Management of a Traumatic Penetrating Cardiac Injury in a Low-Resource Center Without a Cardiothoracic Surgery Department.

Traumatic penetrating cardiac injury is a rare pathology with a high mortality rate, more commonly occurring in a military setting or during violent assaults in a civilian environment. Given the anatomy, these injuries are often managed by cardiothoracic surgeons. However, in an institute that lacks these specialists, the responsibility for managing this condition falls on the shoulders of the general surgeon on call. We herein report a case where a penetrating cardiac injury was managed successfully by general surgeons in the absence of cardiothoracic surgeons. This case serves two educational purposes. The first is that Caribbean hospitals possess the potential to match a developed country's medical standard if additional resources can be obtained from their respective governing bodies. The second is that a general surgeon's role is not yet finished in the modern era of sub-specialization, especially in a setting that lacks dedicated specialists.

Angioembolization for splenic injuries: does it help? Retrospective evaluation of grade III-V splenic injuries at two level I trauma centers.

Background: Splenic angioembolization (SAE) has increased in utilization for blunt splenic injuries. We hypothesized lower SAE usage would not correlate with higher rates of additional intervention or mortality when choosing initial non-operative management (NOM) or surgery. Study design: Trauma registries from two level I trauma centers from 2010 to 2020 were used to identify patients aged >18 years with grade III-V blunt splenic injuries. Results were compared with the National Trauma Data Bank (NTDB) for 2018 for level I and II centers. Additional intervention or failure was defined as any subsequent SAE or surgery. Mortality was defined as death during admission. Results: There were 266 vs 5943 patients who met inclusion/exclusion criteria at Stanford/Santa Clara Valley Medical Center (SCVMC) versus the NTDB. Initial intervention differed significantly between cohorts with the use of SAE (6% vs 17%, p=0.000). Failure differed significantly between cohorts (1.5% vs 6.5%, p=0.005). On multivariate analysis, failure in NOM was significantly associated with NTDB cohort status, age 65+ years, more than one comorbidity, mechanism of injury, grade V spleen injury, and Injury Severity Score (ISS) 25+. On multivariate analysis, failure in SAE was significantly associated with Shock Index >0.9 and 10+ units blood in 24 hours. On multivariate analysis, a higher risk of mortality was significantly associated with NTDB cohort status, age 65+ years, no private insurance, more than one comorbidity, mechanism of injury, ISS 25+, 10+ units blood in 24 hours, NOM, more than one hospital complications, anticoagulant use, other Abbreviated Injury Scale ≥3 abdominal injuries. Conclusions: Compared with national data, our cohort had less SAE, lower rates of additional intervention, and had lower risk-adjusted mortality. Shock Index >0.9, grade V splenic injuries, and increased transfusion requirements in the first 24 hours may signal a need for surgical intervention rather than SAE or NOM and may reduce mortality in appropriately selected patients. Level of evidence: Level II/III.

Poor Acceptance of the Revised Classification of Premalignant Anal Lesions Following the LAST Standardized Project.

INTRODUCTION: The Lower Anogenital Squamous Terminology (LAST) Project recommended unified classification for HPV-associated squamous lesions of the lower anogenital tract, using a 2-tiered nomenclature in 2013. Adherence to the new nomenclature worldwide is unknown. This study aims to assess the trend of the use of the two-tiered High Squamous Intraepithelial Lesion and Low Squamous Intraepithelial Lesion (HSIL/LSIL) as opposed to the traditional three-tiered Anal Intraepithelial Neoplasia (AIN I/II/III) classification as suggested by the LAST Project. METHODS: A literature search on full-text English language studies of premalignant anal lesion was performed on PubMed from 2002-2022. The studies were categorized by continent, and the prevalence of HSIL/LSIL classification vs AIN I/II/III was calculated. RESULTS: 546 studies and 251 studies were identified using the AIN I/II/II and the HSIL/LSIL classification respectively. Global trend suggested a statistically significant downward trend in the use of the two-tiered nomenclature system in publications globally. Regional trend including North America, Europe, and other (Asia and Latin America) showed variance in adoption of the two-tiered nomenclature system. CONCLUSION: Despite multidisciplinary collaborative effort, adherence to the recommendations to use the two-tiered system for HPV-associated premalignant anal lesions continues to be suboptimal. Further efforts are needed to identify the cause of poor adherence to be able to create strategies that reinforces unification of terminology and integration of LAST the recommendations.

