Mortality in hypotensive combat casualties who require emergent laparotomy in the forward deployed environment.

INTRODUCTION: Mortality rates among hypotensive civilian patients requiring emergent laparotomy exceed 40%. Damage control (DCR) principles were incorporated into the military's Clinical Practice Guidelines (CPG) in 2008. We examined combat casualties requiring emergent laparotomy to characterize how mortality rates compare to hypotensive civilian trauma patients. METHODS: The DoD Trauma Registry (2004-2020) was queried for adults who underwent combat laparotomy. Patients who were hypotensive were compared to normotensive patients. Mortality was the outcome of interest. Mortality rates before (2004-2007) and after (2009-2020) DCR CPG implementation were analyzed. RESULTS: 1051 patients were studied. Overall mortality was 6.5% for normotensive casualties and 28.7% for hypotensive casualties. Mortality decreased in normotensive patients but remained unchanged in hypotensive patients following the implementation of the DCR CPG. CONCLUSION: Hypotensive combat casualties undergoing emergent laparotomy demonstrated a mortality rate of 29.5%. Despite many advances, mortality rates remain high in hypotensive patients requiring emergent laparotomy.

The use of mobile thermal imaging and machine learning technology for the detection of early surgical site infections.

BACKGROUND: Surgical Site Infections (SSI) yield subtle, early signs that are not readily identifiable. This study sought to develop a machine learning algorithm that could identify early SSIs based on thermal images. METHODS: Images were taken of surgical incisions on 193 patients who underwent a variety of surgical procedures. Two neural network models were generated to detect SSIs, one using RGB images, and one incorporating thermal images. Accuracy and Jaccard Index were the primary metrics by which models were evaluated. RESULTS: Only 5 patients in our cohort developed SSIs (2.8%). Models were instead generated to demarcate the wound site. The models had 89-92% accuracy in predicting pixel class. The Jaccard indices for the RGB and RGB â€‹+ â€‹Thermal models were 66% and 64%, respectively. CONCLUSIONS: Although the low infection rate precluded the ability of our models to identify surgical site infections, we were able to generate two models to successfully segment wounds. This proof-of-concept study demonstrates that computer vision has the potential to support future surgical applications.

Engineering Human Cells Expressing CRISPR/Cas9-Synergistic Activation Mediators for Recombinant Protein Production.

Recombinant engineering for protein production commonly employs plasmid-based gene templates for introduction and expression of genes in a candidate cell system in vitro. Challenges to this approach include identifying cell types that can facilitate proper post-translational modifications and difficulty expressing large multimeric proteins. We hypothesized that integration of the CRISPR/Cas9-synergistic activator mediator (SAM) system into the human genome would be a powerful tool capable of robust gene expression and protein production. SAMs are comprised of a "dead" Cas9 (dCas9) linked to transcriptional activators viral particle 64 (VP64), nuclear factor-kappa-B p65 subunit (p65), and heat shock factor 1 (HSF1) and are programmable to single or multiple gene targets. We integrated the components of the SAM system into human HEK293, HKB11, SK-HEP1, and HEP-g2 cells using coagulation factor X (FX) and fibrinogen (FBN) as proof of concept. We observed upregulation of mRNA in each cell type with concomitant protein expression. Our findings demonstrate the capability of human cells stably expressing SAM for user-defined singleplex and multiplex gene targeting and highlight their broad potential utility for recombinant engineering as well as transcriptional modulation across networks for basic, translational, and clinical modeling and applications.

Airborne! UAV delivery of blood products and medical logistics for combat zones.

BACKGROUND: Innovative solutions to resupply critical medical logistics and blood products may be required in future near-peer conflicts. Unmanned aerial vehicles (UAVs) are increasingly being used in austere environments and may be a viable platform for medical resupply and the transport of blood products. METHODS: A literature review on PubMed and Google Scholar up to March of 2022 yielded a total of 27 articles that were included in this narrative review. The objectives of this article are to discuss the current limitations of prehospital blood transfusion in military settings, discuss the current uses of UAVs for medical logistics, and highlight the ongoing research surrounding UAVs for blood product delivery. DISCUSSION: UAVs allow for the timely delivery of medical supplies in numerous settings and have been utilized for both military and civilian purposes. Investigations into the effects of aeromedical transportation on blood products have found minimal blood product degradation when appropriately thermoregulated and delivered in a manner that minimizes trauma. UAV delivery of blood products is now actively being explored by numerous entities around the globe. Current limitations surrounding the lack of high-quality safety data, engineering constraints over carrying capacity, storage capability, and distance traveled, as well as air space regulations persist. CONCLUSION: UAVs may offer a novel solution for the transport of medical supplies and blood products in a safe and timely manner for the forward-deployed setting. Further research on optimal UAV design, optimal delivery techniques, and blood product safety following transport should be explored prior to implementation.

