Ischiorectal Fossa Tumors: 30-year Single-Institution Experience.

BACKGROUND: Primary tumors of the ischiorectal fossa are rare and comprise a wide array of pathologies with varying malignant potential. Because of the low prevalence, there is a paucity of data in the literature. This article presents a case series on the management of ischiorectal fossa tumors. OBJECTIVE: To present experience from 30 years of managing ischiorectal fossa tumors. DESIGN: Retrospective single-center analysis. SETTINGS: A quaternary referral academic health care center. PATIENTS: All patients treated for ischiorectal fossa tumors were included in the study. INTERVENTIONS: All patients underwent surgical management of their disease. MAIN OUTCOME MEASURES: Disease recurrence and overall survival. RESULTS: A total of 34 patients (53% women) were identified with a median follow-up of 23 months. Twenty-one patients (62%) were diagnosed with benign and 13 (38%) with malignant tumors. All underwent surgical resection. The median tumor size was 8.4 cm. R0 resection was obtained in 28 patients. Twelve patients (35%) developed recurrence (9 after R0 resection) after a median time of 6.5 months. There were no surgical-related mortalities. LIMITATIONS: Limitations to the study include its retrospective nature, single-center experience, and small patient sample size. CONCLUSIONS: Ischiorectal fossa tumors are primarily benign; however, they are associated with high recurrence rates even in the setting of an R0 resection. Treatment should be approached in a multidisciplinary manner, preferably in centers with experience treating these tumors. Close posttreatment surveillance is imperative. See Video Abstract . TUMORES DE LA FOSA ISQUIORRECTAL EXPERIENCIA DE AOS EN UNA SOLA INSTITUCIN: ANTECEDENTES:Los tumores primarios de la fosa isquiorrectal son raros y comprenden una amplia gama de patologías con potencial maligno variable. Debido a la baja prevalencia, hay escasez de datos en la literatura. Este artículo presenta una serie de casos sobre el tratamiento de los tumores de la fosa isquiorrectal.OBJETIVO:Presentar una experiencia de 30 años en el manejo de tumores de la fosa isquiorrectal.DISEÑO:Análisis retrospectivo de un solo centro.AJUSTES:Un centro de atención médica académico de referencia cuaternaria.PACIENTES:Todos los pacientes tratados por tumores de la fosa isquiorrectal.INTERVENCIONES:Todos los pacientes se sometieron a tratamiento quirúrgico de su enfermedad.PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia de la enfermedad y supervivencia general.RESULTADOS:Se identificaron un total de 34 pacientes (53% mujeres) con una mediana de seguimiento de 23 meses. Veintiún pacientes (62%) fueron diagnosticados con tumores benignos y 13 (38%) con tumores malignos. Todos fueron sometidos a resección quirúrgica. El tamaño medio del tumor fue de 8,4 cm. La resección R0 se obtuvo en 28 pacientes. Doce (35%) desarrollaron recurrencia (nueve después de la resección R0) con una mediana de tiempo de 6,5 meses. No hubo mortalidades relacionadas con la cirugía.LIMITACIONES:Las limitaciones del estudio incluyen su naturaleza retrospectiva, experiencia en un solo centro y tamaño pequeño de la muestra de pacientes.CONCLUSIONES:Los tumores de la fosa isquiorrectal son principalmente benignos, sin embargo, se asocian con altas tasas de recurrencia incluso en el contexto de una resección R0. El tratamiento debe abordarse de forma multidisciplinaria y preferentemente en centros con experiencia en el tratamiento de estos tumores. Vigilancia cercana posterior al tratamiento es imperativa. (Traducción-Dr. Aurian Garcia Gonzalez).

Trends and Distribution of IPAAs in the United States: Becoming Harder to Find in Colon and Rectal Surgery Residency Training?