Economic impact of outpatient follow-up using telemedicine vs in-person visits for patients in general surgery: A secondary analysis of a randomized clinical trial.

INTRODUCTION: Innovation in internet connectivity and the Covid 19 pandemic have caused a dramatic change in the management of patients in the medical field, boosting the use of telemedicine. A comparison of clinical outcomes and satisfaction between conventional face-to-face and telemedicine follow-up in general surgery, an economic evaluation is mandatory. The aim of the present study was to compare the differences in economic costs between these two outpatient approaches in a designed randomized controlled trial (RCT). METHODS: A RCT was conducted enrolling 200 patients to compare conventional in-person vs. digital health follow-up using telemedicine in the outpatient clinics in patients of General Surgery Department after their planned discharge. After a demonstration that no differences were found in clinical outcomes and patient satisfaction, we analyzed the medical costs, including staff wages, initial investment, patent's transportation and impact on social costs. RESULTS: After an initial investment of 7527.53€, the costs for the Medical institution of in-person conventional follow-up were higher (8180.4€) than those using telemedicine (4630.06€). In relation to social costs, loss of productivity was also increased in the conventional follow-up. CONCLUSION: The use of digital Health telemedicine is a cost-effective approach compared to conventional face-to-face follow-up in patients of General Surgery after hospital discharge.

Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey.

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS: This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Intussusception as a Presentation of Anisakis Infestation in the Global Era of Raw Fish Consumption: A Case Report and Literature Review.

Anisakiosis, also known as Anisakis larvae infestation, is an increasing parasitic infestation due to the worldwide spread of raw fish and shellfish consumption habits. We present a rare presentation of intestinal intussusception as a preoperative diagnosis and noticed it postoperatively due to Anisakis larvae. A 43-year-old man presented to the emergency department with abdominal pain around the umbilicus and vomiting for several hours. On physical examination at presentation, he had tenderness in the lower abdomen. His radiological studies showed a right-sided pseudo-kidney sign and ileo-colonic intussusception on ultrasound echography. His computed tomography images added findings of submucosal edema and wall thickening in the terminal ileum, swollen regional lymph nodes, and ascites. An urgent laparotomy was performed for ileo-colonic intussusception of an unknown cause. During the laparotomy, the ileocecal intussusception was manually reduced after dissecting the adhesion due to the previous appendectomy, and a partial ileotomy was undertaken using the Endo-GIA automatic anastomosis device. At the resected ileal wall surface, the presence of Anisakis larvae was noticed, and anisakidosis was diagnosed. The dietary history taken post-operatively revealed that he had eaten salmon, bonito, and squid sashimi four days prior to his emergency department visit. His postoperative course was uneventful, and he was discharged from the hospital on the fifth day postoperatively. Anisakiosis must be in the differential diagnosis of intussusception, and eating history seems like a cue to diagnose, and it might be meaningful to clinicians.

Adult Mesenteric Lymphangioma Resulting in Small Bowel Obstruction.

A mesenteric cystic lymphangioma (MCL) is a rare condition that primarily manifests in children. This case report illustrates an unusual presentation of an MCL causing a small bowel obstruction with volvulus in an adult. We present a 31-year-old male who presented to our hospital with a small bowel obstruction. He underwent laparotomy, and a lymphatic mass acting as a lead point and causing small bowel volvulus was discovered intra-operatively. The patient underwent a small bowel with associated mass resection and primary anastomosis; he recovered well. The final pathology demonstrated an MCL. Despite the MCL being a rare entity in adults, it must be considered as the differential for various abdominal pathologies. Although the majority of these masses lack malignant potential, they should be resected, as they pose a risk of mechanical obstruction, torsion, and perforation. Prior descriptions include individual case reports of symptomatic lesions, proposed non-operative management, and follow-up imaging.

Spigelian Hernia: A Rare Ventral Hernia.

Ventral hernias occur when abdominal contents or the peritoneum displace through a defect in the abdominal wall. Among these, spigelian hernias are an exceptionally rare subtype, representing 0.12% to 2% of all ventral hernias. This case study focuses on an 86-year-old female presenting with a ventral hernia, notably a spigelian hernia, lacking common predisposing factors. The study emphasizes the use of laparoscopic techniques for repair, aiming to offer insights into managing this infrequent hernia type and aiding clinical decision-making. Due to its low incidence and challenging diagnosis and identification, reports such as ours detailing both the clinical course and the operative steps can assist others in their clinical decision-making.

