Malrotation: Management of Disorders of Gut Rotation for the General Surgeon.

In this article, we aim to provide the general surgeon with a clinical blueprint to navigate disorders of gut rotation. We emphasize that bilious emesis in a newborn is malrotation with volvulus until proven otherwise. Although an upper GI series can establish the diagnosis, surgical intervention should not be delayed until the child is ill-appearing. Following detorsion, the key steps are to broaden the mesentery, fully Kocherize the duodenum, and mobilize the cecum. If nonviable bowel is encountered, the principles of damage control can be applied to children. Every effort should be made to preserve bowel length.

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.

Dynamic trend or static variable: Shock Index Pediatric-Adjusted (SIPA) in warzone trauma.

BACKGROUND: Civilian studies suggest that trending Shock-Index Pediatric Adjusted(SIPA) values can prove useful in the prediction of trauma outcomes. The purpose of this study was to evaluate the relationship between trends in SIPA and outcomes in pediatric warzone trauma. METHODS: Retrospective review of the Department of Defense Trauma Registry from 2008 to 2015, including all patients age ≤17years. SIPA was calculated both pre-hospital and upon arrival, then classified as "normal" or "abnormal" based upon previously validated thresholds. Patients were stratified into groups based on the trend of their SIPA (1-normal to normal, 2-normal to abnormal, 3-abnormal to normal, 4-abnormal to abnormal). Key outcomes including ICU admission, severe injury, mechanical ventilation, and mortality were then compared between groups. RESULTS: 669 patients were included, mean ISS 12 ± 10. The most common mechanism of injury was blast (46.5%). Overall, 43% were stratified into Group 1, 13.9% into Group 2, 14.8% into Group 3, and 28.0% into Group 4. Those patients with a persistently abnormal SIPA (Group 4) had significantly increased incidence of severe injury, ICU admission, need for mechanical ventilation, and mortality. CONCLUSION: Trends in SIPA may be used to predict trauma outcomes for children injured in warzones, with persistently abnormal values associated with worse outcomes overall.

Focused Changes in Opioid Prescribing Yield Far-reaching Benefits Through Culture Change and Attention to Opioid Minimization.

OBJECTIVE: Standardization of prescriptions after specific procedures (laparoscopic appendectomy, cholecystectomy, inguinal/umbilical hernia repair) significantly reduces opioid prescriptions for these targeted procedures. We sought to determine the impact of increased attention to responsible opioid prescribing in the absence of protocolization. DESIGN: Prescription practices of Laparoscopic Sleeve Gastrectomies and Roux-en-y Gastric Bypasses at a tertiary medical center (October 1, 2016-September 30, 2018) were retrospectively reviewed. Patients were grouped into whether surgical intervention took place before or after institution of an unrelated opioid protocol in November 2017. Patients with chronic opioid use or extended hospital stay (>4 days) were excluded. Discharge prescriptions, oral morphine equivalents (OME), and need for repeat prescriptions were compared. SETTING: This study was set at Madigan Army Medical Center in Tacoma, Washington. PARTICIPANTS: All general surgery residents engaged in clinical duties at our institution during the dates of the study were included. RESULTS: Study population included 187 patients, with 91 patients undergoing surgery prior to the protocol and 88 post-protocol. Preprotocol patients were provided an average of 413 OME (SD 103) and 5.5% required repeat opioid prescriptions within 3 months of surgery. The most common opioid prescription was 300 mL of oxycodone elixir (450 OME, 88%). Postprotocol, opioid prescriptions fell 61% to an average of 161 OME (SD 71, p < 0.001). Repeat opioid requirements remained statistically unchanged (8.0%, p = 0.562). The most common opioid prescription postprotocol included 20 oxycodone tablets (150 OME, 76%). CONCLUSIONS: Opioid reduction efforts reap benefits beyond those procedures specifically targeted. Focus on responsible opioid prescribing through standardization, even when limited to certain procedures, may result in a hospital culture change with global opioid prescription reduction.

Validation of a novel partial resuscitative endovascular balloon occlusion of the aorta device in a swine hemorrhagic shock model: Fine tuning flow to optimize bleeding control and reperfusion injury.