BACKGROUND: There has been concern among colon and rectal surgery residency programs in the United States that IPAA procedures have been decreasing, but evidence is limited. OBJECTIVE: The study aimed to evaluate the number of IPAAs performed by colon and rectal surgery residents in the United States and analyze the distribution of these cases on a national level. DESIGN: Retrospective. SETTINGS: The Accreditation Council for Graduate Medical Education Case Log National Data Reports were used to evaluate the number of IPAAs performed by residents from 2005 to 2021. The Nationwide Inpatient Sample database was used to identify all patients undergoing these procedures from 2005 to 2019. PATIENTS: All IPAA procedures regardless of indication. MAIN OUTCOME MEASURES: The primary outcome was the number of IPAAs performed by residents yearly. The secondary outcome was the national distribution of these procedures. RESULTS: Among colon and rectal surgery residents, case log data revealed an increase in mean and total number of IPAAs from 2005 to 2013, followed by a decline in both metrics after 2013. Despite the decrease, the mean number of cases per resident remained fewer than 6 between 2011 and 2021. A weighted national estimate of 48,532 IPAA patients were identified in the Nationwide Inpatient Sample database. A significant decrease was noted in the number of IPAAs after 2015 that persisted through 2019. There was a significant decrease in rural and urban nonteaching hospitals (from 2.1% to 1.6% and 25.6% to 4.3%, respectively; p < 0.001) and an increase in urbanteaching hospitals (from 72.4% to 94.1%; p < 0.001). LIMITATIONS: Nonrandomized retrospective study design. CONCLUSIONS: Despite the recent increase in the percentage of IPAAs performed at urban academic centers, there has been a decrease in cases performed by colon and rectal surgery residents. This can have significant implications for residents who graduate without adequate experience in performing this complex procedure independently, as well as training programs that may face challenges with maintaining accreditation. See Video Abstract. TENDENCIAS Y DISTRIBUCIN DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL EN LOS ESTADOS UNIDOS SE EST VOLVIENDO MS DIFCIL DE ENCONTRAR EN LA CAPACITACIN DE RESIDENCIA EN CIRUGA DE COLON Y RECTO: ANTECEDENTES:Ha habido preocupación entre los programas de capacitación de residencia en cirugía de colon y recto en los Estados Unidos porque los procedimientos de anastomosis anal con bolsa ileal han estado disminuyendo; sin embargo, la evidencia es limitada.OBJETIVO:Evaluar el número de anastomosis anales con bolsa ileal realizadas por residentes de cirugía de colon y recto en los Estados Unidos y examinar la distribución de estos casos a nivel nacional.DISEÑO:Retrospectivo.AJUSTES:Se utilizaron los informes de datos nacionales del registro de casos de educación médica de posgrado del Consejo de Acreditación para examinar el número de anastomosis anales con bolsa ileal realizadas por residentes de 2005 a 2021. Se utilizó la base de datos de muestra nacional de pacientes hospitalizados para identificar a todos los pacientes sometidos a estos procedimientos de 2005 a 2019.PACIENTES:Todos los procedimientos de anastomosis anal con bolsa ileal independientemente de la indicación.MEDIDA DE RESULTADO PRINCIPAL:El resultado primario es el número de anastomosis anales con bolsa ileal realizadas por los residentes anualmente. El resultado secundario es la distribución nacional de estos procedimientos.RESULTADOS:Entre los residentes de cirugía de colon y recto, los datos de los registros de casos revelaron un aumento en el número medio y total de anastomosis anal con bolsa ileal de 2005 a 2013, seguido de una disminución en ambas métricas después de 2013. A pesar de la disminución, el número medio de casos por El residente permaneció >6 entre 2011 y 2021. Se identificó una estimación nacional ponderada de 48 532 pacientes con anastomosis anal con bolsa ileal en la base de datos de la Muestra Nacional de Pacientes Hospitalizados. Se observó una disminución significativa en el número de anastomosis anales con bolsa ileal después de 2015 que persistió hasta 2019. Hubo una disminución significativa en los hospitales no docentes rurales y urbanos (del 2,1% al 1,6% y del 25,6% al 4,3% respectivamente, p < 0,001) y un aumento en los hospitales universitarios urbanos (del 72,4% al 94,1%, p < 0,001).LIMITACIONES:Estudio retrospectivo no aleatorizado.CONCLUSIÓN:A pesar del reciente aumento en el porcentaje de anastomosis anal con bolsa ileal realizadas en centros académicos urbanos, ha habido una disminución en los casos realizados por residentes de cirugía de colon y recto. Esto puede tener implicaciones significativas para los residentes que se gradúan sin la experiencia adecuada en la realización de este complejo procedimiento de forma independiente, así como para los programas de capacitación que pueden enfrentar desafíos para mantener la acreditación. (Traduccion-AI-generated).

Surgical management of duodenal crohn's disease.