Surgical Training for a Disaster: Preparation of Surgical Trainees for Victims of Conflict.

INTRODUCTION: With increasing global unrest and military physician shortages potentially leading to a surgeon draft, we sought to evaluate the readiness of graduating general surgery residents to care for casualties of war. MATERIALS AND METHODS: We evaluated the National Data Reports of Surgery Case Logs for general surgery residents from 2009 to 2018 to quantify experience with key procedures that provide critical skills required for wartime surgery. Reported cases from the Accreditation Council for Graduate Medical Education for graduating residents from civilian and military residency programs were analyzed for 28 individual procedures determined to be critical for the care of combat casualties. These included central and peripheral vascular procedures, as well as neck, thoracic, abdominal, and peripheral interventions. RESULTS: From 2009 to 2018, there has been a significant decrease in wartime-relevant cases by graduating residents. Notably, these include aorto-iliac/femoral bypasses (50% reduction; 7.1%/year; P < .001), femoral-popliteal bypasses (60% reduction; 6.9%/year; P < .001), femoral-femoral bypasses (30% reduction; 2.6%/year; P < .001), upper extremity amputations (50% reduction; 6.4%/year; P = .016), fasciotomies for trauma (50% reduction; 4.5%/year; P = .013), open repair of ruptured infrarenal aorto-iliac aneurysms (70% reduction; 5.8%/year; P < .001), repair of traumatic aorta or vena cava injuries (70% reduction; 7%/year; P = .007), carotid endarterectomies (40% reduction; 4%/year; P < .001), lung resections (40% reduction; 3.7%/year; P = .001), trauma splenectomies/splenorrhaphy (30% reduction; 2.9%/year; P < .001), and repair of traumatic liver lacerations (30% reduction; 2.5%/year; P = .036). CONCLUSIONS: Graduating general surgery residents has limited exposure to wartime critical skills due to a significant reduction in open vascular, head and neck, thoracic, and operative trauma cases. As the threat of global war persists and new graduates continue to deploy worldwide, residency training must be augmented to ensure adequate preparation in case a surgeon draft is required to fulfill demand for military surgeons.

Engineering CRISPR/Cas9 for Multiplexed Recombinant Coagulation Factor Production.

Current hemostatic agents are obtained from pooled plasma from multiple donors requiring costly pathogen screening and processing. Recombinant DNA-based production represents an engineering solution that could improve supply, uniformity, and safety. Current approaches are typically for single gene candidate peptides and often employ non-human cells. We devised an approach where multiple gene products could be produced from a single population of cells. We identified gene specific Synergistic Activation Mediators (SAM) from the CRISPR/Cas9 system for targeted overexpression of coagulation factors II, VII, IX, X, and fibrinogen. The components of the CRISPR-SAM system were expressed in Human Embryonic Kidney Cells (HEK293), and single (singleplex) or multi-gene (multiplex) upregulation was assessed by quantitative RT-PCR (qRT-PCR) and protein expression by ELISA analysis. Factor II, VII, IX, and X singleplex and multiplex activation resulted in 120-4700-fold and 60-680-fold increases in gene expression, respectively. Fibrinogen sub-unit gene activation resulted in a 1700-92,000-fold increases and 80-5500-fold increases in singleplex or multiplex approaches, respectively. ELISA analysis showed a concomitant upregulation of candidate gene products. Our findings demonstrate the capability of CRISPR/Cas9 SAMs for single or multi-agent production in human cells and represent an engineering advance that augments current recombinant peptide production techniques.

Adenosine, lidocaine, and magnesium for attenuating ischemia reperfusion injury from resuscitative endovascular balloon occlusion of the aorta in a porcine model.

