Two Decades of Insights into Nontuberculous Mycobacterial Hand Infections.

Background: The objective of our study is to describe the clinical presentation, management, and outcome of a large cohort with nontuberculous mycobacteria (NTM) hand infection. Methods: We reviewed the medical records of all adults (≥18 years) managed at the Mayo Clinic (Rochester, MN) for NTM hand infection between 1998 and 2018. Results: Our cohort included 81 patients. The median age was 61.3 (interquartile range 51.7, 69.6) years; 39.5% were immunocompromised, and 67.9% reported a triggering exposure preceding infection. Infection was deep in 64.2% and disseminated in 3.7%. Up to 16.0% received intralesional steroids because of misdiagnosis with an inflammatory process. Immunocompromised patients had deeper infection, and fewer reports of a triggering exposure. Mycobacterium marinum, Mycobacterium avium complex, and Mycobacterium chelonae/abscessus complex were the most common species. The median antibiotic duration was 6.1 (interquartile range 4.6, 9.9) months. Deep infection and infection with species other than M marinum were associated with using a greater number of antibiotics for combination therapy and an extended duration of treatment. Immunosuppression was also associated with longer courses of antibiotic therapy. Surgery was performed in 86.5% and 32.4% required multiple procedures. Ten patients, mostly with superficial infections, were treated with antibiotics alone. The 5-year cumulative rate of treatment failure was 30.3% (95% confidence interval, 20.9-44.0). Immunosuppression and intralesional steroid use were risk factors for failure. Conclusions: Treatment of NTM hand infection usually requires surgery and antibiotics, but antibiotics alone may occasionally be attempted in select cases. Immunosuppression and intralesional steroids are risk factors for treatment failure.

Animal models in lymph node transfer surgery: A systematic review.

Background and Aim: Lymph node transfer surgery (LNTS) is indicated in secondary lymphedema (LE) patients who do not respond to conservative therapy. Animal models are the spearhead of LE research and were used to pioneer most of the surgical interventions currently in practice. We conducted a systematic review of the literature to explore animal models dedicated to LNTS to compare different species, techniques, and outcomes. Methods: Four databases were searched: PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization. Results: Avascular lymph node graft (ALNG) and vascularized lymph node transfer (VLNT) effectively treated LE and lead to better outcomes than controls. Whole ALNGs are superior to fragmented ALNGs. Larger fragments are more likely to be reintegrated into the lymphatic system than small fragments. VLNT was superior to whole and fragmented ALNG. Increasing the number of VLNT resulted in better outcomes. Adipose-derived stem cells improved outcomes of VLNT; vascular endothelial growth factor C and D and platelet-rich plasma improved outcomes for ALNG. Cryopreservation of lymph nodes (LNs) did not affect outcomes for ALNG. The critical ischemia and venous occlusion time for LN flaps were 4-5 and 4 h, respectively. The critical time for reperfusion injury was 2 h. Some of the novel models included venous LNT, and cervical adipocutaneous flap to groin. Conclusion: Current evidence from animals favors VLNT over other surgical interventions. Several pharmacological therapies significantly improved outcomes of ALNG and VLNT. Relevance to Patients: LE is a chronic condition affecting millions of patients worldwide. LNTS is becoming more popular as a LE treatment. Animal models have led the LE research for decades and developing new models for LE are essential for LE research. This systematic review aims to summarize the existing animal models dedicated to LNTS. We believe that this review is critical to guide researchers in the selection of the model that is best fit for their hypothesis-driven experiments.

Simulation in Hand Surgery: A Literature Review.

BACKGROUND: Due to duty hour regulations, patient safety and inadequate operative time simulation have become a necessary part of surgical education and training in residency. Currently, there is no formal adoption of simulators for the use of surgical education or assessment in hand surgery. This literature review analyzes that the simulation techniques established thus far in hand surgery. METHODS: A comprehensive literature search was performed on PubMed. Search results were filtered by title and abstract to isolate articles that were relevant to simulation in hand surgery. Articles that were nonspecific to the hand, non-English and cadaveric were excluded. Additional articles were identified through references from the initial search. RESULTS: A total of 1192 articles were yielded from the initial query. After the application of the inclusion criteria, this was narrowed down to 28 articles. Another 8 additional articles were excluded as they did not pertain to the hand although the simulators could be adapted for hand surgery. A total of 20 articles were included in this study. CONCLUSIONS: Surgical simulation is a growing and essential field of surgical education. Simulators in hand surgery are limited and require further research and validation. Like other surgical subspecialties, hand surgery may benefit from the adoption of an official simulation curriculum for the assessment of residents and enhancement of technical skills.