BACKGROUND: Operative options for duodenal Crohn's disease include bypass, stricturoplasty, or resection. What factors are associated with operation selection and whether differences exist in outcomes is unknown. METHODS: Patients with duodenal Crohn's disease requiring operative intervention across a multi-state health system were identified. Patient and operative characteristics, short-term surgical outcomes, and the need for future endoscopic or surgical management of duodenal Crohn's disease were analyzed. RESULTS: 40 patients underwent bypass (n = 26), stricturoplasty (n = 8), or resection (n = 6). Median age of diagnosis of Crohn's disease was 23.5 years, and over half of the patients had undergone prior surgery for CD. Operation type varied by the most proximal extent of duodenal involvement. Patients with proximal duodenal CD underwent bypass operations more commonly than those with mid- or distal duodenal disease (p = 0.03). Patients who underwent duodenal stricturoplasty more often required concomitant operations for other sites of small bowel or colonic CD (63%) compared to those who underwent bypass (39%) or resection (33%). No patients required subsequent surgery for duodenal CD at a median follow-up of 2.8 years, but two patients required endoscopic dilation (n = 1 after stricturoplasty, n = 1 after resection). CONCLUSION: Patients who require surgery for duodenal Crohn's disease appear to have an aggressive Crohn's disease phenotype, represented by a younger age of diagnosis and a high rate of prior resection for Crohn's disease. Choice of operation varied by proximal extent of duodenal Crohn's disease.

The growing trend for no primary surgery in colorectal cancer.

AIM: In colorectal cancer (CRC), surgery of the primary site is commonly curative. Our aim was to determine estimates of 'no surgery' for primary CRC while identifying common reasons for no surgery. METHOD: We identified all patients with a diagnosis of colorectal adenocarcinoma from the National Cancer Database between January 2004 and December 2016. Then, we identified patients who did not undergo surgery on the primary tumour and their demographic, tumour and institutional characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to no surgery and recommendations against operative management. RESULTS: A total of 1,208,878 patients with CRC were identified, 14.5% of whom had no surgery of the primary cancer. No surgery was more common in rectal cancer than in colon cancer. Despite a steady incidence of CRC diagnoses, the likelihood of no surgery grew by 170% over the study period. Metastatic disease was noted in 53.7% of the no surgery cohort. Nine per cent of the no surgery patient cohort received a recommendation against surgery despite the absence of metastatic disease, 7.5% refused surgery and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid and receive care at a single hospital. The no surgery patients had significantly lower overall survival. CONCLUSION: A substantial proportion of patients with CRC do not have surgery. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of no surgery in CRC.

Provocative Angiography, Followed by Therapeutic Interventions, in the Management of Hard-To-Diagnose Gastrointestinal Bleeding.

BACKGROUND: Despite significant advances in imaging and endoscopic diagnostic techniques, adequate localization of gastrointestinal bleeding (GIB) can be challenging. Provocative angiography (PROVANGIO) has not been part of the standard diagnostic algorithms yet. We sought to examine the ability of PROVANGIO to identify the bleeding source when conventional radiography fails. METHODS: Patients undergoing PROVANGIO for GIB during 2008-2014 were retrospectively included. Demographics and periprocedural patient characteristics were recorded. PROVANGIO was performed in a multidisciplinary setting, involving interventional radiology, surgery and anesthesiology teams, ready to intervene in case of uncontrolled bleeding. The procedure included conventional angiography of the celiac, superior and inferior mesenteric arteries (SMA, IMA) followed by a stepwise bleeding provocation with anticoagulating, vasodilating and/or thrombolytic agent administration, combined with angiography. RESULTS: Twenty-three PROVANGIO were performed. Patients were predominantly male (15, 65.2%), and hematochezia was the most common presenting symptom (12, 52.2%). Patients with a positive PROVANGIO had lower Charlson comorbidity index (1 vs. 7, p = 0.009) and were less likely to have a prior history of GIB (14.3% vs. 87.5%, p = 0.001). PROVANGIO localized bleeding in 7 (30%) patients. In 6 out of 7 patients, the bleeding source was identified in the SMA and, in one case, in the IMA distribution. The bleeding was controlled angiographically in four cases, endoscopically in one case and surgically in the remaining two. No complications related to PROVANGIO were detected. CONCLUSIONS: In our series, PROVANGIO safely identified the bleeding source, and provided that necessary safeguards are put into place, we recommend incorporating it in the diagnostic algorithms for GIB management.

The Role of Computed Tomography in the Diagnosis of Necrotizing Soft Tissue Infections.

