Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting.

INTRODUCTION: Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting. METHODS: We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016. RESULTS: A total of 1,072 patients were included (preintervention: n = 493, postintervention: n = 579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0-10.2 vs 8.6, 95% CI 8.8-8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; P = .002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; P = .0005 and 2.8% vs 1.0%; P = .029, respectively). CONCLUSION: Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.

Improving Accuracy of Noninvasive Hemoglobin Monitors: A Functional Regression Model for Streaming SpHb Data.

OBJECTIVE: The purpose of this paper is to develop a method for improving the accuracy of SpHb monitors, which are noninvasive hemoglobin monitoring tools, leading to better critical care protocols in trauma care. METHODS: The proposed method is based on fitting smooth spline functions to SpHb measurements collected over a time window and then using a functional regression model to predict the true HgB value for the end of the time window. RESULTS: The accuracy of the proposed method is compared to traditional methods. The mean absolute error between the raw SpHb measurements and the gold standard hemoglobin measurements was 1.26 g/Dl. The proposed method reduced the mean absolute error to 1.08 g/Dl. [1] Conclusion: Fitting a smooth function to SpHb measurements improves the accuracy of Hgb predictions. SIGNIFICANCE: Accurate prediction of current and future HgB levels can lead to sophisticated decision models that determine the optimal timing and amount of blood product transfusions.

Deconstructing dogma: Nonoperative management of small bowel obstruction in the virgin abdomen.

BACKGROUND: Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of computed tomography imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin (GG) administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared with that for SBO with PAS. METHODS: A post hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients younger than 18 years, pregnant patients, and patients with evidence of hypotension, bowel strangulation, peritonitis, closed loop obstruction or pneumatosis intestinalis were excluded. The primary outcome was operative exploration rate for SBO with or without PAS. Rate adjustment was accomplished through multivariate logistic regression. RESULTS: Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, sex, prior abdominal surgery including colon surgery, prior SBO admission, and history of cancer. Multivariate analysis showed that PAS (odds ratio [OR], 0.47; p = 0.03) and the use of GG (OR, 0.11; p < 0.01) were independent predictors of successful nonoperative management, whereas intensive care unit admission (OR, 16.0; p < 0.01) was associated with a higher likelihood of need for operation. The use of GG significantly decreased the need for operation in patients with and without PAS. CONCLUSIONS: Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared with those who did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the nonoperative management approach using GG. LEVEL OF EVIDENCE: Therapeutic, level IV.

Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection.

INTRODUCTION: Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS: Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS: A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION: The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE: Prognostic, level IV.

RESHAPES: Increasing AAST EGS grade is associated with anastomosis type.

INTRODUCTION: Threatened, perforated, and infarcted bowel is managed with conventional resection and anastomosis (hand sewn [HS] or stapled [ST]). The SHAPES analysis demonstrated equivalence between HS and ST techniques, yet surgeons appeared to prefer HS for the critically ill. We hypothesized that HS is more frequent in patients with higher disease severity as measured by the American Association for the Surgery of Trauma Emergency General Surgery (AAST EGS) grading system. METHODS: We performed a post hoc analysis of the SHAPES database. Operative reports were submitted by volunteering SHAPES centers. Final AAST grade was compared with various outcomes including duration of stay, physiologic/laboratory data, anastomosis type, anastomosis failure (dehiscence, abscess, or fistula), and mortality. RESULTS: A total of 391 patients were reviewed, with a mean age (±SD) of 61.2 ± 16.8 years, 47% women. Disease severity distribution was as follows: grade I (n = 0, 0%), grade II (n = 106, 27%), grade III (n = 113, 29%), grade IV (n = 123, 31%), and grade V (n = 49, 13%). Increasing AAST grade was associated with acidosis and hypothermia. There was an association between higher AAST grade and likelihood of HS anastomosis. On regression, factors associated with mortality included development of anastomosis complication and vasopressor use but not increasing AAST EGS grade or anastomotic technique. CONCLUSION: This is the first study to use standardized anatomic injury grades for patients undergoing urgent/emergent bowel resection in EGS. Higher AAST severity scores are associated with key clinical outcomes in EGS diseases requiring bowel resection and anastomosis. Anastomotic-specific complications were not associated with higher AAST grade; however, mortality was influenced by anastomosis complication and vasopressor use. Future EGS studies should routinely include AAST grading as a method for reliable comparison of injury between groups. LEVEL OF EVIDENCE: Prognostic, level III.

Prothrombin Complex Concentrate Reversal of Coagulopathy in Emergency General Surgery Patients.

