Association Between Fecal Contamination and Outcomes After Emergent General Surgery Colorectal Resection: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma (EAST) Multicenter Study.

Background: The impact of fecal contamination on clinical outcomes in patients undergoing emergent colorectal resection is unclear. We hypothesized that fecal contamination is associated with worse clinical outcomes regardless of operative technique. Patients and Methods: This is a post hoc analysis for an Eastern Association for the Surgery of Trauma-sponsored multicenter study that prospectively enrolled emergency general surgery patients undergoing urgent/emergent colorectal resection. Subjects were categorized according to presence versus absence of intra-operative fecal contamination. Propensity score matching (1:1) by age, weight, Charlson comorbidity index, pre-operative vasopressor use, and method of colonic management (primary anastomosis [ANST] vs. ostomy [STM]) was performed. χ2 analysis was then performed to compare the composite outcome (surgical site infection and fascial dehiscence). Results: A total of 428 subjects were included, of whom 147 (34%) had fecal contamination. Propensity score matching (1:1) resulted in a total of 147 pairs. After controlling for operative technique, fecal contamination was still associated with higher odds of the composite outcome (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.45-4.2; p = 0.001). Conclusions: In patients undergoing urgent/emergent colorectal resection, fecal contamination, regardless of operative technique, is associated with worse clinical outcomes. Selection bias is possible, thus randomized controlled trials are needed to confirm or refute a causal relation.

Statistical Power of Randomized Controlled Trials in Trauma Surgery.

BACKGROUND: Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery. STUDY DESIGN: A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance. RESULTS: In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8). CONCLUSIONS: A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting.

Firearm legislation: The association between neighboring states and crude death rates.

BACKGROUND: Few studies have examined the impact of interstate differences in firearm laws on state-level firearm mortality. We aim to study the association between neighboring states' firearm legislation and firearm-related crude death rate (CDR). METHODS: The CDC Web-based Injury Statistics Query and Reporting System was queried for adult all-intent (accidental, suicide, and homicide) firearm-related CDR among the 50 states from 2012 to 2020. States were divided into five cohorts based on the Giffords Law Center Annual Gun Law Scorecard, and two groups were constructed: Strict (A, B, C) and Lenient (D, F). We examined the effect of (1) a single incongruent neighbor, defined as "Different" if the state is bordered by ≥1 state with a grade score difference >1, and (2) the average grade of all neighboring states, defined as "Different" if the average of all neighboring states resulted in a grade score difference >1. RESULTS: Strict states with similar average neighbors had significantly lower CDR compared with Strict states with different average neighbors (2.98 [1.91-5.06] vs. 3.87 [2.37-5.94], p = 0.02), while Lenient states with similar average neighbors had significantly higher CDR compared with Lenient states with different average neighbors (6.02 [4.56-8.11] vs. 4.7 [3.95-5.35], p = 0.002). Lenient states surrounded by all similar Lenient states had the highest CDR, which was significantly higher than Lenient states with ≥1 different neighbor (6.52 [5.09-8.96] vs. 5.19 [3.85-6.61], p < 0.001). However, Strict states with ≥1 different neighbor did not have higher CDR compared with Strict states surrounded by all similar Strict states (3.39 [2.17-5.35] vs. 3.14 [1.91-5.38], p = 0.5). CONCLUSION: We report a lopsided neighboring effect whereby Lenient states may benefit from at least one Strict neighbor, while Strict states may be adversely affected only when surrounded by mostly Lenient neighbors. These findings may assist policymakers regarding the efficacy of their own state's legislation in the context of incongruent neighboring states. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Association Between Child Access Prevention and State Firearm Laws With Pediatric Firearm-Related Deaths.

INTRODUCTION: We aim to study the association between state child access prevention (CAP) and overall firearm laws with pediatric firearm-related mortality. METHODS: The Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System was queried for pediatric (aged < 18 y) all-intent (accidental, suicide, and homicide) firearm-related crude death rates (CDRs) among the 50 states from 1999 to 2019. States were into three groups: Always CAP (throughout the 20-year period), Never CAP, and New CAP (enacted CAP during study period). We used the Giffords Law Center Annual Gun Law Scorecard (A, B, C, D, F) to group states into strict (A, B) and lenient (C, D, F) firearm laws. A scatter plot was constructed to display state CDR based on CAP laws by year. The top 10 states by CDR per year were tabulated based on CAP law status. Wilcoxon rank-sum was used to compare CDR between strict and lenient scorecard states in 2019. RESULTS: There were 12 Always CAP, 21 Never CAP, and 17 New CAP states from 1999 to 2019. No states changed from CAP laws to no CAP laws. Never CAP and New CAP states dominated the high outliers in CDR compared to Always CAP. The top 10 states with the highest CDR per year were most commonly Never CAP. Strict firearm laws states had lower median CDR in 2019 than lenient states (0.79 [0-1.67] versus 2.59 [1.66-3.53], P = 0.007). CONCLUSIONS: Stricter overall gun laws are associated with three-fold lower all-intent pediatric firearm-related deaths. For 2 decades, the 10 states with the highest CDR were almost universally those without CAP laws. Our findings support the RAND Gun Policy in America initiative's claims on the importance of CAP laws in reducing suicide, unintentional deaths, and violent crime among children, but more research is needed.