BACKGROUND: The exact role of IV contrast-enhanced computed tomography (CT) in the diagnosis of necrotizing soft tissue infections (NSTIs) has not yet been established. We aimed to explore the role of CT in patients with clinical suspicion of NSTI and assess its sensitivity and specificity for NSTI. METHODS: The medical records of patients admitted between 2009 and 2016, who received IV contrast-enhanced CT to rule out NSTI, were reviewed. CT was considered positive in case of: (a) gas in soft tissues, (b) multiple fluid collections, (c) absence or heterogeneity of tissue enhancement by the IV contrast, and (d) significant inflammatory changes under the fascia. NSTI was confirmed only by the presence of necrotic tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify necrosis, or if the patient was successfully treated non-operatively. RESULTS: Of the 184 patients, 17 had a positive CT and hence underwent surgical exploration with NSTI being confirmed in 13 of them (76%). Of the 167 patients that had a negative CT, 38 (23%) underwent surgical exploration due to the high clinical suspicion for NSTI and were all found to have non-necrotizing infections; the remaining 129 (77%) were managed non-operatively with successful resolution of symptoms. The sensitivity of CT in identifying NSTI was 100%, the specificity 98%, the positive predictive value 76%, and the negative predictive value 100%. CONCLUSIONS: A negative IV contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI.

Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial.

BACKGROUND: Immobilisation predicts adverse outcomes in patients in the surgical intensive care unit (SICU). Attempts to mobilise critically ill patients early after surgery are frequently restricted, but we tested whether early mobilisation leads to improved mobility, decreased SICU length of stay, and increased functional independence of patients at hospital discharge. METHODS: We did a multicentre, international, parallel-group, assessor-blinded, randomised controlled trial in SICUs of five university hospitals in Austria (n=1), Germany (n=1), and the USA (n=3). Eligible patients (aged 18 years or older, who had been mechanically ventilated for <48 h, and were expected to require mechanical ventilation for ≥24 h) were randomly assigned (1:1) by use of a stratified block randomisation via restricted web platform to standard of care (control) or early, goal-directed mobilisation using an inter-professional approach of closed-loop communication and the SICU optimal mobilisation score (SOMS) algorithm (intervention), which describes patients' mobilisation capacity on a numerical rating scale ranging from 0 (no mobilisation) to 4 (ambulation). We had three main outcomes hierarchically tested in a prespecified order: the mean SOMS level patients achieved during their SICU stay (primary outcome), and patient's length of stay on SICU and the mini-modified functional independence measure score (mmFIM) at hospital discharge (both secondary outcomes). This trial is registered with ClinicalTrials.gov (NCT01363102). FINDINGS: Between July 1, 2011, and Nov 4, 2015, we randomly assigned 200 patients to receive standard treatment (control; n=96) or intervention (n=104). Intention-to-treat analysis showed that the intervention improved the mobilisation level (mean achieved SOMS 2·2 [SD 1·0] in intervention group vs 1·5 [0·8] in control group, p<0·0001), decreased SICU length of stay (mean 7 days [SD 5-12] in intervention group vs 10 days [6-15] in control group, p=0·0054), and improved functional mobility at hospital discharge (mmFIM score 8 [4-8] in intervention group vs 5 [2-8] in control group, p=0·0002). More adverse events were reported in the intervention group (25 cases [2·8%]) than in the control group (ten cases [0·8%]); no serious adverse events were observed. Before hospital discharge 25 patients died (17 [16%] in the intervention group, eight [8%] in the control group). 3 months after hospital discharge 36 patients died (21 [22%] in the intervention group, 15 [17%] in the control group). INTERPRETATION: Early, goal-directed mobilisation improved patient mobilisation throughout SICU admission, shortened patient length of stay in the SICU, and improved patients' functional mobility at hospital discharge. FUNDING: Jeffrey and Judy Buzen.

The Use of Single-Agent Versus Multiple-Agent Concurrent Chemoradiotherapy in the Treatment of Locally Advanced Rectal Cancer.

PURPOSE: The use of concurrent chemoradiotherapy is frequently recommended in the treatment of locally advanced rectal cancer; however, the ideal chemotherapy regimen remains unknown, and there is variability in chemotherapy agents used among different institutions. We sought to examine differences in overall survival between patients receiving single versus multiple-agent concurrent chemoradiotherapy. METHODS: The National Cancer Database was used to identify 31,025 patients with rectal cancer who received concurrent chemoradiotherapy between 01/2006 and 12/2016. We compared patients who received single-agent chemotherapy with those who received multiple-agent concurrent chemoradiotherapy. The primary outcome of interest was overall survival. The groups were compared using univariate analysis and Cox proportional hazard models to adjust for potential confounding factors. RESULTS: 18,544 patients received single-agent and 12,481 patients received multiple-agent chemotherapy. The former were older with more comorbidities as evidenced by their higher Charlson-Deyo Scores. Those receiving multiple-agent chemotherapy were more likely to have clinical stage III disease (52.9% vs 43.3%, p < 0.001) and less likely to have well-differentiated cancer (6.9% vs 7.7%, p < 0.001). The rates of negative resection margin were identical (p = 0.225) between the two groups. On multivariable analysis after adjusting for comorbidities, radiation dose, and resection margins, single-agent chemotherapy was associated with worse overall survival (HR 1.09, 95% CI 1.057-1.124, p < 0.001). CONCLUSION: Multiple-agent chemoradiotherapy is associated with improved overall survival in locally advanced rectal cancer; however, chemotherapy regimen does not affect resection margins. The modest overall survival benefit with multiple-agent chemotherapy must be balanced with the potential associated toxicity.