BACKGROUND: Minimally invasive resuscitative endovascular balloon occlusion of the aorta (REBOA) following noncompressible hemorrhage results in significant ischemia reperfusion injury (IRI). Adverse outcomes from IRI include organ dysfunction and can result in profound hemodynamic and molecular compromise. We hypothesized that adenosine, lidocaine, and magnesium (ALM) attenuates organ injury and inflammation responses following REBOA IRI in a porcine model of hemorrhage. METHODS: Animals underwent a 20% controlled hemorrhage followed by 45 minutes of supraceliac balloon occlusion. They were randomized into two groups: control (n = 9) and ALM intervention (n = 9) to include a posthemorrhage, pre-REBOA bolus (200 mL of 3% NaCl ALM) followed by a continuous drip (2 mL/kg per hour of 0.9% NaCl ALM) during the 4-hour resuscitative period. Primary outcomes included hemodynamic parameters, gene expression of inflammatory signaling molecules, and plasma concentrations of select cytokines and chemokines. RESULTS: The ALM cohort demonstrated a significant reduction in cardiac output and cardiac index. Plasma concentrations of interleukin 2 and interleukin 10 were significantly lower 3 hours post-REBOA in animals treated with ALM versus vehicle. Interleukin 4 levels in plasma were also lower with ALM at 3 and 4 hours post-REBOA (p < 0.05). Liver expression of IL1RN, MTOR, and LAMP3 messenger RNA was significantly lower with ALM as compared with the vehicle. No significant difference in large bowel gene expression was observed between treatments. CONCLUSION: In a porcine model of hemorrhage, ALM treatment mitigated inflammatory responses early during post-REBOA resuscitation. Our findings suggest that ALM use with trauma may reduce inflammatory injury and improve outcomes related to REBOA utilization.

Addition of neurological status to pediatric adjusted shock index to predict early mortality in trauma: A pediatric Trauma Quality Improvement Program analysis.

INTRODUCTION: Pediatric adjusted shock index (SIPA) has demonstrated the ability to prospectively identify children at the highest risk for early mortality. The addition of neurological status to shock index has shown promise as a reliable triage tool in adult trauma populations. This study sought to assess the utility of combining SIPA with Glasgow Coma Scale (GCS) for predicting early trauma-related outcomes. METHODS: Retrospective review of the 2017 Trauma Quality Improvement Program Database was performed for all severely injured patients younger than 18 years old. Pediatric adjusted shock index and reverse SIPA × GCS (rSIG) were calculated. Age-specific cutoff values were derived for reverse shock index multiplied by GCS (rSIG) and compared with their SIPA counterparts for early mortality assessment using area under the receiver operating characteristic curve analyses. RESULTS: A total of 10,389 pediatric patients with an average age of 11.4 years, 67% male, average Injury Severity Score of 24.1, and 4% sustaining a major penetrating injury were included in the analysis. The overall mortality was 9.3%. Furthermore, 32.1% of patients displayed an elevated SIPA score, while only 27.5% displayed a positive rSIG. On area under the receiver operating characteristic curve analysis, rSIG was found to be superior to SIPA as a predictor for in hospital mortality with values of 0.854 versus 0.628, respectively. CONCLUSION: Reverse shock index multiplied by GCS more readily predicted in hospital mortality for pediatric trauma patients when compared with SIPA. These findings suggest that neurological status should be an important factor during initial patient assessment. Further study to assess the applicability of rSIG for expanded trauma-related outcomes in pediatric trauma is necessary. LEVEL OF EVIDENCE: Prognostic study, level IV.

A Surgeon's Guide to Machine Learning.

Machine learning (ML) represents a collection of advanced data modeling techniques beyond the traditional statistical models and tests with which most clinicians are familiar. While a subset of artificial intelligence, ML is far from the science fiction impression frequently associated with AI. At its most basic, ML is about pattern finding, sometimes with complex algorithms. The advanced mathematical modeling of ML is seeing expanding use throughout healthcare and increasingly in the day-to-day practice of surgeons. As with any new technique or technology, a basic understanding of principles, applications, and limitations are essential for appropriate implementation. This primer is intended to provide the surgical reader an accelerated introduction to applied ML and considerations in potential research applications or the review of publications, including ML techniques.

Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma.

INTRODUCTION: Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries. METHODS: Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality. RESULTS: A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality. CONCLUSION: Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population. LEVEL OF EVIDENCE: Prognostic study, level IV.

Safety code blue! Assessing the use of blue surgical sterilization wrap for homemade respirator masks during the COVID-19 crisis.

The use of surgical sterilization wrap for respirator masks during the COVID-19 crisis has become a popularized personal protective equipment alternative option due to claims supporting its ability to meet N95 standards. This study sought to assess these claims using standardized filter testing. The tested material failed to meet N95 standards and suggests its use may place medical personnel at increased risk of harm when managing COVID-19 patients.

Quality Assurance During a Global Pandemic: An Evaluation of Improvised Filter Materials for Healthcare Workers.