Teduglutide for the treatment of low-output enterocutaneous fistula - A pilot randomized controlled study.

BACKGROUND & AIMS: Enterocutaneous fistula (ECF) is a complication of surgery or inflammatory bowel disease associated with disproportionately high healthcare costs, morbidity, and mortality. We performed this proof-of-concept, feasibility, open-label, pilot randomized, crossover study to assess the efficacy and safety of the use of teduglutide (TED) to treat ECF. METHODS: Adults (age >18) with low-output (<200 mL/d) ECF were randomized to 2 months of continuing standard-of-care (SOC) followed by crossover to 2 months of SOC + TED or the reverse order. The primary efficacy endpoint was decrease in fistula volume by 20% of baseline 3-day average. Secondary efficacy endpoints were: fistula resolution and health-related quality of life questionnaire scores. RESULTS: Six out of 10 planned subjects were randomized and completed the study, which was terminated early due to slow enrollment during the Covid-19 pandemic. Overall subject compliance with daily TED injections was high (98%). Five of six enrolled subjects met the definition for the primary efficacy endpoint; these clinical responses were not observed during the SOC arm in these subjects. One subject experienced complete fistula closure during TED treatment. Adverse events during treatment were uncommon, minor, and usually resolved despite ongoing treatment. Quality of life survey responses were highly variable and did not correlate with fistula changes. CONCLUSIONS: Two months of teduglutide treatment was feasible, well-tolerated, and resulted in observable decreases in ECF drainage in the majority of subjects, including spontaneous closure in one subject. This therapy shows promise, but larger, multicenter confirmatory trials are required. CLINICALTRIALS: GOV: (NCT02889393).

Outcomes of Restricted versus Liberal Post-Operative Antibiotic Use in Patients Undergoing Appendectomy: A DOOR/RADAR Post Hoc Analysis of the EAST Appendicitis MUSTANG Study.

Background: There is no consensus on the duration of antibiotic use after appendectomy. We hypothesized that restricted antibiotic use is associated with better clinical outcomes. Patients and Methods: We performed a post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America-Acute, Perforated, and Gangrenous (MUSTANG) study using the desirability of outcome ranking/response adjusted for duration of antibiotic risk (DOOR/RADAR) framework. Three separate datasets were analyzed based on restricted versus liberal post-operative antibiotic groups: simple appendicitis (no vs. yes); complicated appendicitis, only four days (≤24 hours vs. 4 days); and complicated appendicitis, four or more days (≤24 hours vs. ≥4 days). Patients were assigned to one of seven mutually exclusive DOOR categories RADAR ranked within each category. DOOR/RADAR score pairwise comparisons were performed between all patients. Each patient was assigned either 1, 0, or -1 if they had better, same, or worse outcomes than the other patient in the pair, respectively. The sum of these numbers (cumulative comparison score) was calculated for each patient and the group medians of individual sums were compared by Wilcoxon rank sum. Results: For simple appendicitis, the restricted group had higher median sums than the liberal group (552 [552,552] vs. -1,353 [-1,353, -1,353], p < 0.001). For both complicated appendicitis analyses, the restricted group had higher median sums than the liberal: only 4 (196 [23,196] vs. -121 [-121, -121], p < 0.02) and 4 or more (660 [484,660] vs -169 [-444,181], p < 0.001). Conclusions: Restricted post-operative antibiotic use in patients after appendectomy is a dominant strategy when considering treatment effectiveness and antibiotic exposure.

Role of Empiric Antifungal Therapy in Patients with Perforated Peptic Ulcers.

Background: It is unclear if the addition of antifungal therapy for perforated peptic ulcers (PPU) leads to improved outcomes. We hypothesized that empiric antifungal therapy is associated with better clinical outcomes in critically ill patients with PPU. Patients and Methods: The 2001-2012 Medical Information Mart for Intensive Care (MIMIC-III) database was searched for patients with PPU and the included subjects were divided into two groups depending on receipt of antifungal therapy. Propensity score matching by surgical intervention, mechanical ventilation (MV), and vasopressor administration was then performed and clinically important outcomes were compared. Multiple logistic regression was performed to calculate the odds of a composite end point (defined as "alive, hospital-free, and infection-free at 30 days"). Results: A total of 89 patients with PPU were included, of whom 52 (58%) received empiric antifungal therapy. Propensity score matching resulted in 37 pairs. On logistic regression controlling for surgery, vasopressors, and MV, receipt of antifungal therapy was not associated with higher odds (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.5-4.7; p = 0.4798) of the composite end point. Conclusions: In critically ill patients with perforated peptic ulcer, receipt of antifungal therapy, regardless of surgical intervention, was not associated with improved clinical outcomes. Selection bias is possible and therefore randomized controlled trials are required to confirm/refute causality.

