Modern Trends in Surgical Site Infection Rates for Colorectal Surgery: A National Surgical Quality Improvement Project Study 2013-2020.

BACKGROUND: There are few studies investigating trends in global surgical site infection rates in colorectal surgery in the last decade. OBJECTIVE: This study seeks to describe changes in rates of different surgical site infections from 2013-2020, identify risk factors for SSI occurrence and evaluate the association of minimally invasive surgery and infection rates in colorectal resections. DESIGN: A retrospective analysis of the National Surgical Quality Improvement Program database 2013-2020 identifying patients undergoing open or laparoscopic colorectal resections by procedure codes was performed. Patient demographic information, comorbidities, procedures, and complications data were obtained. Univariable and multivariable logistic regression were performed. SETTING: This was a retrospective study. PATIENTS: A total of 279,730 patients received colorectal resection from 2013 - 2020. MAIN OUTCOME MEASURES: Primary outcome measure was rate of surgical site infection, divided into superficial, deep incisional and organ space infections. RESULTS: There was a significant decrease in rates of superficial infections (p < 0.01) and deep incisional infections (p < 0.01) from 5.9% in 2013 to 3.3% in 2020 and from 1.4% in 2013 to 0.6% in 2020, respectively, but a rise in organ space infections (p < 0.01) from 5.2% in 2013 to 7.1% in 2020. Use of minimally invasive techniques was associated with decreased odds of all surgical site infections compared to open techniques (p < 0.01) in multivariate analysis and adoption of minimally invasive techniques increased from 59% in 2013 to 66% in 2020. LIMITATIONS: Study is limited by retrospective nature and variables available for analysis. CONCLUSIONS: Superficial and deep infection rates have significantly decreased, likely secondary to improved adoption of minimally invasive techniques and infection prevention bundles. Organ space infection rates continue to increase. Additional research is warranted to clarify current recommendations for mechanical bowel prep and oral antibiotic use as well as to study novel interventions to decrease postoperative infection occurrence. See Video Abstract.

Patient Acceptance of Routine Serial Postoperative Endoscopy Following Low Anterior Resection (LAR) and Its Ability to Detect Biomarkers in Anastomotic Lavage Fluid.

BACKGROUND: Various reports have now established that postoperative endoscopy to examine and intervene in the process of anastomotic healing is both feasible and safe. Here we present our preliminary experience with serial postoperative endoscopy to determine its feasibility, patient acceptance and the ability to obtain and the utility of perianastomotic material for molecular analysis. METHODS: Patients undergoing LAR with ileostomy for rectal cancer were recruited for study to undergo routine serial endoscopic surveillance (SES) at three time points during the course of LAR: intraoperatively, before discharge (postoperative day 3-7) and at follow-up (postoperative day 10-28). At each endoscopy, images were captured, anastomotic tissues were lavaged and lavage fluid was retrieved. Fluid samples were analyzed using proteomics, zymography, ELISA and bacteria via 16S rRNA gene amplicon sequencing and culture of collagenolytic strains. RESULTS: SES is feasible and acceptable to this limited set of patients following LAR. Biologic analysis of perianastomotic fluids was able to detect the presence of proteins, microbiota and inflammatory mediators previously identified at anastomotic sites in animals with pathologic healing. CONCLUSION: SES can be implemented in patients undergoing LAR with a high degree of patient compliance and capture of biologic information and imaging. Application of this approach has the potential to uncover, for the first time, the natural history of normal versus pathologic anastomotic healing in patients undergoing anastomotic surgery.

Anastomotic Leak after Ileal Pouch-Anal Anastomosis.

There are special considerations when treating anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis. The epidemiology, risk factors, anatomic considerations, diagnosis and management, as well as the short- and long-term consequences to the patient are unique to this patent population. Additionally, there are specific concerns such as "tip of the J" leaks, transanal management of anastomotic leak/presacral sinus, functional outcomes after leak, and considerations of redo pouch procedures.

Identification of Collagenolytic Bacteria in Human Samples: Screening Methods and Clinical Implications for Resolving and Preventing Anastomotic Leaks and Wound Complications.

