wound complications such as hematoma, skin necrosis, and delayed wound healing, which should guide preoperative counseling. Further, medical complications do not increase with advanced age. Overall, however, the safety of ABR in older patients appears uncompromised.

The Godina Principle in the 21st Century: Free Flap Timing after Isolated Lower Extremity Trauma in a Retrospective National Cohort.

BACKGROUND: The timing of free flap reconstruction after lower extremity trauma has been a controversial debate since Marko Godina's original 72-hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction. METHODS: The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing free flap reconstruction after lower extremity trauma. Risk-adjusted statistical methods were used to identify optimal time where risk of infectious and microsurgical complications increase and to quantify the risk associated with time delays. RESULTS: A total of 1,030 patients undergoing reconstruction were identified. The mean time to flap coverage was 24.3 days. Thirty-three percent were performed within 72 hours, 24% from 72 hours to 10 days, 18% from 10 to 30 days, and 24% after 30 days. Flaps performed after 10 days were associated with increased risk of surgical site infection, osteomyelitis, and other wound complications, compared with those performed within 72 hours. There was no increased risk in the period of 72 hours to 10 days. Revision amputation and microsurgical complications were not increased after 10 days. The predicted optimal cutoff was 9.5 days for microsurgical complications and 14.5 days for infectious complications. CONCLUSION: Advances in microsurgery may be responsible for extending the time in which definitive soft tissue coverage is required for wounds resulting from lower extremity trauma. Although it appears the original 72-hour time window can be safely extended, efforts should be made to refer patients to specialty limb salvage centers in a timely fashion.

Incidence and Epidemiology of Traumatic Tympanic Membrane Rupture: A National Trauma Data Bank Analysis.

The incidence of traumatic tympanic membrane rupture (TTMR) has increased over recent decades. The association of certain external injury causes and bone fracture patterns with TTMR is anecdotal. It has been suggested that a diagnosis of TTMR may be missed during the acute trauma admission. The authors sought to evaluate the incidence of TTMR according to external injury cause and evaluate the association of skull fracture patterns with TTMR using a national trauma database. A cross-sectional analysis of trauma encounters was conducted using the National Trauma Data Bank (NTDB) from 2008 to 2015. Demographic and injury data were abstracted. Poisson regression was used to determine the incidence rate ratios of tympanic membrane rupture by external injury cause and logistic regression was used to estimate odds ratios (OR) of TTMR by skull fracture type. A total of 8214 patients were identified with TTMR during acute admission. The majority were on average 30 years old, 76% male, 71% White, had a mean Injury Severity Score of 14, and 42% were admitted to level I centers. The incidence rate ratio was only higher in lightning related injuries [5.262; 95% confidence interval (CI): 4.194-6.602] when using those caused by explosives as a reference. Basilar skull (OR: 12.95; 95% CI: 12.095-12.866) and cranial vault (OR: 2.938; 95% CI: 2.647-3.260) fractures were most associated with TTMR. The high incidence TTMR in association with certain external causes of injury and types of skull fractures should drive screening in the acute setting in order to increase detection and reduce morbidity from missed injuries.

Obesity as a Risk Factor in Cosmetic Abdominal Body Contouring: A Systematic Review and Meta-Analysis.

BACKGROUND: The incidence of obesity is on the rise around the globe. Outside of the massive weight loss (MWL) patient population, knowledge of risk factors associated with abdominal body contouring (BC) is limited. This systematic review and meta-analysis assesses the impact of obesity has on cosmetic abdominal BC outcomes. METHODS: A systematic review conducted in accordance with PRISMA 2020 was done. PubMed, Embase, Scopus, and COCHRANE databases were reviewed under search syntax "obesity," "abdominoplasty," "panniculectomy," and "body contouring" for articles. Cosmetic was defined as abdominoplasty or panniculectomy outside the context of MWL. Obesity was defined as BMI ≥ 30 kg/m2. Studies reporting postoperative outcomes with less than 50% of their population involving MWL patients were included. Postoperative outcomes were assessed by pooled analysis and meta-analysis. RESULTS: Of 3088 initial studies, 16 met inclusion criteria, and nine were used for pooled and meta-analysis. Meta-analysis demonstrated that obesity was associated with more seromas (OR 1.45, 1.06-1.98, p = 0.02), hematomas (OR 2.21, 1.07-4.57, p = 0.03), and total surgical site occurrences (OR 1.99, 1.30-3.04, p = 0.0016). There was no significant difference in odds of any other complications. Analysis by obesity class showed no significant increase in odds in seromas or wound dehiscence. CONCLUSIONS: This review demonstrates obesity increased odds of postoperative complications following cosmetic abdominal BC. However, risk of complications does not continue to increase with higher obesity class. A BMI ≥ 30 kg/m2 should not be a strict contraindication to cosmetic abdominal BC. Instead, plastic surgeons should evaluate patients on a case-by-case basis. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pandemic Puppies: Man's Best Friend or Public Health Problem? A Multidatabase Study.