Publication Inaccuracies Listed in General Surgery Residency Training Program Applications.

BACKGROUND: Professionalism is a core competency that is difficult to assess. We examined the incidence of publication inaccuracies in Electronic Residency Application Service applications to our training program as potential indicators of unprofessional behavior. STUDY DESIGN: We reviewed all 2019-2020 National Resident Matching Program applicants being considered for interview. Applicant demographic characteristics recorded included standardized examination scores, gender, medical school, and medical school ranking (2019 US News & World Report). Publication verification by a medical librarian was performed for peer-reviewed journal articles/abstracts, peer-reviewed book chapters, and peer-reviewed online publications. Inaccuracies were classified as "nonserious" (eg incorrect author order without author rank promotion) or "serious" (eg miscategorization, non-peer-reviewed journal, incorrect author order with author rank promotion, nonauthorship of cited existing publication, and unverifiable publication). Multivariate logistic regression analysis was performed for demographic characteristics to identify predictors of overall inaccuracy and serious inaccuracy. RESULTS: Of 319 applicants, 48 (15%) had a total of 98 inaccuracies; after removing nonserious inaccuracies, 37 (12%) with serious inaccuracies remained. Seven publications were reported in predatory open access journals. In the regression model, none of the variables (US vs non-US medical school, gender, or medical school ranking) were significantly associated with overall inaccuracy or serious inaccuracy. CONCLUSIONS: One in 8 applicants (12%) interviewing at a general surgery residency program were found to have a serious inaccuracy in publication reporting on their Electronic Residency Application Service application. These inaccuracies might represent inattention to detail or professionalism transgressions.

Discordance in Appendicitis Grading and the Association with Outcomes: A Post-Hoc Analysis of an EAST Multicenter Study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) appendicitis severity grading criteria use independent subscales for radiologists (Rad), surgeons (Surg), and pathologists (Path). We reviewed the EAST Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database to determine rates of discordance and clinical consequences of inaccuracy. MATERIALS AND METHODS: A confusion matrix was constructed for pairs among Rad, Surg, and Path. Accuracy was reported using chronologically latest diagnosis as gold standard. "Concordance" (C) was achieved when both agreed on the severity grade and "Discordance"(D) when they disagreed. A composite endpoint("COMP"= 30-d incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED[Emergency Department] visit, hospital readmission, and mortality) was compared between C versus D groups via χ2 test with Bonferroni correction to define statistical significance(P = 0.05/9 = 0.005). RESULTS: For each pair and diagnosis, subjects were categorized as C or D and compared for the incidence of COMP. Incidence of COMP for Surg and/or Path in C versus D: 16% versus. 26% (p = 0.006, NS by Bonferroni) for acute (A), 39% versus 33% (p = 0.39) for gangrenous (G), and 48% versus 37% (p = 0.035, NS by Bonferroni) for perforated (P). For Rad and/or Path in C versus. D: 17% versus 42% (p < 0.001) for A, 27% versus 31% (p = 0.95) for G, and 56% versus 48% (p = 0.48) for P. For C versus D: 17% versus 40% (p < 0.001) for A, 36% versus 26% (p = 0.43) for G, and 51% versus 39% (p = 0.29) for P. CONCLUSIONS: In appendicitis treated by appendectomy, surgeons are most accurate at diagnosing acute appendicitis and least accurate at diagnosing gangrenous. Radiologists are less accurate for all categories. When the surgeon is wrong, clinical outcomes are not significantly worse. However, when the radiologist is wrong about acute appendicitis, patients have worse clinical outcomes.

Prophylactic Drainage after Appendectomy for Perforated Appendicitis in Adults: A Post Hoc Analysis of an EAST Multi-Center Study.