OBJECTIVES: Partial restoration of aortic flow during resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated by some to mitigate distal ischemia. Our laboratory has validated the mechanics and optimal partial REBOA (pREBOA) flow rates using a prototype device. We hypothesize that pREBOA will increase survival when compared with full REBOA (fREBOA) in prolonged nonoperative management of hemorrhagic shock. METHODS: Twenty swine underwent placement of aortic flow probes, zone 1 REBOA placement, and 20% blood volume hemorrhage. They were randomized to either solid organ or abdominal vascular injury. The pREBOA arm (10 swine) underwent full inflation for 10 minutes and then deflation to a flow rate of 0.5 L/min for 2 hours. The fREBOA arm (10 swine) underwent full inflation for 60 minutes, followed by deflation/resuscitation. The primary outcome is survival, and secondary outcomes are serologic/pathologic signs of ischemia-reperfusion injury and quantity of hemorrhage. RESULTS: Two of 10 swine survived in the fREBOA group (2/5 solid organ injury; 0/5 abdominal vascular injury), whereas 7 of 10 swine survived in the pREBOA group (3/5 solid organ injury, 4/5 abdominal vascular injury). Survival was increased (p = 0.03) and hemorrhage was higher in the pREBOA group (solid organ injury, 1.36 ± 0.25 kg vs. 0.70 ± 0.33 kg, p = 0.007; 0.86 ± 0.22 kg vs. 0.71 ± 0.28 kg, not significant). Serum evidence of ischemia was greater with fREBOA, but this was not significant (e.g., lactate, 16.91 ± 3.87 mg/dL vs. 12.96 ± 2.48 mg/dL at 120 minutes, not significant). Swine treated with pREBOA that survived demonstrated trends toward lower alanine aminotransferase, lower potassium, and higher calcium. The potassium was significantly lower in survivors at 60 minutes and 90 minutes time points (5.97 ± 0.60 vs. 7.53 ± 0.90, p = 0.011; 6.67 ± 0.66 vs. 8.15 ± 0.78, p = 0.029). Calcium was significantly higher at 30 minutes, 60 minutes, and 90 minutes (8.56 ± 0.66 vs. 7.50 ± 0.40, p = 0.034; 8.63 ± 0.62 vs. 7.15 ± 0.49, p = 0.019; 8.96 ± 0.64 vs. 7.00, p = 0.028). CONCLUSION: Prolonged pREBOA at a moderate distal flow rate provided adequate hemorrhage control, improved survival, and had evidence of decreased ischemic injury versus fREBOA. Prophylactic aggressive calcium supplementation may have utility before and during the reperfusion phase.

Validation of Shock Index Pediatric-Adjusted for children injured in warzones.

BACKGROUND: Shock Index Pediatric-Adjusted (SIPA) has been used to predict injury severity and outcomes after civilian pediatric trauma. We hypothesize that SIPA can predict the need for blood transfusion and emergent surgery among pediatric patients injured in warzones, where resources are limited and accurate triage is essential. METHODS: Retrospective review of the DoD Trauma Registry for all patients 17 years or younger, from 2008 to 2015. Shock Index Pediatric-Adjusted was determined using vital signs recorded upon arrival to the initial level of care. Patients were classified into two groups (normal vs. elevated SIPA) using age-specific threshold values. The need for blood product transfusion (BPT) within 24 hours and emergent surgical procedures (ESP) was compared between groups. Intensive care unit admission, injury severity, and mortality were also compared. Regression analysis was performed to evaluate the relationship between SIPA and primary outcomes. RESULTS: There were 2,121 patients included with a mean Injury Severity Score of 12 ± 10. The mechanism of injury was penetrating (63%), blunt (25%), and burns (12%). Patients with an elevated SIPA (43%) had a significantly greater need for BPT (49.2% vs. 25.0%) and ESP (22.9% vs. 16.0%), as well as mortality (10.3% vs. 4.8%) and intensive care unit admission (49.9% vs. 36.1%), all p less than 0.001. Regression analysis confirmed an elevated SIPA as independently associated with both BPT (odds ratio, 2.36; 95% confidence interval, 1.19-2.94; p < 0.001) and ESP (odds ratio, 1.29; 95% confidence interval, 1.01-1.64; p = 0.044). CONCLUSION: This is the first study of SIPA in pediatric warzone trauma. Elevated SIPA is associated with significantly increased need for BPT and emergent surgery and may therefore serve as a valuable tool for planning and triage in austere settings. LEVEL OF EVIDENCE: Prognostic/epidemiological, Level III.

