Characteristics and Practice Patterns of Non-certified Surgeons Treating Medicare Patients.

OBJECTIVE: The objective of this study is to explore the patient characteristics and practice patterns of non-certified surgeons who treat Medicare patients in the United States. SUMMARY BACKGROUND DATA: While most surgeons in the United States are board-certified, non-certified surgeons are permitted to practice in many locations. At the same time, surgical workforce shortages threaten access to surgical care for many patients. It is possible that non-certified surgeons may be able to help fill these access gaps. However, little is known about the practice patterns of non-certified surgeons. METHODS: A 100% sample of Medicare claims data from 2014-2019 were used to identify practicing general surgeons. Surgeons were categorized as certified or non-certified in general surgery​​ based on data from the American Board of Surgery. Surgeon practice patterns and patient characteristics were analyzed. RESULTS: A total of 2,097,206 patient cases were included in the study. These patients were treated by 16,076 surgeons, of which 6% were identified as non-certified surgeons. Compared to certified surgeons, non-certified surgeons were less frequently fellowship-trained (20.5% vs. 24.2%, P=0.008) and more likely to be a foreign medical graduate (14.5% vs. 9.2%, P<0.001). Non-certified surgeons were more frequently practicing in for-profit hospitals (21.2% vs. 14.2%, P<0.001) and critical access hospitals (2.2% vs. 1.3%, P<0.001), and were less likely to practice in a teaching hospital (63.2% vs. 72.4%, P<0.001). Compared to certified surgeons, non-certified surgeons treated more non-White patients (19.6% vs. 14%, P<0.001) as well as a higher percentage of patients in the two lowest socioeconomic status (SES) quintiles (36.2% vs. 29.2%, P<0.001). Operations related to emergency admissions were more common amongst non-certified surgeons (68.8% vs. 55.7%, P<0.001). There were no differences in gender or age of the patients treated by certified and non-certified surgeons. CONCLUSION: For Medicare patients, non-certified surgeons treated more patients who are non-White, of lower SES, and in more rural, critical-access hospitals.

Association of Health Professional Shortage Area Hospital Designation With Surgical Outcomes and Expenditures Among Medicare Beneficiaries.

OBJECTIVE: To compare surgical outcomes and expenditures at hospitals located in Health Professional Shortage Areas to nonshortage area designated hospitals among Medicare beneficiaries. BACKGROUND: More than a quarter of Americans live in federally designated Health Professional Shortage Areas. Although there is growing concern that medical outcomes may be worse, far less is known about hospitals providing surgical care in these areas. METHODS: Cross-sectional retrospective study from 2014 to 2018 of 842,787 Medicare beneficiary patient admissions to hospitals with and without Health Professional Shortage Area designations for common operations including appendectomy, cholecystectomy, colectomy, and hernia repair. We assessed risk-adjusted outcomes using multivariable logistic regression accounting for patient factors, admission type, and year were compared for each of the 4 operations. Hospital expenditures were price-standardized, risk-adjusted 30-day surgical episode payments. Primary outcome measures included 30-day mortality, hospital readmissions, and 30-day surgical episode payments. RESULTS: Patients (mean age=75.6 years, males=44.4%) undergoing common surgical procedures in shortage area hospitals were less likely to be White (84.6% vs 88.4%, P <0.001) and less likely to have≥2 Elixhauser comorbidities (75.5% vs 78.2%, P <0.001). Patients undergoing surgery at Health Professional Shortage Area hospitals had lower risk-adjusted rates of 30-day mortality (6.05% vs 6.69%, odds ratio=0.90, CI, 0.90-0.91, P <0.001) and readmission (14.99% vs 15.74%, odds ratio=0.94, CI, 0.94-0.95, P <0.001). Medicare expenditures at Health Professional Shortage Area hospitals were also lower than nonshortage designated hospitals ($28,517 vs $29,685, difference= -$1168, P <0.001). CONCLUSIONS: Patients presenting to Health Professional Shortage Area hospitals obtain safe care for common surgical procedures without evidence of higher expenditures among Medicare beneficiaries. These findings should be taken into account as current legislative proposals to increase funding for care in these underserved communities are considered.

Surgical Procedures at Critical Access Hospitals Within Hospital Networks.