Surgical techniques of phalloplasty in transgender patients: a systematic review.

Gender confirmation surgery has a crucial role among transgender individuals. Phalloplasty is a procedure that uses flaps for phallic shaft creation. Flaps can be classified in free flaps or pedicle flaps and can be obtained from different donor sites such as forearm, thigh, abdomen, groin, and leg, and upper back. We conducted a systematic review about surgical flaps for phallic shaft creation in transgender patients. A systematic review was conducted on PubMed/MEDLINE, Cochrane Clinical Answers, and Cochrane Central Register of Controlled Trials databases without timeframe limitations. Exclusion criteria included articles that reported phalloplasty on patients other than transgender, as well as other surgical techniques such as urethroplasty, vaginectomy, hysterectomy and studies focused on psychosocial outcomes. Two hundred twenty-eight potential articles were identified in the initial search. Forty-one studies fulfilled the inclusion and exclusion criteria. Surgical flaps for phallic shaft creation in transgender patients were reported on 1,391 cases. Microsurgical flaps were the most common (24 of 33). The flap technique most frequently described was radial forearm flap (15 of 33) followed by Anterolateral thigh flap (7 of 33), Latissimus dorsi flap (5 of 33), abdominal flap (4 of 33), fibular flap (3 of 33), and groin flaps (3 of 33). The literature on surgical flaps for phallic shaft creation in transgender patients reflected how challenging the reconstruction of the phallus is. In summary, there is no universal choice of flap that could be applied to every patient. Therefore, the surgical approach must be chosen considering surgeon experience, physical examination, and patient desire. We hope this review supports future studies on surgical flaps for phallic shaft creation in transgender patients.

Single versus two-stage phalloplasty for transgender female-to-male patients: a systematic review of the literature.

Phalloplasty is the main treatment for gender dysphoria disorder. It is difficult to ascertain if staging of phalloplasty influences the rate of complications. We aim to describe and compare the rates of complication between single versus two-stage phalloplasty for transgender female-to-male patients. PubMed, Ovid Medline, EMBASE and SCOPUS databases were queried for studies reporting complications of female-to-male transgender patients who underwent phalloplasty. The keywords "phalloplasty", "female to male", "outcome", "complication" and synonyms in different combinations were used for the search. Only studies that could identify whether phallic shaft creation was performed in a single or two-stage procedure were included. From a total of 336 articles, 20 met the inclusion criteria. Sixteen studies reported complications associated with a single-stage phalloplasty and seven studies identified complications after a two-stage procedure. The most common complications found for both groups of staging were fistula, stricture and total/partial flap necrosis. Patients who underwent two-stage phalloplasty had higher complication rates (partial or total flap necrosis and fistulas), compared with the single-stage procedure (P<0.05). In conclusion, this systematic review identified the impact of staging in the rate of complications related to phalloplasty for transgender female-to-male patients; a two-stage phalloplasty has a higher rate of complications.

Amelanotic melanoma of the head and neck: analysis of tumor characteristics from the National Cancer Database.

BACKGROUND: Amelanotic melanoma is an extremely rare subtype of cutaneous melanoma. The tumor characteristics are still not well understood, especially for those located in the head and neck. METHODS: Tumor characteristics of patients diagnosed with amelanotic melanoma of the head and neck (AMHN) from January 1, 2004, to December 31, 2015, were analyzed by querying the National Cancer Database. Characteristics of AMHN were subsequently compared with common malignant melanoma of the head and neck (CMMHN). RESULTS: Three hundred and sixty-eight patients were diagnosed with AMHN, and 69,267 were diagnosed with CMMHN. Of those with AMHN, 128 (34.8%) had melanoma located on the scalp and neck, and 172 (46.7%) were diagnosed with an early disease stage (i.e., 0, I, or II). When compared with CMMHN, patients with AMHN were more likely to be diagnosed after 80 years of age (25.3% vs. 18.2%; odds ratio [OR], 3.28; 95% CI, 1.09-9.84; P = 0.03), when Breslow depth was between 2.01 and 4.00 mm (28.5% vs. 6.5%; OR, 1.92; 95% CI, 1.15-3.19; P = 0.01), when ulceration was present (36.7% vs. 9.0%; OR, 1.99; 95% CI, 1.34-2.97; P = 0.001), and when mitotic count was 1 or more/mm2 (40.5% vs. 12.8%; OR; 2.53; 95% CI, 1.09-5.89; P = 0.03). No statistical difference was found for sex, specific location, stage, or lymph node involvement. CONCLUSION: Our study determined that AMHN is associated with older age, increased Breslow depth, presence of ulceration, and greater mitotic count when compared with CMMHN.

Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review.

Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included "lymphovenous" OR "lymphaticovenous" AND "bypass" OR "anastomosis" OR "shunt" AND "lower extremity lymphedema." Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.

Group Video Feedback is an Effective and Efficient Tool for Enhancing Skills of Surgical Interns.

BACKGROUND: Our group has shown that personalized video feedback (PVF) is better than a task demonstration video at increasing wound closure skills among incoming surgical interns. However, offering PVF can be time-consuming. We sought to compare the educational effects and time required for group video feedback (GVF) and PVF. METHODS: We have mailed our matched incoming "surgical" interns a "welcome package" in mid-March for the past 3 y. The package includes similar resources each year. Incoming interns were asked to video record themselves performing six tasks three separate times between April 1 and June 15. After each submission in 2016 and 2017, incoming interns received 2 min of personalized feedback on their three separate wound closure videos (PVF). In 2018, incoming interns received 5 min of group-based feedback three separate times covering all six tasks (GVF). We compared performance (July Surgical Olympics) of these six skills against the interns from the previous 2 y who received PVF on only one skill (suturing). RESULTS: Twenty-three incoming interns received the pre-residency package and participated in the 2018 Surgical Olympics. This 2018 GVF class had a higher overall mean score for six stations (31.5 [standard deviation = ±7.7]) than the 2016 and 2017 PVF classes (25.6 [standard deviation = ±8]; P < 0.0001). Knot tying ability and suturing skill were similar between the classes. The GVF group performed better on the remaining four skills . The total time of surgical staff and educators spent per class in 2018 (GVF class) was 30 min and includes six tasks compared with 276 min of effort in each of the 2016 and 2017 classes (PVF included one task). CONCLUSIONS: GVF and PVF as a component of preemptive training had the same effect on improving suturing skills among the interns. GVF required less educator editing and voice over time. GVF is effective and efficient in enhancing incoming interns' performance in multiple skills.

Analysis of Melanoma in African American Patients in the United States.

BACKGROUND/AIM: To characterize the demographics, tumor staging and treatment of African American (AA) patients diagnosed with melanoma in the United States. PATIENTS AND METHODS: The National Cancer Database was used to extrapolate data from patients with melanoma between January 1, 2004, and December 31, 2015. The patients were then further divided based on ethnicity (AAs vs. Caucasians) to compare patient efficacy of treatment. RESULTS: The mean time for AA patients to receive treatment was 20.37 days compared with 11.25 days for Caucasians (p<0.001), while time to surgery was 38.86 days compared to 31.12 days for Caucasians (p<0.001). Moreover, AA race was a predictor of American Joint Committee on Cancer stage greater than II, tumor diagnosed at autopsy, presence of ulceration, and distribution in the extremities. CONCLUSION: AA patients with melanoma are more likely to have worse tumor staging, treatment delay, treatment at an Integrated Cancer Program, and diagnosis at autopsy.

Can the Perceived Difficulty of a Task Enhance Trainee Performance?