OBJECTIVE: The proliferation of improvised masks during the COVID-19 pandemic has raised questions regarding filter effectiveness and safety. We sought to compare the effectiveness of commonly used improvised filter materials against N95 industry standards. METHODS: Six different filter materials commonly used in the community were tested using both single- and multi-layer configurations with the TSI 8130 automated filter tester in accordance with National Institute for Occupational Safety and Health (NIOSH) standards for N95 respirators. RESULTS: Only three of the tested filter material configurations met N95 parameters with regard to filtration efficiency and pressure drop across the filter material-the: True-high-efficiency particulate air (HEPA) filter, four-layer MERV 13 and 14 HVAC filters. CONCLUSIONS: Many proposed filter materials for improvised masks do not meet current industry standards and may pose safety and efficacy concerns. Care should be taken when selecting materials for this critical respirator component, particularly for health care workers or others at high risk for pathogen exposure.

Shock Index as a Predictor of Massive Transfusion and Emergency Surgery on the Modern Battlefield.

BACKGROUND: Shock Index (SI) has been used to predict the need for massive transfusion (MT) and emergency surgical procedures (ESP) in civilian trauma. We hypothesize that SI can reliably identify combat trauma patients that will require MT and ESP when applied to the resource-constrained, combat environment. METHODS: A retrospective review was performed within the Department of Defense Trauma Registry (2008-2016). SI was calculated using heart rate and systolic blood pressure on arrival to the initial facility with surgical capabilities. A threshold value of 0.8 was used to stratify patients into two groups (Group I, SI < 0.8; and Group II, SI ≥ 0.8). The need for MT, ESP, and mortality was compared. Regression analyses were conducted to determine the independent association of SI with MT and ESP. RESULTS: A total of 4008 patients were included. The mean age of the patients was 25.5 y, and the majority were predominately male (98%). Mechanisms of injury were blunt and blast injury (62%), penetrating injury (36.7%), and burn injury (0.5%). Overall, 77% of patients (n = 3070) were stratified to Group I, and 23% of patients (n = 938) were stratified to Group II, by SI. Group II patients had a significantly greater need for MT (8.4% versus 0.4%) and ESP (30.7% versus 6.5%), both P < 0.001. Regression analysis controlling for age, gender, Injury Severity Score, and Glasgow Coma Score confirmed that SI ≥ 0.8 was an independent risk factor for both MT and need for ESPs (P < 0.001). CONCLUSIONS: SI is a significant predictor of the need for MT and ESPs in the military trauma population, representing a simple and potentially potent tool for triage and prediction of resource consumption in the resource-limited, austere setting.

All trauma is not created equal: Redefining severe trauma for combat injuries.

Injury severity scores (ISS) and shock index (SI) are popular trauma scoring systems. We assessed ISS and SI in combat trauma to determine the optimal cut-off values for mortality and trauma outcomes. Retrospective analysis of the Department of Defense Trauma Registry, 2008-2016, was performed. Areas under receiver operating characteristic curves (AUROCs) were calculated for ISS and SI on mortality, massive volume transfusion (MVT), and emergent surgical procedure (ESP). Optimal cut-off values were defined using the Youden index (YI). 22,218 patients (97.1% male), median ages 25-29 years, ISS 9.4 ± 0.07, with 58.1% penetrating injury were studied. Overall mortality was 3.4%. AUROCs for ISS on mortality, MVT, and ESP were 0.882, 0.898, and 0.846, while AUROCs for SI were 0.727, 0.864, and 0.711 respectively. The optimal cut-off values for ISS on mortality, MVT, and ESP were 12.5 (YI = 0.634), 12.5 (YI = 0.666), and 12.5 (YI = 0.819), with optimal values for SI being 0.94 (YI = 0.402), 0.88 (YI = 0.608), and 0.81 (YI = 0.345) respectively. Classic values for severe ISS underrepresent combat injury while the SI values defined in this study are consistent with civilian data.

Influence of preoperative psychotropic medications on opioid requirements and outcomes following bariatric surgery.