Senior surgical resident autonomy and teaching assistant cases: A prospective observational study.

INTRODUCTION: Teaching assistant (TA) cases allow senior residents (SR) to gain autonomy. We compared the safety profiles of TA cases performed under direct vs. indirect staff supervision. METHODS: Prospective observational study of operative cases where a SR served as the TA between 7/2014-6/2017 (n = 161). Patient/operative characteristics, 30-day outcomes, and SR survey data were compared by level of supervision. RESULTS: Case mix included 68 laparoscopic appendectomies (42%), 49 laparoscopic cholecystectomies (30%), 10 I&Ds (6%), 10 umbilical hernia repairs (6%), 4 port placements (3%), and 11 others. Indirectly supervised cases were shorter (61 vs. 76 min, p < 0.01), with less blood loss (11 vs. 24 ml, p < 0.05), and lower conversion rates (0% vs. 5.7%, p < 0.05). Perceived difficulty was high in 20% of cases with indirect vs. 49% with direct supervision (p < 0.01). Mean SR comfort was high (4.4 vs. 4.6 out of 5) regardless of level of staff supervision. 30-day complications did not differ for indirect vs. direct supervision (all p = NS). DISCUSSION: Carefully selected TA cases offer SRs opportunities to practice autonomy without sacrificing operative time or patient safety.

An Evaluation of a Novel Medical Device Versus Standard Interventions in the Treatment of Tension Pneumothorax in a Swine Model (Sus scrofa).

INTRODUCTION: Tension pneumothorax is a common cause of preventable death in trauma. Needle decompression is the traditional first-line intervention but has high failure rates. We sought to evaluate the effectiveness and expedience of needle thoracostomy, surgical tube thoracostomy, and Reactor™ thoracostomy - a novel spring-loaded trocar insertion device. MATERIALS AND METHODS: Yorkshire swine underwent controlled thoracic insufflation to create tension pneumothorax physiology for device comparison. Additional experiments were performed by increasing insufflation pressures to achieve pulseless electrical activity. Intervention was randomized to needle thoracostomy (14 gauge), tube thoracostomy (32Fr), or Reactor™ thoracostomy (36Fr). Air leak was simulated throughout intervention with 40-80 mL/kg/min insufflation. Intrathoracic pressure monitoring and hemodynamic parameters were obtained at 1 and 5 minutes. RESULTS: Tension physiology and tension-induced pulseless electrical activity were created in all iterations. Needle thoracostomy (n = 28) was faster at 7.04 ± 3.04 seconds than both Reactor thoracostomy (n = 32), 11.63 ± 5.30 (p < 0.05) and tube thoracostomy (n = 32), 27.06 ± 10.73 (p < 0.01); however, Reactor™ thoracostomy was faster than tube thoracostomy (p < 0.001). Physiological decompression was achieved in all patients treated with Reactor™ and tube thoracostomy, but only 14% of needle thoracostomy. Cardiac recovery to complete physiologic baseline occurred in only 21% (6/28) of those treated with needle thoracostomy whereas Reactor™ or tube thoracostomy demonstrated 88% (28/32) and 94% (30/32) response rates. When combined, needle thoracostomy successfully treated tension pneumothorax in only 4% (1/28) of subjects as compared to 88% (28/32) with Reactor™ thoracostomy and 94% (30/32) with tube thoracostomy (p < 0.01). CONCLUSIONS: Needle thoracostomy provides a rapid intervention for tension pneumothorax, but is associated with unacceptably high failure rates. Reactor™ thoracostomy was effective, expedient, and may provide a useful and technically simpler first-line treatment for tension pneumothorax or tension-induced pulseless electrical activity.

A simple technique for neoumbilical reconstruction for congenital hernia associated proboscis deformity.

INTRODUCTION: Umbilical reconstruction in pediatric patients who have developed a large proboscoid redundancy can be challenging after standard umbilical repair. We present a simple and unique surgical technique that results in a cosmetically appealing reconstruction. OPERATIVE TECHNIQUE: The operation is initiated with circumferential redundant skin excision and isolation of the hernia sac. Primary fascial repair is performed. Reconstruction utilizes the cut dermal/epidermal edge by approximating it to the exposed fascia just below the skin edge outside of the fascial repair in a purse string fashion for the creation of a neoumbilicus. CONCLUSION: This simple technique is unique from any currently published methods and results in a cosmetically pleasing reconstruction without evidence of any incision. LEVEL OF EVIDENCE: Level V: Expert Opinion.