BACKGROUND: Bacteria that produce collagen-digesting enzymes (collagenolytic bacteria) have been shown to play a critical and previously unappreciated role in anastomotic leak pathogenesis by breaking down host tissue extracellular matrix proteins. Detection of these bacteria is labor intensive, and no screening method currently exists. OBJECTIVES: We evaluated a rapid screening method developed to detect the presence of these collagenolytic bacteria in clinical samples, such as drain fluid, anastomotic tissue, or feces. DESIGN: We compared a new method of detecting collagenolytic bacterial species with a previously used technique using samples from a murine experimental model and then demonstrated the utility of this screening method in samples from patients with anastomotic complications. SETTINGS: All of the laboratory work and previous murine experiments were performed in Dr Alverdy's laboratory at the University of Chicago under institutional review board-approved protocols. PATIENTS: Samples from patients with challenging wound complications were provided by participating clinicians with verbal patient consent. Given the small number of patients, this was determined to be institutional review board exempt. MAIN OUTCOME MEASURES: Whether this analysis can influence patient management and outcomes will require additional study. RESULTS: This screening method detects numerous strains of bacteria with collagenolytic properties, including the collagenolytic species that have been implicated previously in anastomotic leak. Once collagenolytic strains are identified, they can be speciated and tested for antibiotic resistance using standard laboratory techniques. LIMITATIONS: This study is limited by the small number of patient samples tested. CONCLUSIONS: We demonstrated the potential applicability of this assay to evaluate rare and complex anastomotic complications that often require analysis beyond standard culture and sensitivity assays. Future applications of this method may allow the development of strategies to prevent anastomotic leak related to collagenolytic bacteria. See Video Abstract at http://links.lww.com/DCR/A962.

Can Methicillin-resistant Staphylococcus aureus Silently Travel From the Gut to the Wound and Cause Postoperative Infection? Modeling the "Trojan Horse Hypothesis".

OBJECTIVE: To determine whether intestinal colonization with methicillin-resistant Staphylococcus aureus (MRSA) can be the source of surgical site infections (SSIs). BACKGROUND: We hypothesized that gut-derived MRSA may cause SSIs via mechanisms in which circulating immune cells scavenge MRSA from the gut, home to surgical wounds, and cause infection (Trojan Horse Hypothesis). METHODS: MRSA gut colonization was achieved by disrupting the microbiota with antibiotics, imposing a period of starvation and introducing MRSA via gavage. Next, mice were subjected to a surgical injury (30% hepatectomy) and rectus muscle injury and ischemia before skin closure. All wounds were cultured before skin closure. To control for postoperative wound contamination, reiterative experiments were performed in mice in which the closed wound was painted with live MRSA for 2 consecutive postoperative days. To rule out extracellular bacteremia as a cause of wound infection, MRSA was injected intravenously in mice subjected to rectus muscle ischemia and injury. RESULTS: All wound cultures were negative before skin closure, ruling out intraoperative contamination. Out of 40 mice, 4 (10%) developed visible abscesses. Nine mice (22.5%) had MRSA positive cultures of the rectus muscle without visible abscesses. No SSIs were observed in mice injected intravenously with MRSA. Wounds painted with MRSA after closure did not develop infections. Circulating neutrophils from mice captured by flow cytometry demonstrated MRSA in their cytoplasm. CONCLUSIONS: Immune cells as Trojan horses carrying gut-derived MRSA may be a plausible mechanism of SSIs in the absence of direct contamination.

Addressing Language Barriers in the Intensive Care Unit: A Case-Based Reflection and Brief Appraisal of the Literature.

At present, a substantial number of individuals in the US face limited English proficiency (LEP), posing difficulties for healthcare providers. Language barriers between healthcare providers and patients can lead to poor quality of care, especially in patients with hyperacute conditions such as stroke, myocardial infarction, acute trauma, and more. In the intensive care unit (ICU), diagnosis and rapid treatment decision-making rely on taking an accurate patient history and physical exam. While in-person interpreters are the gold standard for patients with LEP, the fast-paced nature of the ICU may require alternate modes of using interpreting services to fit ICU workflows. We present a case-based reflection of a patient with LEP who presented to our ICU after a motor vehicle accident. We present this case from the perspective of a third-year medical student caring for a patient while rotating in an ICU service. We illustrate how language interpretation impacted the patient's care. We conclude by appraising the ICU literature and providing solutions to addressing language barriers for ICU patients with LEP to deliver patient-centered, high-quality care.