INTRODUCTION: Opioid use continues to impose a substantial burden on the healthcare system. Multiple studies suggest that depression and psychosis increase the risk of chronic opioid use. We hypothesized that patients' pharmacologic profiles would affect postoperative opioid requirements following bariatric surgery. MATERIALS AND METHODS: Retrospective analysis identified patients who underwent laparoscopic bariatric surgery at a high-volume center from 2014 to 2016. Prescriptions from one year prior through 3 months after surgery were collected. Patients with complicated operative courses were excluded. RESULTS: A total of 201 patients met inclusion criteria. Forty-six patients(23%) required an opioid refill within 3 months of surgery. Opioid exposure was strongly associated with need for repeat opioid prescription(OR 3.1, p = 0.001). When controlled for preoperative opioid exposure, antidepressant and antipsychotic use showed no such association. Patients using antipsychotics were significantly more likely to have complicated postoperative courses(OR 2.25, p = 0.043). CONCLUSIONS: Opioid exposure increased the risk of chronic opioid requirements after surgery, but other psychotropic medications showed no such effect. Patients using anti-psychotics may be prone to surgical complications making them vulnerable to chronic opioid use.

Viscoelastic testing in combat resuscitation: Is it time for a new standard?

BACKGROUND: Traumatic hemorrhage and coagulopathy represent major sources of morbidity and mortality on the modern battlefield. Viscoelastic testing (VET) offers a potentially more personalized approach to resuscitation. We sought to evaluate outcomes of combat trauma patients who received VET-guided resuscitation compared with standard balanced blood product resuscitation. METHODS: Retrospective analysis of the Department of Defense Trauma Registry, 2008 to 2016 was performed. Multivariate logistic regression analyses of all adult patients initially presenting to NATO Role III facilities who required blood products were performed to identify factors associated with VET-guided resuscitation and mortality. A propensity score matched comparison of outcomes in patient cohorts treated at VET versus non-VET Role III facilities was performed. RESULTS: There are 3,320 patients, predominately male (98%), median age ranges from 25 years to 29 years, Injury Severity Score of 18.8, with a penetrating injury (84%) were studied. Overall mortality was 9.7%. Five hundred ninety-four patients had VET during their initial resuscitation. After adjusting for confounders, VET during initial resuscitation was independently associated with decreased mortality (odds ratio, 0.63; p = 0.04). Propensity analysis confirmed this survival advantage with a 57% reduction in overall mortality (7.3% vs. 13.1%; p = 0.001) for all patients requiring blood products. CONCLUSION: Viscoelastic testing offers the possibility of a product-specific resuscitation for critically injured patients requiring transfusion in combat settings. Routine VET may be superior to non-VET-guided resuscitation for combat trauma victims. LEVEL OF EVIDENCE: Therapeutic study, level IV.

"Stem cell therapy to promote limb function recovery in peripheral nerve damage in a rat model" - Experimental research.

BACKGROUND: Optimizing nerve regeneration and mitigating muscle atrophy are the keys to successful outcomes in peripheral nerve damage. We investigated whether mesenchymal stem cell (MSC) therapy can improve limb function recovery in peripheral nerve damage. MATERIALS AND METHODS: We used sciatic nerve transection/repair (SNR) and individual nerve transection/repair (INR; branches of sciatic nerve - tibial, peroneal, sural) models to study the effect of MSCs on proximal and distal peripheral nerve damages, respectively, in male Lewis rats. Syngeneic MSCs (5 × 106; passage≤6) or saline were administered locally and intravenously. Sensory/motor functions (SF/MF) of the limb were assessed. RESULTS: Rat MSCs (>90%) were CD29+, CD90+, CD34-, CD31- and multipotent. Total SF at two weeks post-SNR & INR with or without MSC therapy was ∼1.2 on a 0-3 grading scale (0 = No function; 3 = Normal); by 12 weeks it was 2.6-2.8 in all groups (n ≥ 9/group). MSCs accelerated SF onset. At eight weeks post-INR, sciatic function index (SFI), a measure of MF (0 = Normal; -100 = Nonfunctional) was -34 and -77 in MSC and vehicle groups, respectively (n ≥ 9); post-SNR it was -72 and -92 in MSC and vehicle groups, respectively. Long-term MF (24 weeks) was apparent in MSC treated INR (SFI -63) but not in SNR (SFI -100). Gastrocnemius muscle atrophy was significantly reduced (P < 0.05) in INR. Nerve histomorphometry revealed reduced axonal area (P < 0.01) but no difference in myelination (P > 0.05) in MSC treated INR compared to the naive contralateral nerve. CONCLUSION: MSC therapy in peripheral nerve damage appears to improve nerve regeneration, mitigate flexion-contractures, and promote limb functional recovery.

Microdermal Implants Show No Effect on Surrounding Tissue During Surgery With Electrocautery.