OBJECTIVE: To compare surgical outcomes and expenditures at critical access hospitals that do versus do not participate in a hospital network among Medicare beneficiaries. BACKGROUND: Critical access hospitals provide essential care to more than 80 million Americans. These hospitals, often rural, are located more than 35 miles away from another hospital and are required to maintain patient transfer agreements with other facilities capable of providing higher levels of care. Some critical access hospitals have gone further to formally participate in a hospital network. METHODS: This was a cross-sectional retrospective study from 2014 to 2018 comparing 16,128 Medicare beneficiary admissions for appendectomy, cholecystectomy, colectomy, or hernia repair at critical access hospitals that do versus do not participate in a hospital network. Thirty-day mortality and readmissions were risk adjusted using multivariable logistic regression accounting for patient and hospital factors. Price-standardized, risk-adjusted Medicare expenditures were compared for the 30-day total episode payments consisting of index hospitalization, physician services, readmissions, and postacute care payments. RESULTS: Beneficiaries (average age = 75.7 years, SD = 7.4) who obtained care at critical access hospitals in a hospital network were more likely to carry ≥2 Elixhauser comorbidities (68.7% vs. 62.8%, P < 0.001). Rates of 30-day mortality were higher at critical access hospitals in a hospital network (4.30% vs. 3.81%, OR = 1.11, P < 0.001). Similarly, readmission rates were higher at critical access hospitals that were in a hospital network (15.13% vs. 14.34%, OR = 1.06, P < 0.001). Additionally, total episode payments were found to be $960 higher per patient at critical access hospitals that were in a hospital network ($23,878 vs. $22,918, P < 0.001). CONCLUSIONS: Critical access hospitals within hospital networks provided care to more medically complex patients and were associated with worse clinical outcomes and higher costs among Medicare beneficiaries undergoing common general surgery operations.

The impact of frailty on ventral hernia repair outcomes in a statewide database.

INTRODUCTION: Preoperative frailty is a strong predictor of postoperative morbidity in the general surgery population. Despite this, there are a paucity of research examining the effect of frailty on outcomes after ventral hernia repair (VHR), one of the most common abdominal operations in the USA. We examined the association of frailty with short-term postoperative outcomes while accounting for differences in preoperative, operative, and hernia characteristics. METHODS: We retrospectively reviewed the Michigan Surgery Quality Collaborative Hernia Registry (MSQC-HR) for adult patients who underwent VHR between January 2020 and January 2022. Patient frailty was assessed using the validated 5-factor modified frailty index (mFI5) and categorized as follows: no (mFI5 = 0), moderate (mFI5 = 1), and severe frailty (mFI5 ≥ 2). Our primary outcome was any 30-day complication. Multivariable logistic regression was used to evaluate the association of frailty with outcomes while controlling for patient, operative, and hernia variables. RESULTS: A total of 4406 patients underwent VHR with a mean age (SD) of 55 (15) years, 2015 (46%) females, and 3591 (82%) white patients. The mean (SD) BMI of the cohort was 33 (8) kg/m2. A total of 2077 (47%) patients had no frailty, 1604 (36%) were moderately frail, and 725 (17%) were severely frail. The median hernia size (interquartile range) was 2.5 cm (1.5-4.0 cm). Severe frailty was associated with increased odds of any complication (adjusted Odds Ratio (aOR) 3.12, 95% CI 1.78-5.47), serious complication (aOR 5.25, 95% CI 2.17-13.19), SSI (aOR 3.41, 95% CI 1.58-7.34), and post-discharge adverse events (aOR 1.70, 95% CI 1.24-2.33). CONCLUSION: After controlling for patient, operative, and hernia characteristics, frailty was independently associated with increased odds of postoperative complications. These findings highlight the importance of preoperative frailty assessment for risk stratification and to inform patient counseling.

Variation of ventral and incisional hernia repairs in kidney transplant recipients.

INTRODUCTION: As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population. METHODS: We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities. RESULTS: Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33). CONCLUSIONS: In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.

Lacking Advanced Degrees are not a Barrier to Entry into Academic Surgery Leadership.

BACKGROUND: Undergraduate and graduate medical education offerings continue to create opportunities for medical students to pursue MD+ degree education. These educational endeavors provide formal education in fields related to surgery, which gives trainees and surgeons diverse perspectives on surgical care. This study sought to assess current prevalence of additional advanced degrees among leaders in academic surgery to assess the relationship between dual degree attainment and holding various leadership positions within surgical departments. METHODS: The Association for Program Directors in Surgery database was used to identify academic surgical programs, which comprised our study population. Each department of surgery website in the APDS database was interrogated for departmental leaders and their reported academic degrees. RESULTS: Among 3223 identified surgeon leaders, 14.6% (470/3223) were found to possess MD+ degrees. Most common degrees possessed included MBA, MPH, and PhD. In comparing different types of surgeon leaders such as chairs, program directors, and division chiefs, no group was found to have a significantly higher prevalence of MD+ degrees than others. CONCLUSION: Prevalence of MD+ degrees among current academic surgery leaders is low, and the lack of an advanced degree should not be considered a barrier to entry into leadership positions. We hypothesize that these findings are likely to evolve as larger proportions of trainees obtain MD+ degrees during medical school and academic development time throughout residency.

US Public's Perceptions of Online Transformation Photos.