Stemming the Tide of Opioid Addiction-Dramatic Reductions in Postoperative Opioid Requirements Through Preoperative Education and a Standardized Analgesic Regimen.

INTRODUCTION: Surgery is a known gateway to opioid use that may result in long-term morbidity. Given the paucity of evidence regarding the appropriate amount of postoperative opioid analgesia and variable prescribing education, we investigated prescribing habits before and after institution of a multimodal postoperative pain management protocol. MATERIALS AND METHODS: Laparoscopic appendectomies, laparoscopic cholecystectomies, inguinal hernia repairs, and umbilical hernia repairs performed at a tertiary military medical center from 01 October 2016 until 30 September 2017 were examined. Prescriptions provided at discharge, oral morphine equivalents (OME), repeat prescriptions, and demographic data were obtained. A pain management regimen emphasizing nonopioid analgesics was then formulated and implemented with patient education about expected postoperative outcomes. After implementation, procedures performed from 01 November 2017 until 28 February 2018 were then examined and analyzed. Additionally, a patient satisfaction survey was provided focusing on efficacy of postoperative pain control. RESULTS: Preprotocol, 559 patients met inclusion criteria. About 97.5% were provided an opioid prescription, but prescriptions varied widely (256 OME, standard deviation [SD] 109). Acetaminophen was prescribed often (89.5%), but nonsteroidal anti-inflammatory drug (NSAID) prescriptions were rare (14.7%). About 6.1% of patients required repeat opioid prescriptions. After implementation, 181 patients met inclusion criteria. Initial opioid prescriptions decreased 69.8% (77 OME, SD 35; P < 0.001), while repeat opioid prescriptions remained statistically unchanged (2.79%; P = 0.122). Acetaminophen prescribing rose to 96.7% (P = 0.002), and NSAID utilization increased to 71.0% (P < 0.001). Postoperative survey data were obtained in 75 patients (41.9%). About 68% stated that they did not use all of the opioids prescribed and 81% endorsed excellent or good pain control throughout their postoperative course. CONCLUSIONS: Appropriate preoperative counseling and utilization of nonopioid analgesics can dramatically reduce opioid use while maintaining high patient satisfaction. Patient-reported data suggest that even greater reductions may be possible.

Big problems in little patients: Nationwide blunt cerebrovascular injury outcomes in the pediatric population.

BACKGROUND: Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating. The epidemiology, outcomes, and screening criteria are well described in adults, but data in pediatric patients are extremely limited. The purpose of this study was to characterize pediatric BCVI in a large nationwide sample. We hypothesized that outcomes of BCVI in the pediatric blunt trauma population will vary by age. METHODS: We conducted a retrospective cohort study of the Kids' Inpatient Database for pediatric BCVI from 2000 to 2012. Epidemiology, associated injuries, outcomes (including stroke and mortality), and the utility of standard screening criteria were analyzed. RESULTS: There were 1,182 cases of BCVI identified, yielding an incidence of 0.21%. Patients were predominately male (69%; mean age, 15 ± 5 years). Injuries were 59% carotid, 13% vertebral, and 28% unspecified, with 15% having bilateral or multivessel BCVI. Although younger patients (<11 years) had significantly lower ISS and decreased severe associated injuries (all p < 0.01), they had a similar mortality rate (10%) versus the older cohort. Additionally, the stroke rate was significantly higher among the younger patients versus their older peers (29% mortality for <11 years vs. 15% for ≥11 years, p < 0.01). Only four of seven commonly utilized risk factors were associated with BCVI overall, but none were significantly associated with BCVI in younger children (<11 years). CONCLUSION: This represents the first nationwide assessment of BCVI in the pediatric population. Pediatric BCVI carry considerable mortality and stroke risk. Despite being less severely injured, younger children (<11 years) had similar a mortality rate and a significantly higher stroke rate compared with older pediatric patients. Furthermore, commonly utilized adult screening criteria had limited utility in the younger cohorts. These findings suggest pediatric BCVI may require screening and treatment protocols that are significantly different than currently utilized adult-based programs. LEVEL OF EVIDENCE: Prognostic/Epidemiological Study, level III.