A Pathologic Microbiome Impacts Post-Operative Anastomotic Healing.

Anastomotic leak after colorectal surgery is a devastating complication that may require re-operation, diverting stoma creation, and prolonged wound healing. Anastomotic leak is associated with a mortality of 4% to 20%. Despite intense research and novel approaches, the anastomotic leak rate has failed to substantially improve over the past decade. Adequate anastomotic healing requires collagen deposition and remodeling through post-translational modification. The human gut microbiome has been previously implicated as a key driver of wound and anastomotic complications. Specific microbes function in a pathogenic fashion by propagating anastomotic leak and poor wound healing. The two most studied organisms, Enterococcus faecalis and Pseudomonas aeruginosa, can be collagenolytic and may activate additional enzymatic pathways that lyse connective tissue. Furthermore, these microbes are enriched in post-operative anastomotic tissue as identified using 16S rRNA sequencing. Commonly encountered stressors including antibiotic administration, a Western (i.e., high-fat, low-fiber) diet, and concomitant infection can trigger dysbiosis and induce a pathobiome phenotype. Therefore, personalized microbiome modulation to maintain homeostasis may be the next step in improving the anastomotic leak rate. Oral phosphate analogs, tranexamic acid, and pre-operative diet rehabilitation have shown promise in in vitro and in vivo studies as ways to address the pathogenic microbiome. However, further translational human studies are required to validate findings. Accordingly, this article reviews the gut microbiome as it pertains to post-operative anastomotic leak, explores microbial impact on anastomotic healing, describes the shift from the commensal microbiome to a pathobiome, and introduces potential therapies to mitigate anastomotic leak risk.

Characteristics and symptomatology of colorectal cancer in the young.

BACKGROUND: The incidence of colorectal cancer in patients <50 years has rapidly risen recently. Understanding the presenting symptoms may facilitate earlier diagnosis. We aimed to delineate patient characteristics, symptomatology, and tumor characteristics of colorectal cancer in a young population. METHODS: A retrospective cohort study was conducted evaluating patients <50 years diagnosed between 2005 and 2019 with primary colorectal cancer at a university teaching hospital. The number and character of colorectal cancer-related symptoms at presentation was the primary outcome measured. Patient and tumor characteristics were also collected. RESULTS: Included were 286 patients with a median age of 44 years, with 56% <45 years. Nearly all patients (95%) were symptomatic at presentation, with 85% having 2 or more symptoms. The most common symptoms were pain (63%), followed by change in stool habits (54%), rectal bleeding (53%), and weight loss (32%). Diarrhea was more common than constipation. More than 50% had symptoms for at least 3 months before diagnosis. The number and duration of symptoms were similar in patients older than 45 compared to those younger. Most cancers were left-sided (77%) and advanced stage at presentation (36% stage III, 39% stage IV). CONCLUSION: In this cohort of young patients with colorectal cancer, the majority presented with multiple symptoms having a median duration of 3 months. It is essential that providers be mindful of the ever-increasing incidence of colorectal malignancy in young patients, and that those with multiple, durable symptoms should be offered screening for colorectal neoplasms based on symptoms alone.

Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients.

PURPOSE: Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS: Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS: Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS: Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.

Combined robotic radical prostatectomy and laparoscopic proctectomy for synchronous prostate and rectal cancer.

Prostatic adenocarcinoma is the second most common cause of cancer related mortality in men. Robotic-assisted laparoscopic prostatectomy represents a standard treatment option for localized disease. We present a case of a 63-year-old male with synchronous presentation of prostate and rectal cancer treated with combined robotic prostatectomy (RALP) and low anterior resection (LAR). Interestingly, a mesorectal lymph node contained metastatic prostate cancer.

Advanced age alone should not preclude surveillance colonoscopy in the octogenarian and older population.

