Practice patterns of hepatobiliary surgery within the military.

BACKGROUND: The purpose of this study is to evaluate the trends of hepatobiliary surgeries performed at military hospitals and to discuss potential implications on resident training and military readiness. While there is data to suggest centralization of surgical specialty services leads to improved patient outcomes, the military does not currently have a specific centralization policy. Implementation of such a policy could potentially impact resident training and readiness of military surgeons. Even in the absence of such a policy, there may still be a trend toward centralization of more complex surgeries like hepatobiliary surgeries. The present study evaluates the numbers and types of hepatobiliary procedures performed at military hospitals. METHODS: This study is a retrospective review of de-identified data from Military Health System Mart (M2) from 2014 to 2020. The M2 database contains patient data from all Defense Health Agency treatment facilities, encompassing all branches of the United States Military. Variables collected include number and types of hepatobiliary procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each medical facility. Linear regression was used to evaluate significant trends in numbers of surgeries over time. RESULTS: Fifty-five military hospitals performed hepatobiliary surgeries from 2014 to 2020. A total of 1,087 hepatobiliary surgeries were performed during this time; cholecystectomies, percutaneous procedures, and endoscopic procedures were excluded. There was no significant decrease in overall case volume. The most commonly performed hepatobiliary surgery was "unlisted laparoscopic liver procedure." The military training facility with the most hepatobiliary cases was Brooke Army Medical Center. CONCLUSION: The number of hepatobiliary surgeries performed in military hospitals has not significantly decreased over the years 2014-2020, despite a national trend toward centralization. Centralization of hepatobiliary surgeries in the future may impact residency training as well as military medical readiness.

Optimal Time to Surgery for Small Bowel Obstruction: A Risk Adjusted Analysis Utilizing the Nationwide Inpatient Sample.

BACKGROUND: The management of a small bowel obstruction (SBO) remains a challenge for general surgeons. The majority of SBOs can be treated conservatively; however, when surgery is required, the timing of operative intervention remains uncertain. Utilizing a large national database, we sought to evaluate the optimal timeframe for surgery following hospital admission with a diagnosis of SBO. METHODS: This was a retrospective review utilizing the Nationwide Inpatient Sample (2006-2015). Outcomes following surgery for SBO were identified using ICD-9-CM coding. Two comorbidity indices were utilized to determine severity of illness. Patients were stratified into four groups based on time in days from admission to surgery. Propensity score models were created to predict the number of days until surgery following admission. Multivariate regression analysis was performed to determine risk adjusted postoperative outcomes. RESULTS: We identified 92 807 cases of non-elective surgery for SBO. The overall mortality rate was 4.7%. Surgery on days 3-5 was associated with the lowest rate of mortality. A longer preoperative length of stay (LOS) (3-5 days) was associated with a significantly greater number of wound (OR = 1.24) and procedural (OR = 1.17) complications compared to day 0. However, delayed surgical intervention (≥6 days) was associated with decreased cardiac (OR = .69) and pulmonary complications (OR = .58). DISCUSSION: After adjustment, a preoperative LOS of 3-5 days was associated with a decreased risk of mortality. In addition, increasing preoperative LOS was associated with decreased cardiopulmonary complications. However, an increased risk of procedural and wound complications during this time period suggest surgery may be more technically challenging.

Outcomes of Casualties Without Airway Trauma Undergoing Prehospital Airway Interventions: A Department of Defense Trauma Registry Study.

INTRODUCTION: Airway obstruction is the second leading cause of preventable death on the battlefield. Most airway obstruction occurs secondary to traumatic disruptions of the airway anatomical structures. However, casualties may require airway interventions for other indications (e.g., depressed mental status). We describe casualties undergoing airway intervention in the prehospital, combat setting without apparent upper airway trauma. MATERIALS AND METHODS: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subgroup analysis of those patients with a documented prehospital airway intervention and no apparent airway trauma as defined by abbreviated injury scale of 0 for body regions 1 (head/neck) and 2 (face). RESULTS: Our predefined search codes captured 28222 DODTR subjects of whom 409 (1.4%) met criteria for study inclusion. Subjects included members of host nation forces (34%) and civilians (30%). Most subjects sustained injuries in Afghanistan (82%). Explosive (57%) and gunshot wounds (36%) were the most frequent mechanisms of injury. Median injury severity scores were 17. The most common anatomical locations of injuries for included subjects included extremities (53%) and thorax (29%). A majority of subjects underwent intubation (89%); comparatively few casualties underwent placement of a nasopharyngeal airway (2%) or supraglottic airway (2%). The proportion of subjects surviving to hospital discharge was 80% and was highest among subjects undergoing intubation (82%). CONCLUSIONS: In this subgroup analysis of casualties without apparent upper airway trauma, survival rates were lower when compared to our previous report. Higher quality data are necessary to better understand the resuscitation needs of this critically ill subset of combat casualties.