Prospective derivation and validation of a NECROtizing Soft tissue InfectionS (NECROSIS) score: An EAST multicenter trial.

BACKGROUND: Although several risk indices have been developed to aid in the diagnosis of NSTIs, these instruments suffer from varying levels of reproducibility and failure to incorporate key clinical variables in model development. The objective of this study was to derive and validate a clinical risk index score - NECROSIS - for identifying NSTIs in emergency general surgery (EGS) patients being evaluated for severe skin and soft tissue infections. METHODS: We performed a prospective study across 16 sites in the US of adult EGS patients with suspected NSTIs over a 30-month period. Variables analyzed included demographics, admission vitals and labs, physical exam, radiographic, and operative findings. The main outcome measure was the presence of NSTI diagnosed clinically at the time of surgery. Multivariate analysis was performed to identify independent predictors for the presence of NSTI using the Hosmer-Lemeshow test and the Akaike information criteria. RESULTS: Of 362 patients, 297 (82%) were diagnosed with a NSTI. Overall mortality was 12.3%. Multivariate analysis identified 3 independent predictors for NSTI: systolic blood pressure ≤ 120 mmHg, violaceous skin, and WBC ≥15 (x103/uL). Multivariate modelling demonstrated Hosmer-Lemeshow goodness of fit (p = 0.9) with a c-statistic for the prediction curve of 0.75. Test characteristics of the NECROSIS score were similar between the derivation and validation cohorts. CONCLUSION: NECROSIS is a simple and potentially useful clinical index score for identifying at-risk EGS patients with NSTIs. Future validation studies are warranted. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria, Level III.

Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study.

INTRODUCTION: To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS: Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS: Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Appropriate Imaging for Geriatric Trauma.

BACKGROUND: Trauma is the leading cause of preventable death in the United States. Early detection of life-threatening injuries leads to improved survival. Computed tomography (CT) scanning has become the modality of choice for early detection of injuries in the stable patient. Some studies have associated selective imaging (Selective-CT) with equivalent outcomes compared to whole body imaging (Pan-CT) with lower costs and radiation exposure. Within the geriatric population, however, the utility of Pan-CT remains controversial. Therefore, the aim of this study was to determine if a difference exists between Selective-CT and Pan-CT imaging in the geriatric trauma patient. METHODS: A retrospective analysis of Level 3 (G60) trauma activations presenting to our urban Level I trauma center between June 2016 and June 2019 was performed. Pan-CT was defined by ICD-10 codes indicating a head, cervical spine, chest, abdomen, and pelvis CT series. Patients with missing images and those who were transferred from other institutions were excluded. Logistic regression controlling for age, gender, injury type, severity, and Glasgow Coma Score was performed. RESULTS: A total of 1014 patients met inclusion criteria. Of these, 30.9% underwent Pan-CT (n = 314), 48.9% had Selective-CT (n = 497), and 20.2% received no CT imaging (n = 203). After logistic regression, no clinically significant variations in emergency department length of stay (LOS), hospital LOS, ICU LOS, ventilator days, discharge disposition, missed injury rate, or mortality rate were observed between imaging strategies. CONCLUSIONS: Pan-CT provides no clinically significant advantage over Selective-CT in the geriatric trauma patient.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma.

BACKGROUND: Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock. METHODS: Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group. RESULTS: A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs (p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group (p > 0.05). CONCLUSION: This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Recruitment & Retainment of Vascular Surgeons: Prophylactic Measures to Improve the Current Workforce Crisis.

BACKGROUND: The vascular surgery workforce is in jeopardy with the current and increasing shortages. This study explores target populations for recruitment and aims to identify potential modifiable and nonmodifiable risk factors associated with reduced job satisfaction among practicing vascular surgeons to improve retention and prevent early retirement. METHODS: A cross-sectional national survey of surgeons (n = 1,043) was conducted from September 2016 to May 2017. Data included, demographic and occupational characteristics, as well as psychological, work-life balance, work-environment, and job-satisfaction variables. Surgeons were grouped into general surgery (n = 507), obstetrics and gynecology (n = 272), surgical subspecialties (n = 212), and vascular surgery (n = 52). Vascular surgeons were recategorized as more satisfied and less satisfied, and potential risk factors for job dissatisfaction were identified. RESULTS: As compared with general surgeons, obstetrics and gynecology, as well as other surgical subspecialties, vascular surgery tended to be male-dominated with higher rates of non-white, minority groups (P < 0.05). Less vascular surgery respondents were found in the Midwest (P < 0.001). Vascular surgeons worked more hours on average than other surgical fields and were less satisfied with work (P < 0.05). Potential job dissatisfaction risk factors among vascular surgeons include: unhealthy work-life balance, poor camaraderie/coworker dissatisfaction, insufficient hospital support, hostile hospital culture, discontent with supervision, minimal patient diversity, dissatisfaction with work in general, and unhappiness with career choice (P < 0.05). CONCLUSIONS: Recruiting new vascular surgery trainees while simultaneously preventing early retirement and attrition is critical to combatting the current workforce crisis. Potential interventions include (1) re-branding of the field with prioritization of work-life balance, (2) increasing hospital administration's support, (3) creating a collaborative work environment, and (4) facilitating personal accomplishment in work.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

Traumatized attendings - When the doctor has the disease.