The Role of Transaminases in Predicting Choledocholithiasis. A Novel Predictive Composite Score Development in a Cohort of 1089 Patients Undergoing Laparoscopic Cholecystectomy.

BACKGROUND: Optimal use of interventional procedures and diagnostic tests for patients with suspected choledocholithiasis depends on accurate pretest risk estimation. We sought to define sensitivity/specificity of transaminases in identifying choledocholithiasis and to incorporate them into a biochemical marker composite score that could accurately predict choledocholithiasis. METHODS: All adult patients who underwent laparoscopic cholecystectomy by our Emergency Surgery Service between 2010 and 2018 were reviewed. Admission total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) was captured. Choledocholithiasis was confirmed via intraoperative cholangiogram, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography. Area under receiver operating characteristic curve (AUC) or C-statistic for AST, ALT, ALP, and TB as a measure of detecting choledocholithiasis was calculated. For score development, our database was randomly dichotomized to derivation and validation cohort and a score was derived. The score was validated by calculating its C-statistic. RESULTS: 1089 patients were included; 210 (20.3%) had confirmed choledocholithiasis. The AUC was .78 for TB, .77 for ALP and AST, and .76 for ALT. 545 and 544 patients were included in the derivation and the validation cohort, respectively. The elements of the derived score were TB, AST, and ALP. The score ranged from 0 to 4. The AUC was .82 in the derivation and .77 in the validation cohort. The probability of choledocholithiasis increased from 8% to 89% at scores 0 to 4, respectively. CONCLUSIONS: Aspartate aminotransferase predicted choledocholithiasis adequately and should be featured in choledocholithiasis screening algorithms. We developed a biochemical composite score, shown to be accurate in preoperative choledocholithiasis risk assessment in an emergency surgery setting.

Denver and Marshall scores successfully predict susceptibility to multiple independent infections in trauma patients.

Trauma patients are at risk of repeated hospital-acquired infections, however predictive scores aiming to identify susceptibility to such infections are lacking. The objective of this study was to investigate whether commonly employed disease-severity scores can successfully predict susceptibility to multiple independent infectious episodes (MIIEs) among trauma patients. A secondary analysis of data derived from the prospective, longitudinal study "Inflammation and the Host Response to Injury" ("Glue Grant") was performed. 1,665 trauma patients, older than 16, were included. Patients who died within seven days from the time of injury were excluded. Five commonly used disease-severity scores [Denver, Marshall, Acute Physiology and Chronic Health Evaluation II (APACHE II), Injury Severity Score (ISS), and New Injury Severity Score (NISS)] were examined as independent predictors of susceptibility to MIIEs. The latter was defined as two or more independent infectious episodes during the index hospital stay. Multivariable logistic regression was used for the statistical analysis. 22.58% of the population was found to be susceptible to MIIEs. Denver and Marshall scores were highly predictive of the MIIE status. For every 1-unit increase in the Denver or the Marshall score, there was a respective 15% (Odds Ratio:1.15; 95% CI: 1.07-1.24; p < 0.001) or 16% (Odds Ratio:1.16; 95% CI: 1.09-1.24; p < 0.001) increase in the odds of MIIE occurrence. APACHE II, ISS, and NISS were not independent predictors of susceptibility to MIIEs. In conclusion, the Denver and Marshall scores can reliably predict which trauma patients are prone to MIIEs, prior to any clinical sign of infection. Early identification of these individuals would potentially allow the implementation of rapid, personalized, preventative measures, thus improving patient outcomes and reducing healthcare costs.

Gallbladder wall thickness as a predictor of intraoperative events during laparoscopic cholecystectomy: A prospective study of 1089 patients.