Structured Textbook Review and Individualized Learning Plans Successfully Remediate Underperforming Residents and Improve General Surgery Program Performance on the ABSITE.

Background: We endeavored to create an evidence-based curriculum to improve general surgery resident fund of knowledge. Global and resident-specific interventions were employed to this end. These interventions were monitored via multiple choice question results on a weekly basis and American Board of Surgery In-Training Examination (ABSITE) performance. Methods: This study was performed in a prospective manner over a 2-year period. A structured textbook review with testing was implemented for all residents. A focused textbook question-writing assignment and a Surgical Council on Resident Education (SCORE)-based individualized learning plan (ILP) were implemented for residents scoring below the 35th percentile on the ABSITE. Results: Curriculum implementation resulted in a statistically significant reduction in the number of residents scoring below the 35th percentile, from 50% to 30.8% (P = .023). One hundred percent of residents initially scoring below the 35th percentile were successfully remediated over the study period. Average overall program ABSITE percentile scores increased from 38.5% to 51.4% over a 2-year period. Conclusion: Structured textbook review and testing combined with a question-writing assignment and a SCORE-focused ILP successfully remediated residents scoring below the 35th percentile and improved general surgery residency ABSITE performance.

Rarely Seen Compartment Syndrome of the Shoulder and Back: Diagnosis and Management.

Compartment syndrome (CS) is a well-known surgical emergency with high morbidity including potential long-term disability and limb loss. The most important factor determining the degree of morbidity with CS is time to treatment; therefore, early diagnosis and surgery are vital. We present a patient who fell off his bicycle and sustained cervical spine fractures causing near complete quadriplegia. He was found by the road over 12 hours later, so his creatine phosphokinase (CPK) was trended and serial examinations were performed. We identified tight deltoid, trapezius, and latissimus compartments and brought him to the operating room for fasciotomies. Although lab values and compartment pressures can be helpful, they should not guide treatment. It is important to consider atypical sites for CS and complete a head to toe physical examination. Patients should proceed to the operating room if clinical suspicion exists for CS because of the morbidity associated with a missed diagnosis.

The Role of Procalcitonin in Predicting Failure of Non-operative Management in Bowel Obstructions.

Procalcitonin has been investigated as a marker for bowel ischemia. This study examined the role of procalcitonin in predicting failure of non-operative management (NOM) in bowel obstructions. Patients with bowel obstructions at a single center from August 2022 to January 2023 were prospectively enrolled (n = 79). Lactic acid (LA) and procalcitonin were collected after surgical consultation. The primary outcome was success or failure of NOM. Univariate analysis, multivariable logistic regression, and performance measures of procalcitonin and LA in predicting bowel ischemia was performed. Of 79 patients included, 48 (61%) required operative intervention during index admission. There were no significant differences in demographics, comorbidities, procalcitonin, nor LA between groups. Time from last bowel movement was associated with failure of NOM (OR 1.03 [95% CI 1.01-1.06]; P = .008), though initial procalcitonin or LA was not. Procalcitonin >.3 ng/mL had acceptable sensitivity in screening for bowel ischemia.

Impact of Language Congruence on Patient Outcomes Following Gastrostomy Tube Insertion.

Inadequate health literacy poses a significant public health challenge, influencing patient treatment adherence and outcomes. This study explores outcomes in the setting of language congruence at the time of discharge for pediatric patients following laparoscopic gastrostomy tube insertion. We conducted a retrospective chart review from 2019 to 2022 at a community children's hospital, including 168 patients categorized based on language congruence. Although trends did suggest increased ER visits among Spanish-speaking patients, there were no statistically significant differences in health care utilization or patient outcomes identified. Further larger studies are needed for a comprehensive analysis of the relationship of language congruence at discharge on outcomes following surgical procedures as this may enable delivery of culturally competent medical care.

Outcomes of Surgical Rib Plating: A Case Series.