BACKGROUND: This study aims to compare PTSD prevalence between seven medical specialties and to identify potential risk factors for PTSD. METHODS: A cross-sectional national survey of attending physicians (n = 2216) was conducted and screened for PTSD using the Primary Care PTSD Screen. Stepwise multivariable regression analysis with backward elimination identified potential risk factors. RESULTS: Overall prevalence of PTSD was 14% and ranged from 7% to 18% for psychiatrists and OBGYNs, respectively (p = 0.004). Six potential risk factors for PTSD included: emotional exhaustion, job dissatisfaction, lack of autonomy, working >60 h per week, poor camaraderie, and female gender (p < 0.05). CONCLUSIONS: The prevalence of PTSD in attending physicians is more than double that of the general population. Higher risk specialties include OBGYN and general surgery. Specialty-specific interventions targeted at reducing physician burnout and improving the physician work-environment are needed to improve physician wellness and reduce PTSD.

Study of Alteplase for Respiratory Failure in SARS-CoV-2 COVID-19: A Vanguard Multicenter, Rapidly Adaptive, Pragmatic, Randomized Controlled Trial.

BACKGROUND: Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION: Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS: Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS: Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao2 to Fio2 ratio at 48 h (16.9% control [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION: The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04357730; URL: www. CLINICALTRIALS: gov.

Recruitment of General Surgery Residents into Vascular Surgery.

BACKGROUND: Vascular surgery fellowship applications among general surgery residents have declined. Given this steady downward trend in vascular applicants in conjunction with a predicted critical shortage of vascular surgeons, a call to action for increased recruitment is needed. To improve recruitment efforts, a subgroup analysis of general surgery residents was performed to explore factors that influence interest in vascular surgery. METHODS: A cross-sectional national survey of residents (n = 467) was conducted from September 2016 to May 2017. In addition to collection of demographic and occupational characteristics, assessment of psychological, work-life balance, and job-satisfaction variables were obtained. Residents were grouped based on their interest in pursuing a fellowship. Chi-squared and Fisher's exact test was performed to determine significant variables. RESULTS: Residents were grouped into "interest in non-vascular fellowship" (n = 350), "interest in vascular fellowship" (n = 21), and "not interested in fellowship" (n = 96). Significant variables between the groups included age, geographic location, residency size, and type of institution (p < 0.05). Those interested in vascular surgery tended to be older. Residents not interested in fellowship were more commonly located in the Midwest and at smaller, community residencies. No significant difference was found between mental wellness and work-life balance variables. Those residents interested in a vascular surgery fellowship were more dissatisfied with their current salary as compared to other residents (p = 0.021). CONCLUSIONS: There is a predicted critical shortage in the vascular surgery workforce making recruitment of the best and brightest residents into the specialty vital to its future. In order to invigorate and broaden our group of vascular surgeons, focused recruitment of younger, Midwest, general surgery residents at smaller, community programs may provide the most yield. Publicizing the strengths of a vascular surgery career including the diversity of patients, continuity of care, proficiency in technical skill, and higher monetary rewards should be emphasized in recruiting these target populations.

Colorectal resection in emergency general surgery: An EAST multicenter trial.

OBJECTIVE: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Great Expectations? Future Competency Requirements Among Candidates Entering Surgery Training.

INTRODUCTION: We describe a multimethod, multi-institutional approach documenting future competencies required for entry into surgery training. METHODS: Five residency programs involved in a statewide collaborative each provided 12 to 15 subject matter experts (SMEs) to participate. These SMEs participated in a 1-hour semistructured interview with organizational psychologists to discuss program culture and expectations, and rated the importance of 20 core competencies derived from the literature for candidates entering general surgery training within the next 3 to 5 years (1 = importance decreases significantly; 3 = importance stays the same; 5 = importance increases significantly). RESULTS: Seventy-three SMEs across 5 programs were interviewed (77% faculty; 23% resident). All competencies were rated to be more important in the next 3 to 5 years, with team orientation (3.87 ± 0.81), communication (3.82 ± 0.79), team leadership (3.81 ± 0.82), feedback receptivity (3.79 ± 0.76), and professionalism (3.76 ± 0.89) rated most highly. CONCLUSIONS: These findings suggest that the competencies desired and required among future surgery residents are likely to change in the near future.

Concomitant bladder and rectal injuries: Results from the American Association for the Surgery of Trauma Multicenter Rectal Injury Study Group.

