The results of rapid source control laparotomy or open abdomen for acute diverticulitis.

INTRODUCTION: Rapid source control laparotomy (RSCL) for the management of non-traumatic intra-abdominal emergencies has increased over the past 25 years when it was advocated for trauma patients. Little data, however, support its widespread use. We hypothesize that the patients with RSCL will have poorer outcomes than those treated with primary fascial closure (PFC). METHODS: Patients operated for acute diverticulitis from 2014 to 2016 using The American College of Surgeons sponsored National Surgical Quality Improvement Program (NSQIP) data were reviewed. Two groups were identified: PFC, patients with their closed fascia but skin left open (PFC) and RSCL, patients with their left open fascia after the initial operation. The primary outcome of the study was 30-day mortality, with secondary analyses evaluating complications, discharge location and length of stay. Univariate analysis was initially performed followed by propensity score matching. RESULTS: A total of 460 patients were surgically treated for Hinchey IV diverticulitis of whom 101 (21.9%) had RSCL. The length of stay of the RSCL patients was significantly longer (15 versus 12 days, p, 0.02) than patients in the PFC group. Similarly, the discharge destination for the PFC group was twice as likely to be discharged home as the RSCL group. CONCLUSION: RSCL for acute diverticulitis is a widely used but is associated with prolonged hospitalizations resulting in high rates of discharge to skilled nursing or rehabilitation facilities. Its routine use for diverticulitis should be limited.

Complications after Oncoplastic Breast Reduction and Impact on Time to Adjuvant Therapy.

Background: Although lumpectomy with oncoplastic breast reduction (OBR) improves cosmetic results and ameliorates symptomatic macromastia, associated complications may delay adjuvant therapy. Methods: This was a single-institution, retrospective study of OBRs (2015-2021). A major complication was defined as need for IV antibiotics, and/or operation under general anesthesia. Association of complications with delay to adjuvant therapy (chemotherapy, radiation) was assessed. Results: In total, 282 patients were included. The major complication rate was 3.9%, and overall complication rate was 31.2%. The most common complication was incisional dehiscence (23.4%). Body mass index [BMI >35 (P < 0.0001)], diabetes (P = 0.02), and HgbA1c [>6.5 (P = 0.0002)] were significantly associated with having a major complication. The occurrence of any complication was associated with a delay in time to radiation (median 7 versus 8 weeks, P < 0.001). The occurrence of a major complication was associated with a more meaningful delay to radiation (median 7 versus 15 weeks, P = 0.002). Occurrence of any complication, or a major complication, was not associated with delay to chemotherapy. Conclusions: The overall complication rate observed after OBR falls within the range reported in the literature. Patients with a BMI more than 35, diabetes, and/or HgbA1c more than 6.5 were at increased risk for a major complication, which was associated with a meaningful delay to radiation. Consideration may be given to partial mastectomy alone without oncoplastic reduction in patients with small tumors when the priority to avoid radiation delay is high (eg, high-risk tumors), or the risk of delay is high (eg, diabetic or BMI >35).

BMI and VTE Risk in Emergency General Surgery, Does Size Matter? : An ACS-NSQIP Database Analysis.

BACKGROUND: Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. Emergency general surgery (EGS) patients comprise 7% of hospital admissions in America with a reported rate of VTE of 2.5%. Of these, >69% required hospital readmission, making VTE the second most common cause for readmission after infection in EGS patients. We hypothesize a correlation between body mass index (BMI) and VTE in EGS patients. METHODS: The American College of Surgeons National Surgery Quality Improvement Database (NSQIP) was queried from January 2015 to December 2016. 83 272 patients met inclusion criteria: age ≥18 and underwent an EGS procedure. Patients were stratified by BMI. Descriptive statistics were used for demographic and numerical data. Categorical comparisons between covariates were completed using the chi-square test. Continuous variables were compared using Student's t-test, Mann Whitney U-test, or Kruskal-Wallis H test. RESULTS: 83 272 patients met the inclusion criteria. 1358 patients developed VTE (903 deep vein thrombosis (DVT) only, 335 pulmonary embolism (PE) only, and 120 with DVT and PE). Morbidly obese patients were 1.7 times more likely to be diagnosed with a PE compared with normal BMI (P = .004). Increased BMI was associated with the co-diagnosis of PE and DVT (P = .027). Patients with BMI <18.5 were 1.4 times more likely to experience a VTE compared with normal BMI (P = .018). Patients with a VTE were 3.2 times more likely to die (P < .001) and less likely to be discharged home (P < .001). DISCUSSION: Our study found that obese and underweight EGS patients had an increased incidence of VTE. Risk recognition and chemoprophylaxis may improve outcomes in this population.