BACKGROUND: Human understanding of how to efficiently train learners in procedural skills is imperfect. The concept of self-efficacy - confidence in one's ability to successfully complete a task - may be useful to learners. Theories of motivation and instructional design suggest there are specific targets for improving learner success. We aimed to study the effects of induced conceptions of ability on motor learning using both undergraduate and medical students. METHODS: Forty undergraduate and medical students underwent a 15-minute training session teaching the basics of colonoscopy on a low-cost, moderate fidelity colonoscopy simulation model. Students were then tasked to intubate the cecum of a similarly constructed colonoscopy model with a real colonoscope. Before each task, participants were given a note which either read "90% of your peers completed the task in less than 5 minutes" (positive [+] comparison group) or "10% of your peers completed the task in less than 5 minutes" (negative [-] comparison group). Immediately after receiving the note, participants were then asked to complete a self-efficacy questionnaire, ranking their confidence on a scale from 0 to 10 for successfully completing the task. A NASA TLX was collected to understand the students' mental effort with the task. Participants then underwent stratified randomization into 2 crossover groups (G1 = + note, then - note; G2 = - note, then + note) and again performed the colonoscopy task. Following the session completion, all students had received both notes and crossed over to complete both tasks. Time spent on both tasks and task completion (reaching the cecum) was the measured outcomes. RESULTS: Self-efficacy (confidence) levels were significantly higher in the positive note condition for both comparison groups in (p < 0.05). However, task completion rates were higher in the negative note group in Task 1 (p < 0.05) and the same in Task 2 (p = 0.6). Time spent by participants in each task was longer in the negative note groups in both tasks (p = 0.06 in Task 1; p = 0.07 in Task 2). No difference was found between both groups in the mental effort after each task (Table 1). CONCLUSIONS: This prospective, cross-over study suggests that performance expectancies can be influenced by preinduced conceptions. Performance was enhanced in Task 1 when participants were given a relatively "low success rate prediction." This may be due to an enhanced focus that led to increased performance-while participants who were given the prediction of a "higher success rate" were more confident but performed less well. The crossover groups for Task 2 performed in a similar manner despite different confidence levels. This study supports the idea that self-efficacy expectations are relevant for trainee education and performance.

Low-cost materials yield high resolution assessment of anatomic knowledge in surgical residents.

INTRODUCTION: Knowledge of anatomy is essential for surgeons. We sought to determine whether it is possible to effectively assess and differentiate the anatomic knowledge of general surgery residents, using pieces of fabric and yarn. METHODS: Postgraduate years 2, 3, and 4 general surgery residents were assessed during a simulation-based assessment known as the Surgical X-Games. Residents were allowed 3 minutes to assemble the anatomic structures of the right upper quadrant region and 2 minutes to create the right lower quadrant of the abdomen, using colored felt and yarn. One point (each) was given for naming and placing the structures in the correct position. A checklist was used to assess trainees with a maximum combined score of 150 points. RESULTS: A total of 34 residents (postgraduate year 2 = 16, postgraduate year 3 = 8, postgraduate year 4 = 10) participated in the 2017 fall Surgical X-Games and 31 residents (postgraduate year 2 = 13, postgraduate year 3 = 9, postgraduate year 4 = 9) participated in the spring Surgical X-Games. Total scores increased respective to the level of clinical training in both the fall Surgical X-Games (postgraduate year 2 = 77, postgraduate year 3 = 84, postgraduate year 4 = 93, P = .04) and the spring Surgical X-Games (postgraduate year 2 = 94, postgraduate year 3 = 101, postgraduate year 4 = 109). We observed significant improvement in the right upper quadrant, right lower quadrant, and total scores from the fall to the spring postgraduate year (P < .001). CONCLUSION: Surgical residents showed an increase in mean anatomical scores from postgraduate years 2 to postgraduate years 3 to postgraduate years 4, using low-fidelity models. This inexpensive, 5-minute test based on a simple checklist may offer surgical educators insight in to residents' anatomic knowledge and potential readiness for clinical rotations.

Surgical interns in 2018: Objective assessment suggests they are better but still lack critical knowledge and skill.