BACKGROUND: Microdermal implants are an increasingly popular form of body jewelry. The potential for electrical conduction burn at the site of metal jewelry left in situ during electrosurgery has prompted surgical societies to recommend routine removal before surgery. To date, however, there is a lack of evidence to support this practice. We assessed in vivo thermal effect and tissue damage around implants during and after electrocautery. MATERIALS AND METHODS: Stainless steel microdermal anchors were surgically implanted into four swine. After allowing for initial healing, negative controls were excised and evaluated. An electrocautery grounding pad was placed 2 cm caudal to the implant. Continuous electrocautery (coagulation/30 W) for 30 s was applied to the skin 2 cm cranial to the implant. Surface skin temperature was recorded during electrocautery using thermal imaging. Tissue damage was assessed by gross examination and histologic evaluation. The same procedure was then performed to the contralateral nonimplanted side as a sham control. RESULTS: Electrocoagulation raised skin temperature around the electrocautery tip 27.7°C (Tmax 64.8°C). Skin temperature around the dermal implant rose 1.58°C (Tmax 38.6°C) compared with 2.03°C (Tmax 39.2°C) in the nonimplanted control skin (P = 0.627). Skin temperatures at implanted and control sites showed no statistical difference at any recorded time interval. Histologic review of excised tissue samples showed no evidence of thermal injury. CONCLUSIONS: Metallic implants appear to have no effect on skin temperature during the use of electrocautery even when in close proximity to both the electrocautery pen and return pad. Aggressive steps to remove microdermal implants before surgery may be unnecessary.

Colonoscopy after Hinchey I and II left-sided diverticulitis: utility or futility?

BACKGROUND: Modern 64- to 128-slice computed tomography (CT) scanners have questioned the need for routine colonoscopy after hospital admission for presumed uncomplicated diverticulitis. METHODS: This is a retrospective review of all patients (>18 years) who underwent planned colonoscopy after admission for Hinchey I or II acute diverticulitis (January 2009 to January 2014). The findings on the final radiologist report were then correlated with the colonoscopy results. RESULTS: In total, 110 patients (mean age, 55.2 ± 16; 46.4% female) underwent a subsequent colonoscopy (median, 60 days) after admission for diverticulitis. Overall, 102 patients (92.7%) had CT findings consistent with definitive diverticulitis, 6 patients had a diagnosis suggestive of diverticulitis on CT scan, and 2 patients had masses on their admission CT scans. Within the group with definitive diverticulitis, follow-up colonoscopy identified diverticulosis in 99 (97.0%), whereas the other 3 had normal findings. Of the patients with CT scans suggestive of diverticulitis, follow-up colonoscopy showed 3 with diverticulosis, 2 with malignancies, and 1 with nonspecific inflammation. The reliability of CT scans for diverticulitis compared with colonoscopy was found to have a kappa = .829 (P < .001; 95% confidence interval, .629, 1.21). CONCLUSIONS: Follow-up colonoscopy should be performed when a CT scan suggests malignancy, nonspecific inflammatory findings, or the patient is otherwise due for routine screening or surveillance. In this study, there was no benefit of follow-up colonoscopy in patients with CT-confirmed diverticulitis in the absence of other concerning or indeterminate findings.

Biliary leak rates after cholecystectomy and intraoperative cholangiogram in surgical residency.

Postoperative bile leak (BL) after cholecystectomy is a rare but dreaded complication, and is felt to be increased during surgical training. We sought to determine the incidence of BL after selective intraoperative cholangiogram (IOC) at a teaching hospital and identify risk factors for predicting BLs. A retrospective review was performed analyzing all cholecystectomy with IOCs between September 2004 and September 2011. Residents performed under staff supervision. Of 1,799 cholecystectomies performed during the study period, only 96 (5.3%) were with IOCs (mean age 43, 65% female) and 4 BLs occurred (4.2%, 1 major duct injury, 3 cystic duct stump leaks). Univariate analysis demonstrated that male gender, significant medical comorbidities, case duration, preoperative endoscopic retrograde cholangiopancreatography, and surgery type (laparoscopic versus open) increased the patient's risk of BL; however, age, performance of secondary procedures, common bile duct exploration, resident level (PGY), and diagnosis did not increase BL risk. Multivariate regression revealed that only surgery type lead to an increased risk of BL (p = 0.001) (OR 31.61, 95% CI 3.96-252.18). Patient factors and PGY level did not significantly affect BL rates, although open and converted procedures were associated with higher rates, suggesting an increased risk of a BL with more complex cases.