BACKGROUND: Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone. METHODS: Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed. RESULTS: Coagulopathic EGS patients (n = 183) received the following blood products: PCC (n = 20, 11%), FFP alone (n = 119, 65%) and PCC/FFP (n = 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4-6), FFP = 5(4-7), PCC/FFP = 5(4-6), p = 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684, p = .09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h, p = 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0, p = 0.03). The incidence of thromboembolic complications was similar in all three groups. CONCLUSIONS: PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone. LEVEL OF EVIDENCE: IV single institutional retrospective review.

Validation of AAST EGS Grade for Acute Pancreatitis.

BACKGROUND: The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods. METHODS: Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems. RESULTS: There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay. CONCLUSIONS: The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system. LEVEL OF EVIDENCE: IV Study Type: Single institutional retrospective review.

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines.

BACKGROUND: Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes. METHODS: Adults (≥18 years) with acute cholecystitis during 2013-2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30-day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics. RESULTS: There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0-6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68). CONCLUSION: Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE: Prognostic, level III.

Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade.

OBJECTIVE: To assess whether the American Association for the Surgery of Trauma (AAST) grading system accurately corresponds with appendicitis outcomes in a US pediatric population. STUDY DESIGN: This single-institution retrospective review included patients <18 years of age (n = 331) who underwent appendectomy for acute appendicitis from 2008 to 2012. Demographic, clinical, procedural, and follow-up data (primary outcome was measured as Clavien-Dindo grade of complication severity) were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and multivariable regression analyses were performed to compare AAST grade and outcomes. RESULTS: Overall, 331 patients (46% female) were identified with a median age of 12 (IQR, 8-15) years. Appendectomy was laparoscopic in 90% and open in 10%. AAST grades included: Normal (n = 13, 4%), I (n = 152, 46%), II (n = 90, 27%), III (n = 43, 13%), IV (n = 24 7.3%), and V (n = 9 2.7%). Increased AAST grade was associated with increased Clavien-Dindo severity, P =.001. The overall complication rate was 13.6% and was comprised by superficial surgical site infection (n = 13, 3.9%), organ space infection (n = 15, 4.5%), and readmission (n = 17, 5.1%). Median duration of stay increased with AAST grade (P < .0001). Nominal logistic regression identified the following as predictors of any complication (P < .05): AAST grade and febrile temperature at admission. CONCLUSIONS: The AAST appendicitis grading system is valid in a single-institution pediatric population. Increasing AAST grade incrementally corresponds with patient outcomes including increased risk of complications and severity of complications. Determination of the generalizability of this grading system is required.

External Validation of a Tube Thoracostomy Complication Classification System.

BACKGROUND: Tube thoracostomy (TT) is a commonly performed procedure which is associated with significant complication rates. Currently, there is no validated taxonomy to classify and compare TT complications across different populations. This study aims to validate such TT complication taxonomy in a cohort of South African trauma patients. METHODS: Post hoc analysis of a prospectively collected trauma database from Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa was performed for the period January 2010 to December 2013. Baseline demographics, mechanism of injury and complications were collected and categorized according to published classification protocols. All patients requiring bedside TT were included in the study. Patients who necessitated operatively placed or image-guided TT insertion were excluded. Summary and univariate analyses were performed. RESULTS: A total of 1010 patients underwent TT. The mean age was (±SD) of 26 ± 8 years. Unilateral TTs were inserted in n = 966 (96%) and bilateral in n = 44 (4%). Complications developed in 162 (16%) patients. Penetrating injury was associated with lower complication rate (11%) than blunt injury (26%), p = 0.0001. Higher complication rate was seen in TT placed by interns (17%) compared to TT placed by residents (7%), p = 0.0001. Complications were classified as: insertional (38%), positional (44%), removal (9%), infective/immunologic (9%), and instructional, educational or equipment related (0%). CONCLUSIONS: Despite being developed in the USA, this classification system is robust and was able to comprehensively assign and categorize all the complications of TT in this South African trauma cohort. A universal standardized definition and classification system permits equitable comparisons of complication rates. The use of this classification taxonomy may help develop strategies to improve TT placement techniques and reduce the complications associated with the procedure. LEVEL OF EVIDENCE: V. STUDY TYPE: Single Institution Retrospective review.

Perioperative use of nonsteroidal anti-inflammatory drugs and the risk of anastomotic failure in emergency general surgery.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis. METHODS: Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed. RESULTS: Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03). CONCLUSION: Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF. LEVEL OF EVIDENCE: Therapeutic study, level III.