INTRODUCTION: The public health implications of the COVID-19 pandemic reach beyond those of the disease itself. Various centers have anecdotally reported increases in the incidence of dog bite injuries which predominate in pediatric populations. The reasons for this increase are likely multifactorial and include an increase in canine adoptions, remote learning, and psychosocial stressors induced by lockdowns. We hypothesized that there was a significant increase in the proportion of dog bite injuries at our institution and within a nationally representative cohort. METHODS: We queried our electronic health record and the National Electronic Injury Surveillance System (NEISS) for all records pertaining to dog bites between 2015 and 2020, and the annual incidence was calculated. Poisson regression was then used to estimate whether there was a significant difference in the adjusted risk ratio for each year. RESULTS: The institutional and national cohorts revealed relative increases in the incidence of dog bite injury of 243 and 147.9 per 100,000 over the study period, respectively. Both cohorts observed significant increases of 44% and 25% in the annual incidence relative to 2019, respectively. Poisson regression revealed a significantly elevated adjusted relative risk in the institutional cohort for 2020 (2.664, CI: 2.076-3.419, P < 0.001). The national cohort also revealed an increase (1.129, CI: 1.091-1.169, P < 0.001). CONCLUSIONS: A nationwide increase in the incidence of dog bite injuries among children was observed during COVID-19 in 2020. These findings suggest that dog bites remain a public health problem that must be addressed by public health agencies.

Treatment of Sagittal Craniosynostosis Using Osteoplastic Parietal Craniotomy Flap With Distraction Osteogenesis: A Variation on Technique.

ABSTRACT: Late presentation sagittal craniosynostosis presents a unique challenge due to the decreased ability of the skull to repair the bony defects created by standard of care techniques. Distraction osteogenesis is a viable strategy to correct this defect in late presenting cases. The authors describe a variation in technique in which the temporalis muscle origin is retained, creating an osteoplastic bone flap with retained vascularity through the tem-poralis muscle. This may improve postoperative bony healing of bony defects in this compromised population. The authors present two patients who presented to them late with sagittal synostosis who were treated with distraction osteogenesis in which vascular continuity to the parietal bones is preserved through the temporalis muscle.

Demonstrating the Non-inferiority of a Plastic Surgery Microscopic Technique for Hepatic Artery Anastomosis in Pediatric Liver Transplant: A Single-Institution Study.

INTRODUCTION: Before advancements in liver transplantation, conditions such as acute liver failure, decompensated liver cirrhosis, and hepatocellular carcinoma were associated with poor prognosis. Orthotopic liver transplantation has since emerged as a curative treatment. Despite its benefits, liver transplantation can lead to complications, including hepatic artery thrombosis (HAT), which is especially significant in pediatric patients. This study evaluates the utility of microsurgical anastomosis by plastic surgeons in reducing postoperative HAT compared to standard loupe-assisted anastomosis performed by transplant surgeons. METHODS: This retrospective chart review included pediatric patients who underwent orthotopic liver transplantation at a single institution between September 2015 and September 2023. Patients were divided into two groups: one receiving standard loupe-assisted anastomosis by transplant surgeons (n = 28) and the other receiving microsurgical anastomosis by plastic surgeons (n = 22). The primary outcomes measured were the rates of HAT. Secondary outcomes included graft survival, patient survival, postoperative hospital stay, resistive indices, bleeding, biliary complications, venous complications, transplant rejection, and reoperation rates. RESULTS: In 50 pediatric patients who underwent orthotopic liver transplantation, we compared outcomes between standard anastomosis (n = 28) and microscope-assisted anastomosis (n = 22). Demographic characteristics were similar between the groups. Hemorrhage occurred significantly more frequently in the standard anastomosis group (35.7%) compared to the microscope-assisted group (9.1%), with a p-value of 0.045. Other complications, including HAT (28.6% vs. 13.6%, p = 0.306), biliary leak (14.3% vs. 27.3%, p = 0.302), and organ rejection (21.4% vs. 13.6%, p = 0.713), did not differ significantly between the groups. Additionally, survival rates were comparable, with 71% in the standard group and 86% in the microscope group (p = 0.306). These findings suggest that while microscope-assisted anastomosis may reduce the risk of hemorrhage, other outcomes remain similar between the techniques. CONCLUSION: Our findings suggest that microsurgical anastomosis techniques performed by plastic surgeons are non-inferior to standard loupe-assisted techniques in pediatric liver transplantation and may decrease the rate of postoperative hemorrhage. Microsurgical anastomosis is a viable alternative to standard loupe-assisted techniques in pediatric hepatic artery transplants. Further research with larger sample sizes is warranted to confirm these findings and optimize surgical techniques.