Background: We sought to assess the efficacy of prophylactic abdominal drainage to prevent complications after appendectomy for perforated appendicitis. Methods: In this post hoc analysis of a prospective multi-center study of appendicitis in adults (≥ 18 years), we included patients with perforated appendicitis diagnosed intra-operatively. The 634 subjects were divided into groups on the basis of receipt of prophylactic drains. The demographics and outcomes analyzed were surgical site infection (SSI), intra-abdominal abscess (IAA), Clavien-Dindo complications, secondary interventions, and hospital length of stay (LOS). Multivariable logistic regression for the cumulative 30-day incidence of IAA was performed controlling for age, Charlson Comorbidity Index (CCI), antibiotic duration, presence of drains, and Operative American Association for the Surgery of Trauma (AAST) Grade. Results: In comparing the Drain (n = 159) versus No-Drain (n = 475) groups, there was no difference in the frequency of male gender (61% versus 55%; p = 0.168), weight (87.9 ± 27.9 versus 83.8 ± 23.4 kg; p = 0.071), Alvarado score (7 [6-8] versus 7 [6-8]; p = 0.591), white blood cell (WBC) count (14.8 ± 4.8 versus 14.9 ± 4.5; p = 0.867), or CCI (1 [0-3] versus 1 [0-2]; p = 0.113). The Drain group was significantly older (51 ± 16 versus 48 ± 17 years; p = 0.017). Drain use increased as AAST EGS Appendicitis Operative Severity Grade increased: Grade 3 (62/311; 20%), Grade 4 (46/168; 27%), and Grade 5 (51/155; 33%); p = 0.007. For index hospitalization, the Drain group had a higher complication rate (43% versus 28%; p = 0.001) and longer LOS (4 [3-7] versus 3 [1-5] days; p < 0.001). We could not detect a difference between the groups in the incidence of SSI, IAA, or secondary interventions. There was no difference in 30-day emergency department visits, re-admissions, or secondary interventions. Multi-variable logistic regression showed that only AAST Grade (odds ratio 2.7; 95% confidence interval7 1.5-4.7; p = 0.001) was predictive of the cumulative 30-day incidence of IAA. Conclusions: Prophylactic drainage after appendectomy for perforated appendicitis in adults is not associated with fewer intra-abdominal abscesses but is associated with longer hospital LOS. Increasing AAST EGS Appendicitis Operative Grade is a strong predictor of intra-abdominal abscess.

Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study.

Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.

A survey of the practice and attitudes of surgeons regarding the treatment of appendicitis.

BACKGROUND: We surveyed surgeons to document their attitudes, practice, and risk tolerance regarding the treatment of appendicitis. METHODS: A web-based survey was sent to the EAST membership. The primary composite endpoint was defined as 1-year incidence of perioperative complications, antibiotic failure, infections, ED visits, and readmissions. RESULTS: A total of 563 of 1645 surveys were completed (34% response). Mean age was 47 ±â€¯10 years and 98% were from the United States. Most (72%) were employed at academic teaching hospitals and 66% practiced in an urban setting. There were significant differences in treatment recommendations for different presentations of appendicitis. Regarding the primary composite endpoint, surgeons would tolerate a median 17% [10%-25%] excess morbidity in order to avoid an operation (i.e. non-inferiority) and would require a median 24% [10%-50% lower morbidity for the surgical approach in order to declare it a superior treatment (i.e. superiority). CONCLUSIONS: To be considered non-inferior, antibiotic therapy of appendicitis cannot have >17% excess morbidity and appendectomy must have at least 24% lower morbidity to be considered superior.

Use of Telemedicine in Surgical Education: A Seven-Year Experience.

Uniformity in surgical education is challenging because surgical experience is based on rotation assignments. With work hour restrictions, the likelihood of residents being exposed to rare or unusual cases is diminished. Telemedicine may create a new learning paradigm for surgical education and supplement exposure for rare or unusual cases. A retrospective review (2010-2016) of teleconferences involving trauma centers worldwide was conducted. Participating hospitals included centers from underdeveloped countries to first world nations. Trauma cases were discussed among surgeons with different levels of experience and resource availability. Data collected included types of cases, anatomic injury patterns, hospital location, and the number of telemedicine centers and viewers participating. Seventy-three hospitals in 64 cities, spanning 27 countries, participated in 276 telemedicine grand round conferences. Cases discussed included penetrating trauma (47%), blunt trauma (42%), and blast injury (4%). The anatomic regions included were the thorax (28%), abdomen (26%), thoracoabdominal region (13%), neck (7%), and pelvis (6%). The most common injury discussed was vascular in nature (18%), followed by the lung, liver, diaphragm, and heart. The most common vascular lesion was in the aorta (18%), followed by the iliac vessels (8%) and the vena cava (7%). Telemedicine is a valuable tool, allowing the dissemination of diverse experiences. Most cases presented evaluated rare injuries or complex surgical approaches, which are not commonly seen on trauma sites. Learning different approaches in the management of complex trauma will make surgeons more prepared to deal with challenging cases.

Resuscitative thoracotomy.

Resuscitative thoracotomy is often performed on trauma patients with thoracoabdominal penetrating or blunt injuries arriving in cardiac arrest. The goal of this procedure is to immediately restore cardiac output and to control major hemorrhage within the thorax and abdominal cavity. Only surgeons with experience in the management of cardiac and thoracic injuries should perform this procedure.