Preperitoneal balloon tamponade and resuscitative endovascular balloon occlusion of the aorta: Alternatives to open packing for pelvic fracture-associated hemorrhage.

BACKGROUND: The objective of this study was to compare the efficacy of preperitoneal balloon tamponade (PPB), resuscitative endovascular balloon occlusion of the orta (REBOA), and open preperitoneal packing (OP) in a realistic animal model of pelvic fracture-associated hemorrhage. METHODS: Thirty-nine swine underwent creation of open-book pelvic fracture and iliac vascular injury. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), zone 1 REBOA (n = 7), and zone 3 REBOA (n = 6) at a mean arterial pressure less than 40 mm Hg from uncontrolled hemorrhage. Primary outcome was survival at 1 hour. Secondary outcomes included survival in the immediate 10 m following intervention reversal, peak preperitoneal pressure (PP), blood loss, bleed rate, and peak lactate. RESULTS: Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p = NS). The injury was uniformly lethal without intervention, with survival time (mean) of 5 m, peak PP of 14 mm Hg, blood loss of 960 g, bleed rate of 450 g/m, and peak lactate of 2.6 mmol/L. Survival time (m) was extended to 44 with OP, 60 with PPB, and 60 with REBOA (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, 10 with zone 1 REBOA, and 6 with zone 3 REBOA (p < 0.05). Blood loss (g) was 850 with OP, 930 with PPB, 610 with zone 1 REBOA, and 370 with zone 3 REBOA (p < 0.01). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, 13.4 with zone 1 REBOA, and 5.3 with zone 3 REBOA (p < 0.01). Only 33% of zone 1 REBOA animals survived the initial 10 m after balloon deflation, compared to 60% for OP, 67% for PPB, and 100% for zone 3 REBOA (p < 0.01). CONCLUSION: Preperitoneal balloon tamponade and zone 3 REBOA are effective alternatives to OP in this animal model of lethal pelvic fracture-associated hemorrhage. Zone 1 REBOA extends survival time but with high mortality upon reversal.

Predictors of Bowel Resection During Nonelective Ladd Procedure for Pediatric Malrotation.

BACKGROUND: The objective of this study was to identify risk factors for bowel resection in a modern cohort of patients undergoing nonelective Ladd procedures. MATERIALS AND METHODS: Retrospective descriptive analysis of patients with Ladd procedure (CPT 44055) in the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012-2015). Exclusion criteria were elective case, duodenal atresia, or other known congenital anomaly (except cardiac, structural central nervous system, or airway anomaly) and open wounds from prior surgery or drains. Independent variables included all preoperative variables within NSQIP-P. The primary outcome variable was bowel resection as a concurrent procedure. Multivariate analysis was performed by incorporating all independent variables into a stepwise forward logistic regression model to identify independent risk factors for bowel resection. RESULTS: Of 267,289 patients in NSQIP-P, 1284 had a Ladd procedure. Of these, 292 were performed urgently or emergently in children with no known atresias, congenital anomalies, or open wounds. Twenty-nine (10%) had a bowel resection. On univariate analysis, bowel resection rates did not differ by age, weight, prematurity, ventilator dependence, asthma, chronic lung disease, tracheostomy, esophageal or gastrointestinal disease, hepatobiliary or pancreatic disease, cerebral palsy, central nervous system abnormality, neuromuscular disorder, intraventricular hemorrhage, steroid use, hematologic disorder, malignancy, sepsis, inotropic support, or CPR (P = nonsignificant). Higher rates of bowel resection were observed in patients with cardiac risk factors, white blood count (WBC) >15K, oxygen support, nutritional support, and developmental delay (P < 0.05). Only cardiac risk factors and WBC >15K were significant on multivariate analysis. CONCLUSIONS: Bowel resections (10% in this cohort of nonelective Ladd procedures) were independently associated with cardiac risk factors and WBC >15K. LEVEL OF EVIDENCE: III.