The Use of Tranexamic Acid in Breast Reduction and Abdominoplasty: A Review of a Multicenter Federated Electronic Health Record Database.

Background: Tranexamic acid (TXA), a fibrinolysis inhibitor, is widely used in various surgical fields to minimize blood loss. However, its efficacy and safety in plastic surgery, especially in reduction mammaplasty and abdominoplasty, remain underexplored. This study investigates the utility of intravenous (IV) TXA in these procedures, focusing on reducing postoperative complications and evaluating its safety in the context of venous thromboembolism (VTE). Objectives: To evaluate the efficacy and safety of TXA in reduction mammaplasty and abdominoplasty. Methods: Using data from the TriNetX LLC (Cambridge, MA) National Health Research Network database, this retrospective study compared adult patients undergoing reduction mammaplasty or abdominoplasty who received intraoperative IV TXA against those who did not. Primary outcomes included postoperative seroma and hematoma incidences, whereas secondary outcomes assessed the necessity for procedural drainage and the occurrence of VTE within 1-year postsurgery. Results: No significant differences in the rates or risks of hematoma, seroma, or the need for procedural drainage between patients administered IV TXA and those who were not, for both reduction mammaplasty and abdominoplasty. Additionally, IV TXA did not increase the risk of VTE in either patient group. Conclusions: IV TXA application in reduction mammaplasty and abdominoplasty does not provide added benefits in reducing postoperative complications such as seroma, hematoma, or the necessity for procedural drainage. Furthermore, it does not alter the risk of thromboembolic events. These findings highlight the need for further research, particularly through randomized control trials, to understand TXA's efficacy in plastic surgery.

Factors associated with late surgical correction of craniosynostosis: A decade-long review of the United States nationwide readmission database.

Late-repair craniosynostosis (LRC), defined as craniosynostosis surgery beyond 1 year of age, is often associated with increased complexity and potential complications. Our study analyzed data from the 2010-2019 Nationwide Readmissions Database to investigate patient factors related to LRC. Of 10 830 craniosynostosis repair cases, 17% were LRC. These patients were predominantly from lower-income families and had more comorbidities, indicating that socioeconomic status could be a significant contributor. LRC patients were typically treated at teaching hospitals and privately owned investment institutions. Our risk-adjusted analysis revealed that LRC patients were more likely to belong to the lowest-income quartile, receive treatment at privately owned investment hospitals, and use self-payment methods. Despite these challenges, the hospital stay duration did not significantly differ between the two groups. Interestingly, LRC patients faced a higher predicted mean total cost compared with those who had surgery before turning 1. This difference in cost did not translate to a longer length of stay, further emphasizing the complexity of managing LRC. These findings highlight the urgent need for earlier intervention in craniosynostosis cases, particularly in lower-income communities. The medical community must strive to improve early diagnosis and treatment strategies in order to mitigate the socioeconomic and health disparities observed in LRC patients.

Increased Incidence of Suspected Smoke Inhalation During the Coronavirus Disease 2019 Pandemic: A National Database Study.

The COVID-19 pandemic has forced many Americans to adapt their daily routines. In 2020, there was a significant increase in house fires according to the National Fire Prevention Association (NFPA). The objective of this study was to characterize the changes in suspected smoke inhalations (SSIs) during the first year of the pandemic in the National Emergency Medical Services Information System (NEMSIS). The NEMSIS database was queried for all EMS transports captured between 2017 and 2020. Differences in the incidences of SSIs and fire dispatches in 2020 were estimated using Poisson regression models. There was a 13.4% increase in the incidence of fire dispatches and a 15% increase in SSIs transported in 2020 compared to the previous 3 years. The incidence rate ratio of both fire dispatches (1.271; 95% CI: 1.254-1.288; P < .001) and SSI (1.152; 95% CI: 1.070-1.241; P < .001) was significantly elevated in 2020. The increases in fire dispatches and SSIs observed in the NEMSIS database are in concordance with other literature indicating the increase in fire incidence and morbidity observed during the pandemic. These results should inform fire prevention outreach efforts and resource allocation in burn centers in the event of future pandemic.

Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study.

BACKGROUND: Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. METHODS: We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. RESULTS: Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). CONCLUSION: The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III.