BACKGROUND: Laparoscopic cholecystectomy (LC) has a wide range of technical difficulty. Preoperative risk stratification is essential for adequate planning and patient counseling. We hypothesized that gallbladder wall thickness (GWT) is more objective marker than symptom duration in predicting complexity, as determined by operative time (OT), intraoperative events (IE), and postoperative complications. METHODS: All adult patients who underwent LC during 2010-2018 were included. GWT, measured on imaging and on the histopathologic exam, was divided into three groups: <3 mm (normal), 3-7 mm and >7 mm. Univariate and multivariable analyses were performed to determine the association between GWT and 1) operative time, 2) the incidence of IE and 3) postoperative outcomes. RESULTS: A total of 1089 patients, subjects to LC, were included in the study. GWT was positively correlated with median OT (p < 0.001), the incidence of IE (p < 0.001) and median length of hospital stay (p < 0.001). GWT independently predicted IE (OR = 2.1 95% CI: 1.3-3.4) and outperformed symptom duration, which was not significantly associated with any of the outcomes (p = 0.7). CONCLUSIONS: GWT independently predicted IE and may serve as an objective marker of LC complexity.

Impact of Intra-Operative Adverse Events on the Risk of Surgical Site Infection in Abdominal Surgery.

BACKGROUND: Intra-operative adverse events (iAEs) recently were shown to correlate independently with an increased risk of post-operative death, morbidity, re-admissions, and length of hospital stay. We sought to understand further the impact of iAEs on surgical site infections (SSIs) in abdominal surgical procedures and delineate which patient populations are most affected. We hypothesized that all patients with iAEs have an increased risk for SSI, especially those with pre-existing risk factors for SSI. PATIENTS AND METHODS: To identify iAEs, a well-described three-step methodology was used: (1) the 2007-2012 American College of Surgeons-National Surgical Quality Improvement Program database was merged with the administrative database of our tertiary academic center, (2) the merged database was screened for iAEs in abdominal surgical procedures using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "Accidental Puncture/Laceration," and (3) each flagged record was systematically reviewed to confirm iAE occurrence. Uni-variable and backward stepwise multi-variable analyses (adjusting for demographics, co-morbidities, type and complexity of operation) were performed to study the independent correlation between iAEs and SSIs (superficial, deep incisional, and organ-space). The correlation between iAEs and SSIs was investigated especially in patients deemed a priori at high risk for SSIs, specifically those older than age 60 and those with diabetes mellitus, obesity, cigarette smoking, steroid use, or American Society of Anesthesiologists class ≥III. RESULTS: A total of 9,288 operations were included, and iAEs were detected in 183 (2.0%). Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intra-operatively (92%). SSI occurred in 686 (7.4%) cases and included 331 (3.5%) superficial, 32 (0.34%) deep incisional, and 333 (3.6%) organ/space infections. iAEs were correlated independently with SSI (odds ratio [OR] = 1.67; 95% confidence interval [CI], 1.11-2.52, p = 0.013), and more severe iAEs were associated with a higher risk of infection. Analysis by SSI type revealed a significant association with organ/space SSI (OR = 1.81, 95% CI 1.07-3.05; p = 0.027), but not incisional infections. Most interestingly, the occurrence of an iAE was correlated with increased SSI rate in the low-risk but not the high-risk patient populations. Specifically, iAEs increased SSI in patients younger than 60 (OR = 2.69, 95% CI 1.55-4.67, p < 0.001), non-diabetic patients (OR = 1.64, 95% CI 1.04-2.58, p = 0.034), non-obese patients (OR = 2.9, 95% CI 1.81-4.66, p < 0.001), non-smokers (OR = 1.67, 95% CI 1.08-2.6, p = 0.022), with no steroid use (OR = 1.73, 95% CI 1.15-2.6, p < 0.008), and with ASA class

Cervical spinal cord injury after blunt assault: Just a pain in the neck?

BACKGROUND: We aimed to determine the incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault. METHODS: The ACS National Trauma Data Bank (NTDB) 2012 Research Data Set was used to identify victims of blunt assault using the ICD-9 E-codes 960.0, 968.2, 973. ICD-9 codes 805.00, 839.00, 806.00, 952.00 identified cervical vertebral fractures/dislocations and CSCI. Multivariable analyses were performed to identify independent predictors of CSCI. RESULTS: 14,835 (2%) out of 833,311 NTDB cases were blunt assault victims and thus included. 217 (1%) had cervical vertebral fracture/dislocation without CSCI; 57 (0.4%) had CSCI. Age ≥55 years was independently predictive of CSCI; assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI. 25 (0.02%) patients with CSCI underwent cervical spinal fusion. CONCLUSIONS: CSCI is rare after blunt assault. While the odds of CSCI increase with age, facial fracture or intracranial injury predicts the absence of CSCI. SUMMARY: The incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault was investigated. 14,835 blunt assault victims were identified; 217 had cervical vertebral fracture/dislocation without CSCI; 57 had CSCI. Age ≥55 years was found to independently predict CSCI, while assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI.