Titrate to equilibrate and not exsanguinate! Characterization and validation of a novel partial resuscitative endovascular balloon occlusion of the aorta catheter in normal and hemorrhagic shock conditions.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a significant advancement in the control of noncompressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. METHODS: Twenty-five swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1 (N = 5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N = 10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and rebleeding from injuries. Experiment 3 (N = 10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2 hours followed by complete deflation for 30 minutes. RESULTS: Balloon volume at minimum flow (mean, 0.09 L/min) was 3.5 mL to 6.0 mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. Partial REBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45 L/min to 0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3 L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3, respectively. There was a trend toward hyperkalemia and hypocalcemia in nonsurvivors. CONCLUSION: The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5 L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest.

Sage wisdom or anecdotal dictum? Equivalent opioid use after open, laparoscopic, and robotic inguinal hernia repair.

BACKGROUND: Purported benefits of minimally-invasive inguinal hernia repair techniques include less postoperative pain, but objective data is lacking. We analyzed prescribing habits and opiate requirements to provide an objective comparison. METHODOLOGY: Inguinal hernia repairs performed on patients aged 18-65 from October 2016 through February 2018 were examined. Patients with prior opiate use or complicated operative courses were excluded. Discharge prescriptions, morphine milligram equivalents(MME), and additional prescriptions within three months were evaluated. RESULTS: 173 patients met criteria including 90 open(OMR), 34 laparoscopic(TEP), and 49 robotic(RTAPP) repairs. There was no difference in age or gender. There was no difference in average opiate prescriptions(OMR 230 MME, TEP 229 MME, RTAP 208 MME; p = 0.581), percentage prescribed acetaminophen(OMR 96.7%, TEP 97.1%, RTAPP 98.0%; p = 0.910), or percentage prescribed NSAIDs(OMR 43.3%, TEP 44.1%, RTAP 46.9%; p = 0.919). On follow up, there was no difference in repeat opiate prescriptions(OMR 10.0%, TEP 8.8%, RTAPP 8.2%; p = 0.934). CONCLUSIONS: Patients undergoing open, laparoscopic, and robotic inguinal hernia repairs showed no evidence of differing pain medication requirements. The implication that minimally-invasive techniques cause less pain may be inaccurate.

Poor compliance despite equal access: Military experience with screening breast MRI in high risk women.

BACKGROUND: Using the military as a model for an equal-access, no-cost healthcare system, we sought to (1) describe screening breast MRI compliance rates and (2) identify patient-perceived barriers to screening. METHODS: In this retrospective cohort study of a prospectively maintained database at a tertiary level center, we compared compliance among women at ≥20% risk of developing breast cancer (Tyrer-Cuzick) and conducted structured phone interviews with women at ≥30% risk. RESULTS: From 2015 to 2016, 1,052 women met criteria for screening MRI. Of these, only 251 (24%) underwent MRI screening. Compliance among women with a 20-24%, 25-29%, 30-39%, and ≥40% risk was 16%, 24%, 37%, and 51%, respectively (p < 0.02). 37 of 128 unique patients (29%) with ≥30% risk agreed to interview. 43% cited time/inconvenience as the key barrier to screening; 22% cited questions regarding screening recommendations; and only 3% cited fear/concerns as the key barrier. CONCLUSIONS: Even in an equal-access system, there is poor compliance in patients who are at high risk for developing breast cancer. Patients cited time/inconvenience and questions regarding screening as key barriers to screening.

Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage.

BACKGROUND: Focused assessment with sonography for trauma (FAST) performance metrics are unknown in patients with non-compressible torso hemorrhage (NCTH). METHODS: Retrospective review of a dedicated NCTH database from four level 1 trauma centers (2008-2012). NCTH was defined as (1) named axial torso vessel disruption; (2) AIS chest or abdomen >2 with shock (base deficit < -4) or truncal operation in ≤ 90 min; or (3) pelvic fracture with ring disruption. Patients were grouped by cavity of hemorrhage source and by shock (SBP ≤ 90). RESULTS: 274 patients had a FAST prior to diagnosis of NCTH. FAST was positive in 51% of patients with abdominal/pelvic hemorrhage for a false negative rate (FNR) of 49%. FNR was higher for pelvic (61%) versus abdominal (43%) sources (p = 0.02). There was no difference between FAST negative or positive patients for ISS, shock, length of stay, or mortality (all p = NS). FNR was not improved among the subgroup of NCTH patients with shock (p = NS). CONCLUSION: FAST identified abdominal/pelvic hemorrhage in approximately half of NCTH patients, and this was not improved among patients presenting with shock.

