Appendiceal Neoplasms.

Appendiceal neoplasms are identified in 0.9 to 1.4% of appendiceal specimens, and the incidence is increasing. It has long been professed that neuroendocrine tumors (formerly carcinoids) are the most common neoplastic process of the appendix; recent data, however, has suggested a shift in epidemiology. Our intent is to distill the complex into an algorithm, and, in doing so, enable the surgeon to seamlessly maneuver through operative decisions, treatment strategies, and patient counseling. The algorithm for evaluation and treatment is complex, often starts from the nonspecific presenting complaint of appendicitis, and relies heavily on often subtle histopathologic differences.

Fluorescence Angiography in Colorectal Resection.

BACKGROUND: Intraoperative laser fluorescence angiography is a relatively new tool that can be used by colorectal surgeons to ensure adequate perfusion to bowel that remains after resection. It has been used mostly to determine an appropriate point of transection of the proximal bowel, as well as to ensure perfusion after the anastomosis has been constructed. We propose a different use of the technology in complex cases to ensure the ability to safely transect a major vascular pedicle and to ensure that perfusion will remain adequate. OBJECTIVE: The purpose of this article is to describe a new use for fluorescence angiography technology. DESIGN: This is a technical note. SETTINGS: The work was conducted at a tertiary care military medical center. PATIENTS: Patients included individuals requiring oncologic colorectal resection where the status of 1 major vascular pedicle was unknown or impaired. MAIN OUTCOME MEASURES: We assessed perfusion after occlusion of a major vascular pedicle for the short term in hospital outcomes. RESULTS: Adequate studies were obtained, and perfusion was maintained in both patients. Oncologic resections were performed, and short-term outcomes were comparable with any individual undergoing these procedures. LIMITATIONS: This study was limited because it is early experience that was not performed in the setting of a scientific investigation. CONCLUSIONS: Application of intraoperative fluorescence angiography in this setting appears to be safe and may assist the surgeon in estimating reliable vascular perfusion in patients such as these who require oncologic colorectal resection.

Have we progressed in the surgical literature? Thirty-year trends in clinical studies in 3 surgical journals.

BACKGROUND: We practice in an era of evidence-based medicine. In 1993, Solomon and McLeod published an article examining study designs in 3 surgical journals from 1980 and 1990. OBJECTIVE: The purpose of this study was to evaluate subsequent 30-year trends in the quality of selected literature. DESIGN: All of the articles from Diseases of the Colon & Rectum, Surgery, and the British Journal of Surgery during 2000 and 2010 were classified by study design. Nonclinical studies were substratified by animal/laboratory, surgical technique, editorial/review, or miscellaneous articles. Clinical articles were categorized as case or comparative studies, further categorized by study design, and rated on a 10-point scale to determine strength. We compared interobserver reliability using a random sample. SETTING: This study was conducted at 3 North American medical centers. PATIENTS: Patients described in the scope of the literature were included in this study. MAIN OUTCOME MEASURES: Frequency, type, and strength of study design were measured. RESULTS: We evaluated 1911 articles (967 clinical; 17% comparative). There was a significant increase in multicenter clinical studies (from 12% to 27%; p < 0.0001) and mean study population (from 326 to 6775; p < 0.05). Studies using administrative data increased from 14% to 43% (p < 0.0001). Case reports decreased from 16% to 7% of all clinical studies (p < 0.001), whereas the percentage of comparative studies increased from 14% to 21% (p = 0.001). The percentage of randomized controlled trials did not increase significantly (8.5% in 2000; 10.0% in 2010; p = 0.44). The mean 10-point score for comparative studies was 6.7 for both years (p = 0.50). There was good interobserver agreement in the classification of studies (κ = 0.70) and moderate agreement in scoring comparative studies (κ = 0.47). LIMITATIONS: This descriptive study cannot fully account for the reasons behind the identified differences. CONCLUSIONS: Comparative and multicenter studies, mean study population, and the use of administrative data increased from 2000 to 2010. This suggests that increased use of administrative databases has allowed larger populations of patients from more institutions to be studied and may be more generalizable. Researchers should strive toward improving the level of evidence (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A167).

Crohn's disease and pregnancy: the impact of perianal disease on delivery methods and complications.