BACKGROUND: The transition from fourth-year medical student to surgical intern is difficult. A lack of repetitions, experience, and knowledge is problematic. We report our experience using simulation-based technical and nontechnical skills to assess the competency of surgical interns in July and January of their intern year. DESIGN: As part of a larger assessment effort, our general surgery interns (2010-2016) have been tested on performing an emergent cricothyrotomy, interpreting 2 arterial blood gases, and reading 3 chest x-rays in fewer than 7 minutes. We retrospectively analyzed general surgery interns' performance on these 3 tests (total score = 20). RESULTS: A total of 210 interns completed both July and January (identical) assessments. Overall mean scores improved from July (12.62 ± 3.44) to January (16.5 ± 2.46; P < .05). During the study period general surgery interns' mean baseline scores improved in both July (P < .05) and in January (P < .05). Although most individual general surgery interns did improve their total scores (92% improved, 3% same, 5% worse) between July and January (P < .05), in January 40% could not perform an emergent cricothyrotomy swiftly, and 6% missed a tension pneumothorax on chest x-ray. CONCLUSION: Our data suggest that surgical interns start residency training with low levels of skill and comprehension with emergent cricothyrotomy, arterial blood gas, and chest x-ray. They improve with 6 months of clinical and simulation training. Encouragingly, overall scores for both July and January assessments have improved during the study period. Given that some interns still struggle in January to perform these three tasks, we believe that 2018 interns are better, but still potentially lack critical knowledge and skill.

Outcomes of laparoscopic and open CAPD catheter placement: A single-center experience.

BACKGROUND: Continuous Ambulatory Peritoneal Dialysis (CAPD) catheter placement is typically a straightforward surgical procedure performed on chronically ill patients with end-stage renal disease (ESRD). Post-operative outcomes and reoperative rates vary greatly in the medical literature. We report our experience using both minimally invasive and open techniques in placing CAPD catheters and offer our surgical outcomes. METHODS: This study is an IRB-approved, retrospective review (2005-2018) of all patients undergoing CAPD catheter placement at Mayo Clinic-Rochester. Analysis focused on specific patient outcomes, including early (< 30 days) versus late (≥ 30 days) complication and reoperation rates. RESULTS: A total of 173 patients with ESRD (mean ASA score = 3.1) underwent laparoscopic (n = 22) and open (n = 151) CAPD catheter placement (mean follow-up = 309 days; range: 1-3497 days). The total index operation complication rate was 41%. The total index reoperation rate was 37% and was similar in open and laparoscopic approaches. CAPD catheters malfunctioned in 19 patients (11% of total) and each underwent reoperation. CAPD catheter infections occurred in 30 patients (17% of total), and 24 required reoperation; 6 patients were treated successfully with antibiotics. CAPD catheter migrations occurred in 21 patients (12% of total) and all underwent reoperation. CONCLUSION: Although CAPD catheter placements in patients with ESRD are technically easy to accomplish, the long term outcomes suggest as many as one in three patients will struggle with catheter function or infection. This study has led to changes in our technical CAPD catheter placement procedures, as well as the post-operative patient care algorithm.

Transversus abdominis plane blocks with liposomal bupivacaine after open major hepatectomy is associated with reduced early patient-reported pain scores and opioid administration.

BACKGROUND: Opioid overprescription can contribute to suboptimal patient outcomes. Surgeon-performed transversus abdominis plane blocks appear to be associated with pain reduction. We compared the analgesic efficacy of surgeon-performed transversus abdominis plane blocks for major hepatectomy with or without concurrent neuraxial analgesia. METHODS: We performed a single-institution review, assessing surgeon-performed transversus abdominis plane blocks for major hepatectomy during 2013-2016. The primary outcome was patient-reported pain (11-point numeric pain-rating scale) and the secondary outcome was opioid consumption. Independent factors predictive of pain control were identified using logistic regression and reported as odds ratios with 95% confidence intervals. RESULTS: A total of 232 patients with a mean (± SD) age of 56.5 (±13.9) years; 51.7% were female. Operative duration, incision type, and American Society of Anesthesiologists score were similar between groups. The 24-hour pain score was decreased substantially in patients who received a transversus abdominis plane block compared with those who did not (3 [2-4] versus 5 [4-6], P = .001) and this decrease in pain sscore persisted at 48 hours (2 [1-2] versus 4 [4-5], P = .001). In patients who received a transversus abdominis plane block, there were decreasess in consumption of oral morphine equivalents at 24 hours (322 [± 18] versus 183 [± 15], P = .0001) and 48 hours (100 [± 11] versus 33 [± 9.4], P = .03) compared with those without transversus abdominis plane block respectively. CONCLUSION: In patients receiving a transversus abdominis plane block, early patient opioid consumption was decreased and utilization was predictive for improved pain control. Routine transversus abdominis plane block administration should be considered during major hepatectomy as a step toward curbing systematic reliance on opioids for pain management. A prospective study on the utility of transversus abdominis plane block in hepatectomy is warranted.