Rib fractures are a common result of blunt thoracic trauma. Complications of rib fractures include pneumothorax, hemothorax, respiratory failure, and death. The conservative management of rib fractures has been the mainstay of care with surgical rib fixation as a secondary management only performed in complicated flail segments. The purpose of this retrospective study is to describe the outcomes of six patients who underwent surgical rib fixation following a traumatic injury at a Level 1 trauma center. All care for these cases was performed at Desert Regional Medical Center in Palm Springs, CA. On average, patients stayed 12.3 total days in the hospital and 4.6 in the intensive care unit. Out of the six patients, only one required prolonged respiratory support eventually resulting in respiratory failure and death. This retrospective study on surgical rib fixation highlights the importance of early surgical intervention and the need for more general and trauma surgeons to be familiar with the procedure itself.

Efficacy of Landmark-Guided Transverse Abdominis Plane (LTAP) Block in Pediatric Patients Undergoing Laparoscopic Appendectomy.

INTRODUCTION: Optimizing perioperative analgesia in patients undergoing abdominal surgery remains a challenge given the side effects of narcotics and the potential for abuse. While transversus abdominis plane block has been shown to improve clinical outcomes, such as decreased opioid consumption and pain scores among adult patients, there is limited data regarding its efficacy for pediatric patients. This study evaluates efficacy amongst pediatric patients undergoing landmark-guided transversus abdominis plane (LTAP) during laparoscopic appendectomy. METHODS: A retrospective chart review of patients, ages 0-18 years old, who underwent laparoscopic appendectomy for uncomplicated appendicitis at a single institution from January 2021 to December 2022 was conducted. Pearson's chi-square test or Fisher's exact test and Welch's t test were used to assess differences between the two cohorts for categorical and continuous variables, respectively. Results are statistically significant at P < .05. RESULTS: Of the 90 patients who met inclusion criteria, 40% (n = 36) underwent LTAP block. Those with LTAP block had a shorter average operative time than those without LTAP block (.6 vs .7 hours; P = .009). Similarly, patients with LTAP block had a shorter average time to discharge (4.1 vs 11.0 h; P = .039). There were no other statistically significant differences in postoperative outcomes including narcotic use between both cohorts. DISCUSSION: Landmark-guided transversus abdominis plane blocks did not increase operative times yet reduced time to discharge for pediatric patients who underwent laparoscopic appendectomy at our institution. Larger studies are needed to evaluate the relationship between LTAP administration and postoperative narcotic consumption to make clinical recommendations.

Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis.

BACKGROUND: Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort. METHODS: All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest. RESULTS: Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (ß + 1.04 days, CI + .91-1.17) and greater costs (ß+$3,490, CI + 2840-4140). DISCUSSION: While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Informing the surgical workforce pathway: how rural community characteristics matter.

INTRODUCTION: Rural areas worldwide face a general surgeon shortage, limiting rural populations' access to surgical care. While individual and practice-related factors have been well-studied in the US, we need a better understanding of the role of community characteristics in surgeons' location choices. This study aimed to understand the deeper meanings surgeons associated with community characteristics in order to inform efforts spanning the rural surgeon workforce pathway, from early educational exposures, and undergraduate and graduate medical education, to recruitment and retention. METHODS: We conducted a qualitative, descriptive interview study with general surgeons in the Midwestern US about the role and meaning of community characteristics, exploring their backgrounds, education, practice location choices, and future plans. We focused on rural surgeons and used an urban comparison group. We used convenience and snowball sampling, then conducted interviews in-person and via phone, and digitally recorded and professionally transcribed them. We coded inductively and continued collecting data until reaching code saturation. We used thematic network analysis to organize codes and draw conclusions. RESULTS: A total of 37 general surgeons (22 rural and 15 urban) participated. Interviews totaled over 52 hours. Three global themes described how rural surgeons associated different, often deeper, meanings with certain community characteristics compared to their urban colleagues: physical environment symbolism, health resources' relationship to scope of practice, and implications of intense role overlap (professional and personal roles). All interviewees spoke to all three themes, but the meanings they found differed importantly between urban and rural surgeons. Physical landscapes and community infrastructure were representative of autonomy and freedom for rural surgeons. They also shared how facilities, equipment, staff, staff education, and surgical partners combined to create different scopes of practice than their urban counterparts experienced. Often, rural surgeons found these resources dictated when they needed to transfer patients to higher-acuity facilities. Rural surgeons experienced role overlap intensely, as they cared for patients who were also friends and neighbors. CONCLUSION: Rural surgeons associated different meanings with certain community characteristics than their urban counterparts. As they work with prospective rural surgeons, educators and rural communities should highlight how health resources can translate into desired scopes of practice. They also should share with trainees the realities of role overlap, both how intense and stressful it can be but also how gratifying. Educators should include the rural social context in medical and surgical education, looking for even more opportunities to collaborate with rural communities to provide learners with firsthand experiences of rural environments, resources, and role overlap.