Preoperative endoscopic retrograde cholangio-pancreatography (ERCP) is a risk factor for surgical site infections after laparoscopic cholecystectomy.

BACKGROUND: We sought to examine whether preoperative endoscopic retrograde cholangio-pancreatography (ERCP) increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. METHODS: Patients admitted to an academic hospital from 2010 to 2016, who were older than 18 and had a laparoscopic or a laparoscopic converted to open cholecystectomy for complicated biliary tract disease were included. We compared those who had a preoperative ERCP to those who did not. Our primary endpoint was the rate of SSI. RESULTS: A total of 640 patients were included. Of them, 122 (19.1%) received preoperative ERCP and 518 (80.9%) did not. The former had different preoperative diagnoses compared to non-ERCP patients (choledocholithiasis [35.2%-7.0%], acute cholecystitis [31.2%-76.4%], gallstone pancreatitis [20.5%-16.2%], and cholangitis [13.1%-0.4%], p < 0.001). The rate of SSI was higher in the preoperative ERCP group (11.5%-4.0%, p = 0.005). In a multivariable analysis conversion to open (OR = 2.57, 95% CI = 1.06-6.21, p = 0.037) and preoperative ERCP (OR = 3.12, 95% CI = 1.34-7.22, p = 0.008) were the only independent predictors of SSI. CONCLUSION: Preoperative ERCP is associated with a threefold increase in the risk of SSI after laparoscopic cholecystectomy.

Systemically Administered Hemostatic Nanoparticles for Identification and Treatment of Internal Bleeding.

Internal bleeding is an injury that can be difficult to localize and effectively treat without invasive surgeries. Injectable polymeric nanoparticles have been developed that can reduce clotting times and blood loss, but they have yet to incorporate sufficient diagnostic capabilities to assist in identifying bleeding sources. Herein, polymeric nanoparticles were developed to simultaneously treat internal bleeding while incorporating tracers for visualization of the nanoparticles by standard clinical imaging modalities. Addition of 1,1'-dioctadecyl-3,3,3',3'-tetramethylindodicarbocyanine perchlorate (DiD; a fluorescent dye), biotin functionality, and gold nanoparticles to hemostatic polymeric nanoparticles resulted in nanoparticles amenable to imaging with near-infrared (NIR) imaging, immunohistochemistry, and X-ray computed tomography (CT), respectively. Following a lethal liver resection injury, visualization of accumulated nanoparticles by multiple imaging methods was achieved in rodents, with the highest accumulation observed at the liver injury site, resulting in improved survival rates. Tracer addition to therapeutic nanoparticles allows for an expansion of their applicability, during stabilization by first responders to diagnosis and identification of unknown internal bleeding sites by clinicians using standard clinical imaging modalities.

Bile Spillage as a Risk Factor for Surgical Site Infection after Laparoscopic Cholecystectomy: A Prospective Study of 1,001 Patients.

BACKGROUND: Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. STUDY DESIGN: Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. RESULTS: Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of them. In 202 (20.2%) patients, BS was accompanied by stone spillage. Patients with BS were older (median age of 52 vs 42, p < 0.001) and were more frequently male (44.8% vs 27.8%, p < 0.001). Conversion to open was more likely in operations with BS (13.0% vs 4.4%, p < 0.001). Bile spillage was associated with a higher SSI rate (7.1% vs 2.4%, p = 0.001) and longer hospital stay (median of 3 vs 2 days, p < 0.001). In the multivariable analysis, BS, conversion to open, and American Society of Anesthesiologists (ASA) score > 2 were independent predictors of SSI (odds ratios: 2.29, 2.46, and 2.1 respectively, p < 0.05). CONCLUSIONS: Bile spillage is associated with SSI, and surgeons should take extra caution to avoid it during laparoscopic cholecystectomy.

Operating at night does not increase the risk of intraoperative adverse events.