BACKGROUND: Although the risk of colorectal cancer increases with advancing age, there remains a lack of guidelines for surveillance colonoscopy in the octogenarian and older population. Our objective is to document the diagnostic yield of surveillance colonoscopies, and to analyze adenoma characteristics, complications, and short-term survival in asymptomatic octogenarian and older patients undergoing adenoma surveillance colonoscopy. METHODS: Surveillance colonoscopies performed at a tertiary level hospital colorectal surgery department between January 2010 and September 2018 were queried from a prospectively maintained institutional colonoscopy database. Patients 80 years old or older undergoing routine surveillance colonoscopy after having had an adenoma or advanced adenoma diagnosed on a prior exam were included in the study. RESULTS: 604 patients were included in the study with a median age of 82 and 43% were female. Median follow-up was 52 months (range 2-110), with 511(85%) patients alive at their last available follow-up. Overall, 292 patients had at least one had adenomatous lesion and 105 (17.4%) patients had advanced adenomas. Increasing age was not associated with increased rate of sessile serrated lesions (p = 0.2) however, there was an association between increasing age and advanced adenoma rates (p = 0.01). Advanced adenomas were more commonly found to be right-sided (p = 0.02). Four asymptomatic patients were diagnosed with cancer at surveillance (0.6%). CONCLUSIONS: Patients 80 years of age or older with a previous history of colorectal adenoma(s) may have a high risk of future advanced lesions and can be considered to undergo surveillance colonoscopy.

Comparative genetics of Enterococcus faecalis intestinal tissue isolates before and after surgery in a rat model of colon anastomosis.

We have recently demonstrated that collagenolytic Enterococcus faecalis plays a key and causative role in the pathogenesis of anastomotic leak, an uncommon but potentially lethal complication characterized by disruption of the intestinal wound following segmental removal of the colon (resection) and its reconnection (anastomosis). Here we hypothesized that comparative genetic analysis of E. faecalis isolates present at the anastomotic wound site before and after surgery would shed insight into the mechanisms by which collagenolytic strains are selected for and predominate at sites of anastomotic disruption. Whole genome optical mapping of four pairs of isolates from rat colonic tissue obtained following surgical resection (herein named "pre-op" isolates) and then 6 days later from the anastomotic site (herein named "post-op" isolates) demonstrated that the isolates with higher collagenolytic activity formed a distinct cluster. In order to perform analysis at a deeper level, a single pair of E. faecalis isolates (16A pre-op and 16A post-op) was selected for whole genome sequencing and assembled using a hybrid assembly algorithm. Comparative genomics demonstrated absence of multiple gene clusters, notably a pathogenicity island in the post-op isolate. No differences were found in the fsr-gelE-sprE genes (EF1817-1822) responsible for regulation and production of collagenolytic activity. Analysis of unique genes among the 16A pre-op and post-op isolates revealed the predominance of transporter systems-related genes in the pre-op isolate and phage-related and hydrolytic enzyme-encoding genes in the post-op isolate. Despite genetic differences observed between pre-op and post-op isolates, the precise genetic determinants responsible for their differential expression of collagenolytic activity remains unknown.

Resident Perspectives on Teaching During Awake Surgical Procedures.

INTRODUCTION: Residents learn technical and communication skills during training and practice both concurrently during awake surgical procedures. Patients have expressed mixed views on resident involvement in their surgical care, making this context challenging for residents to navigate. We sought to qualitatively explore resident perspectives on teaching during awake surgical procedures. METHODS: Residents in Urology, Obstetrics and Gynecology, and General Surgery who had been exposed to 10 or more awake surgical procedures were recruited for recorded focus groups at the University of Chicago. Recordings were transcribed, coded, and reviewed by 3 researchers using the constant comparative method until thematic saturation was reached. RESULTS: Twenty-five residents participated in 5 focus groups. Residents identified positive educational techniques during awake surgery including preprocedural communication, explaining teaching and the resident role, whispering/nonverbal communication, involving the patient in education, and confident educator. Residents described challenges and failures in education, including hesitating to ask questions, hesitating to correct a learner, whispering/nonverbal communication, and taking over. In discussing informed consent during awake procedures, some residents described that the consent process should or did change during awake procedures, for example, to include more information about the resident role. CONCLUSIONS: Residents participating in awake surgical procedures offer new insights on successful techniques for teaching during awake surgery, emphasizing that good communication in the procedure room starts beforehand. They also identify challenges with teaching in this context, often related to a lack of open and clear communication.

The gut microbiota and gastrointestinal surgery.