Is bigger better? Twenty-year institutional experience of atypical ductal hyperplasia discovered by core needle biopsy.

OBJECTIVES: The increasing accuracy of large-bore (11- or 8-gauge) vacuum-assisted core needle biopsies (VACNB) has challenged the commonly-accepted practice that surgery is needed for definitive diagnosis when atypical ductal hyperplasia (ADH) is found on VACNB. This study seeks to demonstrate the impact of increased VACNB caliber on the pathologic upgrade rate of ADH. METHODS: Patients diagnosed with isolated ADH by VACNB who subsequently underwent surgical excision at our tertiary medical center were retrospectively studied. Demographics, needle gauge, number of needle passes, and pathology results were analyzed. RESULTS: From June 1996 to June 2016, approximately 3740 VACNBs were performed. 139 patients were diagnosed with isolated ADH on VACNB and underwent surgical excision. 30 patients (22%) were upgraded to ductal carcinoma in-situ or invasive cancer; 17 upgrades (21%) from 11-gauge CNB vs. 13 upgrades (23%) from 8-gauge CNB (p = 0.67). CONCLUSION: Increasing core needle biopsy size from 11 g to 8 g does not decrease the rate of pathologic upstaging at the time of surgical excision. Surgical excision of ADH is still required for complete diagnosis.

Minimally invasive preperitoneal balloon tamponade and abdominal aortic junctional tourniquet versus open packing for pelvic fracture-associated hemorrhage: Not all extrinsic compression is equal.

BACKGROUND: Minimally invasive preperitoneal balloon tamponade (PPB) and abdominal aortic junctional tourniquets (AAJT) have been proposed as alternatives to open preperitoneal packing (OP) for the management of pelvic fracture-associated hemorrhage. We hypothesized that the PPB (SpaceMaker Pro) and AAJT would result in similar rates of survival and blood loss versus OP. METHODS: Thirty-two swine underwent creation of a combined open-book pelvic fracture and major iliac vascular injuries. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), or AAJT (n = 6) at a mean arterial pressure <40 mm Hg following initiation of uncontrolled hemorrhage. Survival (up to 60 minutes + 10 minutes after intervention reversal), hemodynamics, extraperitoneal pressures, blood loss, and associated complications were compared between groups. RESULTS: Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p > 0.05). The injury was uniformly lethal without intervention, with survival time (mean) of 5 minutes, peak preperitoneal pressure (PP) of 14 mm Hg, blood loss of 960 g, and peak lactate of 2.6 mmol/L. Survival time was 44 minutes with OP versus 60 minutes with PPB and AAJT (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, and 23 with AAJT (p > 0.05). Blood loss (g) was 850 with OP, 930 with PPB, and 600 with AAJT (p > 0.05). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, and 6.3 with AAJT (p < 0.01). Only 33% of AAJT animals survived intervention reversal versus 60% for OP and 67% for PPB (p < 0.01). Necropsy revealed bowel/bladder injury in 50% of AAJT subjects versus 0% in all other arms (p < 0.01). CONCLUSION: Preperitoneal balloon tamponade is a safe and potentially effective alternative to OP for the management of lethal pelvic fracture-associated hemorrhage. Abdominal aortic junctional tourniquet offers a similar survival benefit to PPB but has concerning rates of ischemia-reperfusion and compressive abdominal organ injury.

The Highest-Impact Combat Orthopedic and Extremity Injury Articles in the Past 70 Years: A Citation Analysis.

The objective of this study was to identify the most-cited peer-reviewed combat orthopedic and extremity injury articles published during the past 70 years. Orthopedic trauma presents ongoing challenges to both US civilian and military healthcare personnel. Improvements in combat trauma and extremity injury survival and quality of life are the result of advances in orthopedic trauma research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to combat orthopedic trauma, published from 1940 to 2013. The most-cited article was by Owens et al. (Journal of Orthopaedic Trauma, 2007; 137 citations). Between the 1990s and 2000s, there was a 256% increase in the number of highly cited publications. A total of 69% of the articles were on the topics of comorbid vascular trauma (25%), epidemiology (23%), or orthopedic trauma (21%). This study identifies some of the most important contributions to combat orthopedic trauma and research and the areas of greatest scientific interest to the specialty during the past seven decades and highlights key research that has contributed to the evolution of modern combat orthopedic traumatology.