BACKGROUND: We sought to investigate the association between nighttime (NT) operating and the occurrence of intraoperative adverse events (iAEs). STUDY DESIGN: Our 2007-2012 institutional ACS-NSQIP and administrative databases were screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture or laceration". Procedures were defined as AM (06.00-14.00 h), PM (14.00-22.00 h), or NT (22.00-06.00 h). Univariate and multivariable analyses were performed to investigate the association between PM and NT operating and the occurrence of iAEs. RESULTS: 9136 surgical procedures were included: 7445 AM, 1303 PM, 388 NT. iAEs occurred in 183 procedures. NT patients were younger and less comorbid, but sicker, and with less complex surgeries. There was no correlation between PM or NT operations and iAEs (multivariable analysis [reference: AM operations]: OR = 0.66 [95% CI = 0.40-1.12], P = 0.123; OR = 1.22 [95% CI = 0.51-2.93], P = 0.659, respectively). CONCLUSION: Operating at night does increase the risk of iAEs.

Are surgeons reluctant to accurately report intraoperative adverse events? A prospective study of 1,989 patients.

BACKGROUND: The true incidence of intraoperative adverse events (iAEs) remains unknown. METHODS: All patients undergoing abdominal surgery at an academic institution between January and July 2016 were included in a prospective fashion. At the end of surgery, using a secure REDCap database, the surgeon was given the Institute of Medicine definition of intraoperative adverse events and asked whether an intraoperative adverse event had occurred. Blinded reviewers systematically examined all operative reports for intraoperative adverse events and their severity. The response rate and the intraoperative adverse event rate reported by surgeons were calculated. The latter was compared with the rate of intraoperative adverse events detected by operative report review. The severity of intraoperative adverse events was assessed based on a previously validated intraoperative adverse event classification system. RESULTS: A total of 1,989 operations were included. The surgeons' response rate was 71.9%, reporting intraoperative adverse events in 107 operations (7.5%). Of those intraoperative adverse events, 26 (24.3%) were not described in the operative report. Operative report review revealed intraoperative adverse events in 417 operations (21.0%). Most injuries were of lower severity (85.8% were either class I or II). The surgeons' response rate was similar in operations with and without intraoperative adverse events (69.8% versus 72.5%, P=.28), but they underreported low severity intraoperative adverse events-only 13.2% of class I compared with 35.3%, 36.8%, and 55.6% of injury classes II, III, and IV respectively (P<.001). CONCLUSION: Surgeons are willing to report intraoperative adverse events, but systematically and significantly underreport them, especially if they are of lower severity. This is potentially related to the absence of a clear intraoperative adverse event definition or their personal interpretation of their clinical significance.

Interrupted versus continuous fascial closure in patients undergoing emergent laparotomy: A randomized controlled trial.

BACKGROUND: The optimal method of fascial closure, interrupted fascial closure (IFC) versus continuous fascial closure (CFC) has never been studied exclusively in the setting of emergency surgery. We hypothesized that IFC decreases postoperative incisional hernia development following emergent laparotomies. METHODS: Between August 2008 and September 2015, patients undergoing emergent laparotomies were consented and randomly assigned to either IFC or CFC. Patients were followed up postoperatively for at least 3 months and assessed for incisional hernia, dehiscence, or wound infection. We excluded those with trauma, elective surgery, mesh in place, primary ventral hernia, previous abdominal surgery within 30 days, or those not expected to survive for more than 48 hours. Our primary endpoint was the incidence of postoperative incisional hernias. RESULTS: One hundred thirty-six patients were randomly assigned to IFC (n = 67) or CFC (n = 69). Baseline characteristics were similar between the groups. No difference was noted in the length of the abdominal incision, or the peak inspiratory pressure after the closure. The median time needed for closure was significantly longer in the IFC group (22 minutes vs. 13 minutes, p < 0.001). Thirty-seven (55.2%) IFC and 41 (59.4%) CFC patients completed their follow-up visits. There was no statistically significant difference in baseline and intraoperative characteristics between those who completed follow-ups and those who did not. The median time from the day of surgery to the day of the last follow-up was similar between IFC and CFC (233 days vs. 216 days, p = 0.67), as were the rates of incisional hernia (13.5% versus 22.0%, p = 0.25), dehiscence (2.7% vs. 2.4%, p = 1.0), and surgical site infection (16.2% vs. 12.2%, p = 0.75). CONCLUSION: There was no statistically detectable difference in postoperative hernia development between those undergoing IFC versus CFC after emergent laparotomies. However, this may be due to the relatively low sample size. LEVEL OF EVIDENCE: Therapeutic/Care Management Study, level III.

Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery.

OBJECTIVE: Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs. DESIGN: The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs. SETTING: A large tertiary care teaching hospital. PARTICIPANTS: Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident. RESULTS: A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs. CONCLUSIONS: The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.