Surgery involving the gastrointestinal tract continues to prove challenging because of the persistence of unpredictable complications such as anastomotic leakage and life-threatening infections. Removal of diseased intestinal segments results in substantial catabolic stress and might require complex reconstructive surgery to maintain the functional continuity of the intestinal tract. As gastrointestinal surgery necessarily involves a breach of an epithelial barrier colonized by microorganisms, preoperative intestinal antisepsis is used to reduce infection-related complications. The current approach to intestinal antisepsis varies widely across institutions and countries with little understanding of its mechanism of action, effect on the gut microbiota and overall efficacy. Many of the current approaches to intestinal antisepsis before gastrointestinal surgery run counter to emerging concepts of intestinal microbiota contributing to immune function and recovery from injury. Here, we review evidence outlining the role of gut microbiota in recovery from gastrointestinal surgery, particularly in the development of infections and anastomotic leak. To make surgery safer and further reduce complications, a molecular, genetic and functional understanding of the response of the gastrointestinal tract to alterations in its microbiota is needed. Methods can then be developed to preserve the health-promoting functions of the microbiota while at the same time suppressing their harmful effects.

Media from macrophages co-incubated with Enterococcus faecalis induces epithelial cell monolayer reassembly and altered cell morphology.

Signal exchange between intestinal epithelial cells, microbes and local immune cells is an important mechanism of intestinal homeostasis. Given that intestinal macrophages are in close proximity to both the intestinal epithelium and the microbiota, their pathologic interactions may result in epithelial damage. The present study demonstrates that co-incubation of murine macrophages with E. faecalis strains producing gelatinase (GelE) and serine protease (SprE) leads to resultant condition media (CM) capable of inducing reassembly of primary colonic epithelial cell monolayers. Following the conditioned media (CM) exposure, some epithelial cells are shed whereas adherent cells are observed to undergo dissolution of cell-cell junctions and morphologic transformation with actin cytoskeleton reorganization resulting in flattened and elongated shapes. These cells exhibit marked filamentous filopodia and lamellipodia formation. Cellular reorganization is not observed when epithelial monolayers are exposed to: CM from macrophages co-incubated with E. faecalis GelE/SprE-deficient mutants, CM from macrophages alone, or E. faecalis (GelE/SprE) alone. Flow cytometry analysis reveals increased expression of CD24 and CD44 in cells treated with macrophage/E. faecalis CM. This finding in combination with the appearance colony formation in matrigel demonstrate that the cells treated with macrophage/E. faecalis CM contain a higher proportion progenitor cells compared to untreated control. Taken together, these findings provide evidence for a triangulated molecular dialogue between E. faecalis, macrophages and colonic epithelial cells, which may have important implications for conditions in the gut that involve inflammation, injury or tumorigenesis.

Surgeon-patient communication during awake procedures.

BACKGROUND: Surgeons are increasingly performing procedures on awake patients. Communication during such procedures is complex and underexplored in the literature. METHODS: Surgeons were recruited from the faculty of 2 hospitals to participate in an interview regarding their approaches to communication during awake procedures. Three researchers used the constant comparative method to transcribe, code, and review interviews until saturation was reached. RESULTS: Twenty-three surgeons described the advantages and disadvantages of awake procedures, their communication with the awake patient, their interactions with staff and with trainees, the environment of awake procedures, and how communication in this context is taught and learned. CONCLUSIONS: Surgeons recognized communication during awake procedures as important and reported varied strategies for ensuring patient comfort in this context. However, they also acknowledged challenges with multiparty communication during awake procedures, especially in balancing commitments to teaching with their duty to comfort the patient.

Bacterial colonization and succession in a newly opened hospital.

The microorganisms that inhabit hospitals may influence patient recovery and outcome, although the complexity and diversity of these bacterial communities can confound our ability to focus on potential pathogens in isolation. To develop a community-level understanding of how microorganisms colonize and move through the hospital environment, we characterized the bacterial dynamics among hospital surfaces, patients, and staff over the course of 1 year as a new hospital became operational. The bacteria in patient rooms, particularly on bedrails, consistently resembled the skin microbiota of the patient occupying the room. Bacterial communities on patients and room surfaces became increasingly similar over the course of a patient's stay. Temporal correlations in community structure demonstrated that patients initially acquired room-associated taxa that predated their stay but that their own microbial signatures began to influence the room community structure over time. The α- and ß-diversity of patient skin samples were only weakly or nonsignificantly associated with clinical factors such as chemotherapy, antibiotic usage, and surgical recovery, and no factor except for ambulatory status affected microbial similarity between the microbiotas of a patient and their room. Metagenomic analyses revealed that genes conferring antimicrobial resistance were consistently more abundant on room surfaces than on the skin of the patients inhabiting those rooms. In addition, persistent unique genotypes of Staphylococcus and Propionibacterium were identified. Dynamic Bayesian network analysis suggested that hospital staff were more likely to be a source of bacteria on the skin of patients than the reverse but that there were no universal patterns of transmission across patient rooms.