Prolonged Ileus Due to Underlying Shigella Infection After Bilateral Open Inguinal Hernia Repair.

We present a rare case of prolonged ileus caused by underlying Shigella infection after surgical hernia repair. Infectious disease is an uncommon cause of postoperative prolonged ileus in adults. Our 48-year-old male patient underwent bilateral open inguinal hernia repair and open umbilical hernia repair without complication at an academic institution, with same-day discharge. Eight days later, he presented to the emergency department with complaints of severe cramping abdominal pain, nausea, emesis, and watery diarrhea. Physical examination, computed tomography scan of the abdomen and pelvis, and abdominal X-ray were initially concerning for bowel obstruction. The patient was admitted to the general surgery service. Concern for ileus with underlying gastritis arose after a small bowel follow-through showed contrast eventually reaching the rectum. A subsequent gastrointestinal pathogens panel was positive for Shigella. The patient's symptoms resolved after appropriate antibiotic treatment. Shigellosis and other infectious diseases should be considered in the differential diagnosis of postoperative prolonged ileus.

Optimization of a standardized letter of recommendation for faculty who wish to support candidates applying to surgical training programs.

Letters of recommendation (LORs) play an important role in applicant selection for graduate medical education programs. LORs may be of increasing importance in the evaluation of applicants given the recent change of the USMLE Step 1 to pass/fail scoring and the relative lack of other objective measures by which to differentiate and stratify applicants. Narrative letters of recommendation (NLORs), although widely used, have certain limitations, namely variability in interpretation, introduction of gender/race bias, and performance inflation. Standardized letters of recommendation (SLOR) have been proposed as a potential corrective to these limitations. We conducted a series of semi-structured interviews and focus groups to gather perspectives from letter writers and readers to inform methods for improving information elicited by SLORs from which we collected and analyzed data using the constant comparative method and a process of iterative coding. We applied our findings to the development of a novel SLOR for use in surgical residency program applications and were subsequently invited to help revise existing SLORs for a surgical post-graduate training program.

"The Prognostic Role of Aspartate Transaminase to Platelet Ratio Index (APRI) on Outcomes Following Non-emergent Minor Hepatectomy".

INTRODUCTION: Fibrosis and cirrhosis are associated with worse outcomes after hepatectomy. Aspartate transaminase to platelet ratio index (APRI) is associated with fibrosis and cirrhosis in hepatitis C patients. However, APRI has not been studied to predict outcomes after hepatectomy in patients without viral hepatitis. METHODS: We reviewed the ACS-NSQIP dataset to identify patients who underwent a minor hepatectomy between 2014 and 2021. We excluded patients with viral hepatitis or ascites as well as patients who underwent emergent operations or biliary reconstruction. APRI was calculated using the following equation: (AST/40)/(platelet count) × 100. APRI ≥0.7 was used to identify significant fibrosis. Univariable analysis was performed to identify factors associated with APRI ≥0.7, transfusion, serious morbidity, overall morbidity, and 30-day mortality. Multivariable logistic regression was performed to identify adjusted predictors of these outcomes. RESULTS: Of the 18,069 patients who met inclusion criteria, 1630 (9.0%) patients had an APRI ≥0.7. A perioperative blood transfusion was administered to 2139 (11.8%). Overall morbidity, serious morbidity, and mortality were experienced by 3162 (17.5%), 2475 (13.7%), and 131 (.7%) patients, respectively. APRI ≥0.7 was an independent predictor of transfusion (adjusted OR: 1.48 [1.26-1.74], P < .001), overall morbidity (1.17 [1.02-1.33], P = .022), and mortality (1.97 [1.22-3.06], P = .004). Transfusion was an independent predictor of overall morbidity (3.31 [2.99-3.65], P < .001), serious morbidity (3.70 [3.33-4.11], P < .001), and mortality (5.73 [4.01-8.14], P < .001). CONCLUSIONS: APRI ≥0.7 is associated with perioperative transfusion, overall morbidity, and 30-day mortality. APRI may serve as a noninvasive tool to risk stratify patients prior to elective minor hepatectomy.