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study.

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP). METHODS: As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB. RESULTS: Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity. CONCLUSION: Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction.

INTRODUCTION: Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications. METHODS: A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG. RESULTS: Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2-7 vs. 5 days IQR 2-12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management. CONCLUSION: Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality. LEVEL OF EVIDENCE: Therapeutic, level III.

Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation.

OBJECTIVE: We aimed to understand the setting and litigation outcomes of surgical fires and operative burns. METHODS: Westlaw, an online legal research data-set, was utilized. Data were collected on patient, procedure, and case characteristics. RESULTS: One hundred thirty-nine cases were identified; 114 (82%) operative burns and 25 (18%) surgical fires. Median plaintiff (patient) age was 46 (IQR:28-59). Most common site of operative burn was the face (26% [n = 36]). Most common source of injury was a high energy device (43% [n = 52]). Death was reported in 2 (1.4%) cases. Plaintiff age <18 vs age 18-50 and mention of a non-surgical physician as a defendant both were shown to be independently associated with an award payout (OR = 4.90 [95% CI, 1.23-25.45]; p = .02) and (OR = 4.50 [95% CI, 1.63-13.63]; p = .003) respectively. Plaintiff award payment (settlement or plaintiff verdict) was reported in 83 (60%) cases; median award payout was $215,000 (IQR: $82,000-$518,000). CONCLUSION: High energy devices remain as the most common cause of injury. Understanding and addressing pitfalls in operative care may mitigate errors and potentially lessen future liability. LEVEL OF EVIDENCE: III.

Medical Malpractice in Bariatric Surgery: a Review of 140 Medicolegal Claims.

OBJECTIVE: Given the current rate of obesity in the USA, it has been estimated that close to half of the US adult population could be obese by 2030, resulting in greater demand for bariatric procedures. Our objective was to analyze malpractice litigation related to bariatric surgery. METHODS: We conducted a retrospective review of Westlaw (Thompson Reuters) of all bariatric operations that resulted in the filing of a malpractice claim. Each case was reviewed for pertinent medicolegal information related to the procedure, claim, and trial. RESULTS: The search criteria yielded 298 case briefs, of which 140 met inclusion criteria. Thirty-two percent (n = 49) of cases involved male plaintiffs (patients). Mean patient age with standard deviation (SD) was 43 (10) years. The most common procedure litigated was the Roux-en-Y gastric bypass (76 %, n = 107). Overall, the most common alleged reason for a malpractice claim was delay in diagnosis or management of a complication in the postoperative period (n = 66, 47 %), the most common of which was an anastomotic leak (45 %, n = 34). Death was reported in 74 (52 %) cases. Fifty-seven cases (47 %) were decided in favor of the plaintiff (patient), with a median award payout of $1,090,000 (interquartile range [IQR] $412,500 to $2,550,000). CONCLUSION: Delay in diagnosing or managing complications in the postoperative setting, most commonly an anastomotic leak, accounted for the majority of malpractice claims. Measures taken to identify and address anastomotic leaks and other complications early in the postoperative period could potentially reduce the amount of filed malpractice claims related to bariatric surgery. LEVEL OF EVIDENCE: III.

Medical malpractice in the management of small bowel obstruction: A 33-year review of case law.

BACKGROUND: Annually, 15% of practicing general surgeons face a malpractice claim. Small bowel obstruction accounts for 12-16% of all surgical admissions. Our objective was to analyze malpractice related to small bowel obstruction. METHODS: Using the search terms "medical malpractice" and "small bowel obstruction," we searched through all jury verdicts and settlements for Westlaw. Information was collected on case demographics, alleged reasons for malpractice, and case outcomes. RESULTS: The search criteria yielded 359 initial case briefs; 156 met inclusion criteria. The most common reason for litigation was failure to diagnose and timely manage the small bowel obstruction (69%, n = 107). Overall, 54% (n = 84) of cases were decided in favor of the defendant (physician). Mortality was noted in 61% (n = 96) of cases. Eighty-six percent (42/49) of cases litigated as a result of failing to diagnose and manage the small bowel obstruction in a timely manner, resulting in patient mortality, had a verdict with an award payout for the plaintiff (patient). The median award payout was $1,136,220 (range, $29,575-$12,535,000). CONCLUSION: A majority of malpractice cases were decided in favor of the defendants; however, cases with an award payout were costly. Timely intervention may prevent a substantial number of medical malpractice lawsuits in small bowel obstruction, arguing in favor of small bowel obstruction management protocols.