Morphine Promotes Colonization of Anastomotic Tissues with Collagenase - Producing Enterococcus faecalis and Causes Leak.

BACKGROUND: Despite ever more powerful antibiotics, newer surgical techniques, and enhanced recovery programs, anastomotic leaks remain a clear and present danger to patients. Previous work from our laboratory suggests that anastomotic leakage may be caused by Enterococcus faecalis strains that express a high collagenase phenotype (i.e., collagenolytic). Yet the mechanisms by which the practice of surgery shifts or selects for collagenolytic phenotypes to colonize anastomotic tissues remain unknown. METHODS: Here, we hypothesized that morphine, an analgesic agent universally used in gastrointestinal surgery, promotes tissue colonization with collagenolytic E. faecalis and causes anastomotic leak. To test this, rats were administered morphine in a chronic release form as would occur during routine surgery or vehicle. Rats were observed for 6 days and then underwent exploratory laparotomy for anastomotic inspection and tissue harvest for microbial analysis. These results provide further rationale to enhanced recovery after surgery (i.e., ERAS) programs that suggest limiting or avoiding the use of opioids in gastrointestinal surgery. RESULTS: Results demonstrated that compared to placebo-treated rats, morphine-treated rats demonstrated markedly impaired anastomotic healing and gross leaks that correlated with the presence of high collagenase-producing E. faecalis adherent to anastomotic tissues. To determine the direct role of morphine on this response, various isolates of E. faecalis from the rats were exposed to morphine and their collagenase activity and adherence capacity determined in vitro. Morphine increased both the adhesiveness and collagenase production of four strains of E. faecalis harvested from anastomotic tissues, two that were low collagenase producers at baseline, and two that were high collagenase producers at baseline. CONCLUSION: These results provide further rationale to enhanced recovery after surgery (i.e., ERAS) programs that suggest limiting or avoiding the use of opioids in gastrointestinal surgery.

Equestrian injury is costly, disabling, and frequently preventable: the imperative for improved safety awareness.

Horse-related injury can be severe and disabling. We investigated the causes, severity, and costs of equestrian injury with the goal of injury prevention. A retrospective review of horse-related injuries from 2001 to 2008 identified 231 patients with a mean age of 38 years and a mean Injury Severity Score of 11 (range, 1 to 45). Mean length of stay was 5.5 days. Fifty-nine patients (25%) required 84 surgeries. Helmet use was 20 per cent and of the 172 patients not wearing a helmet while mounted, 38 per cent received potentially preventable head injuries. There were three deaths of which two were the result of intracranial hemorrhage in riders not wearing a helmet. Mean hospital charge was $29,800 for a total of $6.9 million. Ninety-one patients completed a survey regarding causation and disability. Thirty-four per cent reported wearing a helmet at the time of injury. Forty per cent reported that poor environmental factors contributed, 30 per cent reported poor horse and rider pairing, and 9 per cent reported equipment failure. Fifty-nine per cent reported long-term disabilities. Compared with the general population, respondents had diminution in their ability to perform usual daily activities associated with physical problems, diminution in social function, and higher bodily pain. We conclude that equestrian injury is costly, disabling, and frequently preventable.

A new, removable, sliding noose for adjustable-suture strabismus surgery.

We describe a new removable sliding polyglactin 910 suture noose for postoperative suture adjustment following extraocular muscle surgery. No excess suture material remains after adjustment has been completed, helping to reduce discomfort, inflammation, and scarring. We have used this noose with the cul-de-sac conjunctival incision in approximately 360 patients over a period of 18 months. This report details how to fashion, use, and remove the noose.