BACKGROUND: Combined traumatic injuries to the rectum and bladder are rare. We hypothesized that the combination of bladder and rectal injures would have worse outcomes than rectal injury alone. METHODS: This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 traumatic rectal injury patients who were admitted to one of 22 participating centers. Demographics, mechanism, and management of rectal injury were collected. Patients who sustained a rectal injury alone were compared with patients who sustained a combined injury to the bladder and rectum. Multivariable logistic regression was used to determine if abdominal complications, mortality, and length of stay were impacted by a concomitant bladder injury after adjusting for cofounders. RESULTS: There were 424 patients who sustained a traumatic rectal injury, of which 117 (28%) had a combined injury to the bladder. When comparing the patients with a combined bladder/rectal injury to the rectal alone group, there was no difference in admission demographics admission physiology, or Injury Severity Score. There were also no differences in management of the rectal injury and no difference in abdominal complications (13% vs. 16%, p = 0.38), mortality (3% vs. 2%, p = 0.68), or length of stay (17 days vs. 21 days, p = 0.10). When looking at only the 117 patients with a combined injury, the addition of a colostomy did not significantly decrease the rate of abdominal complications (14% vs. 8%, p = 0.42), mortality (3% vs. 0%, p = 0.99), or length of stay (17 days vs. 17 days, p = 0.94). After adjusting for cofounders (AAST rectal injury grade, sex, damage-control surgery, diverting colostomy, and length of stay) the presence of a bladder injury did not impact outcomes. CONCLUSION: For patients with traumatic rectal injury, a concomitant bladder injury does not increase the rates of abdominal complications, mortality, or length of stay. Furthermore, the addition of a diverting colostomy for management of traumatic bladder and rectal injury does not change outcomes. LEVEL OF EVIDENCE: Level IV; prognostic/therapeutic.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group.

BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

Evaluation of a water-soluble contrast protocol for small bowel obstruction: A southwestern surgical congress multicenter trial.

Differentiation between SBO that will resolve with supportive measures and those requiring surgery remains challenging. WSC administration may be diagnostic and therapeutic. The purpose of this study was to evaluate use of a SBO protocol using WSC challenge. A protocol was implemented at five tertiary care centers. Demographics, prior surgical history, time to operation, complications, and LOS were analyzed. 283 patients were admitted with SBO; 13% underwent immediate laparotomy; these patients had a median LOS of 7.5 days. The remaining 245 were candidates for WSC challenge. Of those, 80% received contrast. 139 (71%) had contrast passage to the colon. LOS in these patients was 4 days. Sixty-five patients (29%) failed contrast passage within 24 h and underwent surgery. LOS was 9 days. 8% of patients in whom contrast passage was observed at 24 h nevertheless subsequently underwent surgery. 4% of patients who failed WSC challenge did not proceed to surgery. Our multicenter trial revealed that implementation of a WSC protocol may facilitate early recognition of partial from complete obstruction.

Traumatized Residents - It's Not Surgery. It's Medicine.

BACKGROUND: Post-traumatic stress disorder (PTSD) has been shown to be more common in surgical residents than the general population. This may be due to the rigors of a surgical residency. This study aims to compare the prevalence of screening positive for PTSD (PTSD+) among 7 medical specialties. Further, we intend to identify independent risk factors for the development of PTSD. METHODS: A cross-sectional national survey of residents (n = 1904) was conducted from September 2016 to May 2017. Residents were screened for PTSD. Traumatic stressors were identified in those who reported symptoms of PTSD. Potential risk factors for PTSD were assessed using multivariate regression analysis with stepwise backward elimination against 30 demographic, occupational, psychological, work-life balance, and work-environment variables. RESULTS: Residents from anesthesiology (n = 180), emergency medicine (n = 222), internal medicine (n = 473), general surgery (n = 464), obstetrics and gynecology (n = 226), psychiatry (n = 208), and surgical subspecialties (n = 131) were surveyed. No statistical difference was found in the prevalence of PTSD between specialties. Prevalence ranged from 14% to 23%. Eight independent risk factors for the development of PTSD+ were identified: higher postgraduate year, female gender, public embarrassment, emotional exhaustion, feeling unhealthy, job dissatisfaction, hostile hospital culture, and unsafe patient load. CONCLUSIONS: The prevalence of PTSD in surgery residents was not statistically different when compared to those in other medical specialties. However, the overall prevalence of PTSD (20%) remains more than 3 times that of the general population. Overall, 8 risk factors for PTSD were identified. These risk factors varied by specialty. This may highlight the unique challenges of training in each discipline. Specialty specific interventions to improve resident wellness should be emphasized in the development of our young physicians.

Follow-up trends after emergency department discharge for acutely symptomatic hernias: A southwestern surgical congress multi-center trial.

BACKGROUND: The objective of this multi-center study was to examine the follow-up trends after emergency department (ED) discharge in a large and socioeconomically diverse patient population. METHODS: We performed a 3-year retrospective analysis of adult patients with acutely symptomatic hernias who were discharged from the EDs of five geographically diverse hospitals. RESULTS: Of 674 patients, 288 (43%) were evaluated in the clinic after discharge from the ED and 253 (37%) underwent repair. Follow-up was highest among those with insurance. A total of 119 patients (18%) returned to the ED for hernia-related complaints, of which 25 (21%) underwent urgent intervention. CONCLUSION: The plan of care for patients with acutely symptomatic hernias discharged from the ED depends on outpatient follow-up, but more than 50% of patients are lost to follow-up, and nearly 1 in 5 return to the ED. The uninsured are at particularly high risk.