The FES Test: Are We Ready?

PURPOSE: The FES hands-on skills test is administered using a $100,000 computer-based simulator. Few of our trainees have practiced on this device. Our aim was to evaluate our GS residents' baseline endoscopic skills and eventually develop a simulation-based endoscopy curriculum and clarify performance-based assessment criteria. METHODS: General surgery residents' colonoscopy skills were assessed using a computer-based endoscopy simulator (CBES) during their biannual simulation-based OSCE-type assessments. Trainees were asked to reach the ileum in <5 minutes with minimal patient pain and complications. Module 1 (easy) was assigned to PGY 1-4 residents and module 5 (hard) to both PGY 4s and 5s. The colonoscope insertion length, % time with no pain, % time in "red out", and complications were recorded. Performance grading criteria were driven by literature review and expert opinion. Residents were assessed in the fall 2017; they were then given scoring criteria, a step-by-step instruction manual, and a voluntary hands-on session with the CBES. Residents repeated the same assessment in the spring 2018. RESULTS: 30 PGY-1s, 12 PGY-2s, 8 PGY-3s, 9 PGY-4s and 7 PGY-5s GS residents participated in the fall colonoscopy assessment. In module 1, 66% of PGY-4s, 50% of PGY-3s, 8% of PGY-2s and 0% of the PGY-1s intubated the ileum (p<0.05). In module 5, 30% of PGY 5 and 22% of PGY 4 residents completed the task (p<0.05). 15 PGY-1s, 5 PGY-2s, 1 PGY-3, 2 PGY-4s, and 1 PGY-5 participated in the voluntary hands-on session. All residents completing the fall assessment undertook the same task in the spring. In module 1, 89% of PGY-4s, 100% of the PGY-3s, 75% of PGY-2s and 70% of the PGY-1s completed the task. In module 5, 30% of PGY 5 and 34 % of PGY 4 residents completed the task. Residents who participated in the voluntary hands-on session (n= 24, 96% task completion) outperformed residents (n= 42, 64% task completion) that did not participate (p<0.05). CONCLUSIONS: Most of our GS residents could not initially intubate the ileum using the CBES. Prior experience with the CBES was the only factor strongly correlated with successful task completion. A voluntary hands-on teaching session allowed 96% of participating trainees to subsequently achieve CBES task completion. Developing a formal simulation-based curriculum suggests we can better prepare surgical trainees for the FES exam.

Validation of the American Association for the Surgery of Trauma's emergency general surgery breast infection grading system.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed emergency general surgery (EGS) grading systems for multiple diseases to standardize classification of disease severity. The grading system for breast infections has not been validated. We aimed to validate the AAST breast infection grading system. METHODS: Multi-institutional retrospective review of all adult patients with a breast infection diagnosis at Mayo Clinic Rochester 1/2015-10/2015 and Pietermaritzburg South African Hospital 1/2010-4/2016 was performed. AAST EGS grades were assigned by two independent reviewers. Inter-rater reliability was measured using the agreement statistic (kappa). Final AAST grade was correlated with patient and treatment factors using Pearson's correlation coefficient. RESULTS: Two hundred twenty-five patients were identified: grade I (n = 152, 67.6%), II (n = 44, 19.6%), III (n = 25, 11.1%), IV (n = 0, 0.0%), and V (n = 4, 1.8%). At Mayo Clinic Rochester, AAST grades ranged from I-III. The kappa was 1.0, demonstrating 100% agreement between reviewers. Within the South African patients, grades included II, III, and V, with a kappa of 0.34, due to issues of the grading system application to this patient population. Treatment received correlated with AAST grade; less severe breast infections (grade I-II) received more oral antibiotics (correlation [-0.23, P = 0.0004]), however, higher AAST grades (III) received more intravenous antibiotics (correlation 0.29, P <0.0001). CONCLUSIONS: The AAST EGS breast infection grading system demonstrates reliability and ease for disease classification, and correlates with required treatment, in patients presenting with low-to-moderate severity infections at an academic medical center; however, it needs further refinement before being applicable to patients with more severe disease presenting for treatment in low-/middle-income countries.

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.

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.