BACKGROUND: The optimal delivery method in patients with Crohn's disease is unknown, and there is no large-scale evidence on which to base decisions. OBJECTIVE: The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn's disease. DESIGN AND PATIENTS: The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn's disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis). SETTINGS: A large population-cohort database was used for the analysis. MAIN OUTCOME MEASURES: The primary outcomes measured were cesarean delivery and perineal lacerations. RESULTS: Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn's disease. Rates of cesarean delivery were higher in patients who had Crohn's disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn's disease with (38.9%) and without (25.6%) perianal disease (p < 0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn's disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p < 0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3-4.1; p < 0.001) and smoking (OR, 1.6; 95% CI, 1.5-1.7; p < 0.001) were independently associated with higher rates of 4th degree laceration. Crohn's disease was not independently associated with 4th degree laceration. LIMITATIONS: This was a retrospective study with the inherent limitations of large databases. CONCLUSIONS: Patients with Crohn's disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn's disease. In the absence of perianal disease, the method of delivery in women with Crohn's disease should be predicated on obstetric indication.

The impact of pregnancy on surgical Crohn disease: an analysis of the Nationwide Inpatient Sample.

BACKGROUND: The impact of pregnancy on the course of Crohn disease is largely unknown. Retrospective surveys have suggested a variable effect, but there are limited population-based clinical data. We hypothesized pregnant women with Crohn disease will have similar rates of surgical disease as a nonpregnant Crohn disease cohort. MATERIAL AND METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify female Crohn patients from all patients admitted using the Nationwide Inpatient Sample (1998-2009). Women were stratified as either pregnant or nonpregnant. We defined Crohn-related surgical disease as peritonitis, gastrointestinal hemorrhage, intra-abdominal abscess, toxic colitis, anorectal suppuration, intestinal-intestinal fistulas, intestinal-genitourinary fistulas, obstruction and/or stricture, or perforation (excluding appendicitis). RESULTS: Of the 92,335 women admitted with a primary Crohn-related diagnosis, 265 (0.3%) were pregnant. Pregnant patients were younger (29 versus 44 y; P<0.001) and had lower rates of tobacco use (6% versus 13%; P<0.001). Pregnant women with Crohn disease had higher rates of intestinal-genitourinary fistulas (23.4% versus 3.0%; P<0.001), anorectal suppuration (21.1% versus 4.1%; P<0.001), and overall surgical disease (59.6% versus 39.2%; P<0.001). On multivariate logistic regression analysis controlling for malnutrition, smoking, age, and prednisone use, pregnancy was independently associated with higher rates of anorectal suppuration (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.8-7.0; P<0.001), intestinal-genitourinary fistulas (OR, 10.4; 95% CI, 7.8-13.8; P<0.001), and overall surgical disease (OR, 2.9; 95% CI, 2.3-3.7; P<0.001). CONCLUSIONS: Pregnancy in women with Crohn disease is a significant risk factor for Crohn-related surgical disease, in particular, anorectal suppuration and intestinal-genitourinary fistulas.

Predictors of appendiceal perforation in an equal access system.

BACKGROUND: Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. MATERIALS AND METHODS: All patients undergoing appendectomy for acute appendicitis (November 2004-October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. RESULTS: A total of 680 patients (mean age 30±16 y; 37% female) were included. The majority were Caucasian (56.4% [n=384]; African Americans 5.6% [n=38]; Asians 1.9% [n=13]; and other 48.9% [n=245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P=0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P=0.273; 6.60% junior versus 5.50% senior enlisted, P=0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P=0.7). Only age had a correlation, with individuals aged 66-75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02-1.05; P<0.001). CONCLUSIONS: In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Surgical Emergencies in Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) patients are at risk for undergoing emergency surgery for fulminant disease, toxic megacolon, bowel perforation, intestinal obstruction, or uncontrolled gastrointestinal hemorrhage. Unfortunately, medical advancements have failed to significantly decrease rates of emergency surgery for IBD. It is therefore important for all acute care and colorectal surgeons to understand the unique considerations owed to this often-challenging patient population.

Anal Cryptoglandular Suppuration: Evidence-Based Management.

Anal suppurative processes are commonly encountered in surgical practice. While the initial therapeutic intervention is philosophically straightforward (incision and drainage), drainage of the appropriate space and treatment of the subsequent fistula in ano require a thorough understanding of perianal anatomy and nuanced decision making. Balancing the risk of fecal incontinence with simple fistulotomy versus the higher risk of fistula recurrence with all sphincter-sparing fistula treatments can be a challenge for surgeons and patients alike.

Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education.

BACKGROUND: Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. METHODS: Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. RESULTS: The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). CONCLUSIONS: There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis.

IMPORTANCE: Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making. OBJECTIVE: To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021. EXPOSURES: Appendectomy vs antibiotics. MAIN OUTCOMES AND MEASURES: Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons. RESULTS: Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91). CONCLUSIONS AND RELEVANCE: This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.

Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis.

Importance: In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs. Objective: To assess the use and safety of outpatient management of acute appendicitis. Design, Setting, and Participants: This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020. Exposures: Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively. Main Outcomes and Measures: Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared. Results: Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores. Conclusions and Relevance: These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients.

OBJECTIVE: To determine whether implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival. BACKGROUND: DCR aims at preventing coagulopathy through permissive hypotension, limiting crystalloids and delivering higher ratios of plasma and platelets. Previous work has focused only on the impact of delivering higher ratios (1:1:1). METHODS: A retrospective cohort study was performed on all DCL patients admitted between January 2004 and August 2010. Patients were divided into pre-DCR implementation and DCR groups and were excluded if they died before completion of the initial laparotomy. The lethal triad was defined as immediate postoperative temperature less than 95°F, international normalized ratio more than 1.5, or a pH less than 7.30. RESULTS: A total of 390 patients underwent DCL. Of these, 282 were pre-DCR and 108 were DCR. Groups were similar in demographics, injury severity, admission vitals, and laboratory values. DCR patients received less crystalloids (median: 14 L vs 5 L), red blood cells (13 U vs 7 U), plasma (11 U vs 8 U), and platelets (6 U vs 0 U) in 24 hours, all P < 0.05. DCR patients had less evidence of the lethal triad upon intensive care unit arrival (80% vs 46%, P < 0.001). 24-hour and 30-day survival was higher with DCR (88% vs 97%, P = 0.006 and 76% vs 86%, P = 0.03). Multivariate analysis controlling for age, injury severity, and emergency department variables, demonstrated DCR was associated with a significant increase in 30-day survival (OR: 2.5, 95% CI: 1.10-5.58, P = 0.028). CONCLUSION: In patients undergoing DCL, implementation of DCR reduces crystalloid and blood product administration. More importantly, DCR is associated with an improvement in 30-day survival.

Identifying risk factors for renal failure and myocardial infarction following colorectal surgery.

BACKGROUND: The development of acute renal failure and myocardial infarction (MI) following colectomy prolongs recovery and is associated with worse outcomes. The purpose of this study is to identify perioperative factors that predispose patients to an adverse cardiac or renal complication. MATERIALS AND METHODS: We conducted a retrospective review of colectomies from 2001 to 2009. Patients were evaluated based upon the electronic inpatient record and followed to determine the incidence of acute renal failure (creatinine elevation over 50% of baseline) and myocardial injury. RESULTS: A total of 339 inpatient records were reviewed, of which 134 were female (40%) and 205 male (60%). The mean age was 61.96 ± 16.2 years with 39.5% right hemicolectomies, 22.7% sigmoidectomy, 13.9% Left hemicolectomy, 11.5% total abdominal colectomy, and 6.2% for ileocectomy and transverse colectomy. Within the cohort, 13.9% had baseline renal insufficiency (Cr > 1.4), 7.1% sustained anastomotic leak, 23.9% required postoperative intubation, 15% sustained postoperative sepsis, 11.2% postoperative MI, and 5% clinically significant acidosis. Excluding patients with an anastomotic leak, postoperative intubation, and sepsis, we found that the need for blood product transfusion was associated with postoperative acute renal failure (OR= 7.15 [2.4-20.7]). Preoperative creatinine > 1.5, limited functional capacity, and preoperative systolic blood pressure < 90 mm Hg were all associated with increased MI rates (OR= 15.7 [3.6-66.8], 9.5 [2.1-42.2], 12.0 [5.523-26.072], and 40.6 [1.7-968], respectively). CONCLUSION: This study demonstrates that several potentially modifiable preoperative and intraoperative factors exist that predispose patients to postoperative cardiac and renal dysfunction in the absence of major surgical complications.

Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back.

BACKGROUND: Damage-control laparotomy (DCL) is a lifesaving technique but carries significant morbidity. If DCL is over used and the factors that predict early fascial closure have not been fully evaluated. The purpose of the current study was to determine (1) the current rate of DCL, (2) the percentage of DCLs that are closed at first take-back, and (3) possible physiologic and resuscitative parameters predicting early fascial closure. METHODS: A retrospective review of all trauma laparotomies from a Level I trauma center between January 2004 and December 2008 was performed. Patients were excluded if they died before first take-back. Univariate and multivariate analyses were performed. RESULTS: Nine hundred thirty patients were eligible, 278 (30%) underwent DCL, 36 excluded for death before first take-back. Of the remaining 242 DCL patients, 83 (34%) were closed at first take-back and 159 (66%) were not closed at first take-back. These two groups were similar in injury severity, demographics, and prehospital and emergency department fluids and vitals. Median emergency department international normalized ratio (INR; 1.13 vs. 1.29, p = 0.010), post-op INR (1.4 vs. 1.5, p = 0.028), 24-hour fluids (11.9 L vs. 15.5 L, p = 0.006), peak post-op intra-abdominal pressure (IAP; 15 vs. 18, p < 0.001), and mortality (1.2% vs. 8.2%, p = 0.027) were different between groups. Multivariate analysis noted vacuum-assisted closure at initial laparotomy (Odds ratio, 3.1; 95% confidence interval [CI], 1.42-6.63; p = 0.004) was an independent predictor of closure at first take-back. However, post-op INR (Odds ratio, 0.18; 95% CI, 0.03-0.97; p = 0.04) and post-op peak IAP (Odds ratio, 0.85; 95% CI, 0.76-0.95; p = 0.005) predicted failure to close fascia at first take-back. CONCLUSION: In similarly injured DCL patients, increased post-op INR and IAP predicted inability to achieve primary fascial closure on first take-back, while use of the vacuum-assisted closure was associated with increased likelihood of early fascial closure. At a busy academic Level I trauma center, the current rate of DCL among those undergoing emergent laparotomy is 30%. Whether this represents optimal use or overutilization of this technique still needs to be determined.

Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission.

BACKGROUND: Recognition of trauma-induced coagulopathy by conventional coagulation testing (CCT) is limited by their slow results, incomplete characterization, and their poor predictive nature. Rapid thrombelastography (r-TEG) delivers a more comprehensive assessment of the coagulation system but has not been prospectively validated in trauma patients. The purpose of this pilot study was to evaluate the timeliness of r-TEG results, their correlation with CCTs, and the ability of r-TEG to predict early blood transfusion. METHODS: Over a 5-month period, 583 consecutive major trauma activations were prospectively entered into a database, of which 272 met entry criteria. r-TEG and CCTs (prothrombin time, international normalized ratio, partial thromboplastin time, and platelet count) were obtained on all patients. Graphical results for r-TEG were displayed "real time" in the trauma bay. Spearman's correlation and regression models were used to compare r-TEG and CCTs. RESULTS: Early r-TEG values (activated clotting time [ACT], k-time, and r-value) were available within 5 minutes, late r-TEG values (maximal amplitude and α-angle) within 15 minutes, and CCTs within 48 minutes (p < 0.001). ACT, r-value, and k-time showed strong correlation with prothrombin time, international normalized ratio, and partial thromboplastin time (all r >0.70; p < 0.001), whereas maximal amplitude (r = -0.49) and α-angle (r = 0.40) correlated with platelet count (both p < 0.001). Linear regression demonstrated ACT predicted red blood cells (coef. 0.05; 95% confidence interval [CI], 0.04-0.06; p < 0.001), plasma (coef. 0.03; 95% CI, 0.02-0.04; p < 0.001), and platelet (coef. 0.06; 95% CI, 0.04-0.07; p < 0.001) transfusions within the first 2 hours of arrival. Controlling for all demographics and Emergency Department vitals, ACT >128 predicted massive transfusion (≥10 U) in the first 6 hours (odds ratio, 5.15; 95% CI, 1.36-19.49; p = 0.01). In addition, ACT <105 predicted patients who did not receive any transfusions in the first 24 hours (odds ratio, 2.80; CI, 1.02-7.07; p = 0.04). CONCLUSIONS: Graphical r-TEG results are available within minutes, correlate with conventional coagulation test that are not as rapidly available, and are predictive of early transfusions of packed red blood cells, plasma, and platelets.

Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy.

BACKGROUND: Damage control laparotomy (DCL) is a lifesaving technique initially employed to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. Recently, it has been recognized that DCL itself carries significant morbidity and may be overutilized. The purpose of this study was to determine (1) whether early fascial closure is associated with a reduction in postoperative complications and (2) whether patients at our institution met traditional DCL indications (acidosis, hypothermia, and coagulopathy). METHODS: This is a retrospective review of all patients undergoing immediate laparotomy at a Level I trauma center between 2004 and 2008. DCL was defined as temporary abdominal closure at the initial surgery. Early closure was defined as primary fascial closure at initial take back laparotomy. Patients were excluded if they died before first take back. Acidosis (pH <7.30), hypothermia (temperature <95.0°F), and coagulopathy (international normalized ratio >1.5) were measured on intensive care unit (ICU) arrival. RESULTS: Totally, 925 patients were eligible. Thirty percent had DCL employed. Of these, 86 subjects (34%) were closed at first take back while 161 (66%) were not. Both groups were similar in demographics, injury severity score, resuscitation volumes, blood products, and prehospital, emergency department, and operating room vital signs. Univariate analyses noted that intra-abdominal abscesses (8.4% vs. 21.3%), respiratory failure (14.4% vs. 37.1%), sepsis (8.4% vs. 25.1%), and renal failure (3.6% vs. 25.1%) were lower in patients closed at first take back (all <0.05). Controlling for age, gender, injury severity score, and transfusions, logistic regression analysis noted that closure at the first take back was associated with a reduction in infectious (odds ratio, 0.28; 95% confidence interval [CI], 0.12-0.66; p = 0.004) and noninfectious abdominal complications (odds ratio, 0.23; 95% CI, 0.09-0.56; p = 0.001) as well as wound (odds ratio, 0.31; 95% CI, 0.13-0.72; p = 0.007) and pulmonary complications (odds ratio, 0.35; CI, 0.20-0.62; p < 0.001). Of patients closed at the initial take back, 78% were acidotic (35%), coagulopathic (49%), or hypothermic (44%) on initial ICU admission. CONCLUSION: Early fascial closure is an independent predictor of reduced complications in DCL patients. One in five patients closed at initial take back did not meet any of the traditional indications for DCL upon initial ICU admission. This may represent an overutilization of this valuable technique, exposing patients to increased complications. Further efforts should be directed at achieving both early facial closure as well as redefining the appropriate indications for DCL.

Maintaining Wellness and Instilling Resilience in General Surgeons.

Obtaining wellness and enhancing resilience will be increasingly more important for General Surgeons. Although these concepts are not new, the increased complexity of health care delivery has elevated the importance of these essential attributes. Instilling these practices should be emphasized during surgery residency and be modeled by surgical educators and surgeon leaders. The enhanced emphasis of wellness and resiliency is a positive step forward; however, more must be accomplished to ensure the well-being of a particularly group of vulnerable physicians. This chapter discusses the history and scientific theory behind wellness and resiliency, as well as practical suggestions for consideration.

Postoperative outcomes of Bascom cleft lift for pilonidal disease: A single-center experience.

INTRODUCTION: Limited data exists regarding outcomes for the Bascom cleft lift procedure for pilonidal disease. METHODS: Single-center retrospective review of patients who underwent a Bascom cleft lift from 2013 to 2018. Univariate analysis was performed to determine associations between patient-specific characteristics and post-operative complications. Postoperative complications were categorized as major or minor. Multivariate analysis was performed to identify predictors of postoperative complications. RESULTS: 235 patients were included. Forty-five percent were obese and 24% were active smokers. Minor complications occurred in 34.5% (81); major complications occurred in 19.1% (45). The recurrence rate was 4.7% (11). Smoking was not associated with postoperative complications. Obesity was independently associated with higher rates of both minor (OR 2.6, p = 0.001) and major (OR 2.3, p = 0.001) complications. DISCUSSION: Wound complications are common after Bascom cleft lift. Obesity is an independent predictor of postoperative complications. Obese patients should be appropriately counseled regarding their increased risk prior to surgery.