BACKGROUND: Although many plastic surgeons seek to optimize their online presence and reach a broader patient base, no studies to our knowledge have evaluated the general public's perceptions of one of the most valued informational tools: transformation photos. OBJECTIVES: The aim of this study was to evaluate the general public's preferences for viewing transformation photos online. METHODS: Respondents representative of the US public, crowdsourced through Amazon Mechanical Turk, answered a survey assessing perceptions of the posting of before-and-after photos. RESULTS: One thousand respondents completed the questionnaire. Ninety percent (905/1000) of respondents are willing to view online before-and-after photos. Sixty-three percent (634/1000) would consent to online posting of before-and-after photos of at least 1 body area, with comfort levels highest for facelift (36.4%), nonoperative facial rejuvenation (31.9%), liposuction (24.9%), and abdominoplasty (23.2%). Breast reduction (12.4%), breast reconstruction (10.9%), gluteal augmentation (14.0%), and vaginal rejuvenation (4.4%) are considered least acceptable for public posting. Respondents are significantly more opposed to online viewing of genitals than any other body area (P < 0.0001). Of those willing to have their own transformation photos posted online, 74.0% would allow posting on professional practice websites, 35.1% on Instagram, 26.6% on Facebook, 17.2% on Twitter, and 10.7% on Snapchat. Significantly more respondents prefer their transformation photos reside only on professional practice websites rather than on a social media platform (P < 0.0001). CONCLUSIONS: The public considers aesthetic facial procedures and body contouring most acceptable for showcasing transformation photos online. Although most respondents prefer viewing these photos on professional practice websites, Instagram is the favored social media platform. The majority of the public seek transformation photos when choosing a plastic surgeon for a cosmetic procedure.

Analysis of Outcomes in Living Donor Liver Transplants Involving Reconstructive Microsurgeons.

BACKGROUND: Living donor transplantation is becoming increasingly popular as a modality for patients necessitating liver transplantation. Hepatic artery thrombosis (HAT) remains the most feared acute postoperative complication associated with living-donor liver transplantation. Preoperative planning, including scheduling reconstructive microsurgeons to perform the hepatic artery anastomosis using a surgical microscope or loupes, can decrease HAT rates. METHODS: A retrospective review of two reconstructive microsurgeons at a single institution was performed to analyze postoperative outcomes of adult and pediatric live donor liver transplants where reconstructive microsurgeons performed the hepatic artery anastomosis. One surgeon utilized the surgical microscope, while the other surgeon opted to use surgical loupes for the anastomosis. RESULTS: A total of 38 patients (30 adult and eight pediatric) met inclusion criteria for this study, and average patient age in the adult and pediatric population studied was 48.5 and 3.6 years, respectively. Etiologies of adult patients' liver failure were most commonly cholestatic (43%), followed by alcohol (23%), hepatitis C virus-related cirrhosis (17%), and nonalcoholic steatohepatitis (7%), while etiologies of pediatric liver failure were most commonly cholestatic (62.5%). None of the patients (0%) experienced acute postoperative HAT. On average, 22 and 25 months of postoperative follow-up was obtained for the adult and pediatric cohorts, respectively, and only one adult patient was found to have any liver-related complication. CONCLUSION: A collaborative relationship between reconstructive microsurgeons and transplant surgeons mitigates the risk of HAT and improves patient outcomes in living donor liver transplantation.

A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities.

BACKGROUND: Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS: The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS: During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS: Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.

Linea Arcuate Hernia Following Transversus Abdominis Release Incisional Hernia Repair.

Open abdominal surgery continues to be most commonly complicated by postoperative herniation at the incision line. In 2012, Novitsky et al described a novel hernia repair technique that utilized a transversus abdominis release coupled with a posterior (retrorectus) component separation (TAR-PCS) of the ventral abdominal wall. Early reports attest to the versatility and low recurrence rate of this technique, particularly when repairing large and complex defects. We present a rare case of herniation below the linea arcuate (LAH) following repair via TAR-PCS. Given its novelty compared with more widely utilized techniques, literature review revealed less discussion regarding potential pitfalls associated with this type of reconstruction, in particular the potential for LAH. To date, only 9 cases of symptomatic LAH have been described, although 2 previously described "suprapubic" herniations following TAR-PCS may represent previously mischaracterized cases of this type of complication. Nonetheless, none of these reports were in the setting of ventral hernia repair.

The Emergence of Rural Emergency Hospitals: Safely Implementing New Models of Care.

This Viewpoint discusses the potential benefits of the rural emergency hospital model, which exclusively provides outpatient and emergency services, in rural communities faced with possible hospital closures, as well as safeguards to monitor and minimize unintended consequences.

Understanding the impacts of rural hospital closures: A scoping review.

PURPOSE: Rural hospitals are closing at unprecedented rates, with hundreds more at risk of closure in the coming 2 years. Multiple federal policies are being developed and implemented without a salient understanding of the emerging literature evaluating rural hospital closures and its impacts. We conducted a scoping review to understand the impacts of rural hospital closure to inform ongoing policy debates and research. METHODS: A comprehensive search strategy was devised by library faculty to collate publications using the PRISMA extension for scoping reviews. Two coauthors then independently performed title and abstract screening, full text review, and study extraction. FINDINGS: We identified 5054 unique citations and assessed 236 full texts for possible inclusion in our narrative synthesis of the literature on the impacts of rural hospital closure. Twenty total original studies were included in our narrative synthesis. Key domains of adverse impacts related to rural hospital closure included emergency medical service transport, local economies, availability and utilization of emergency care and hospital services, availability of outpatient services, changes in quality of care, and workforce and community members. However, significant heterogeneity existed within these findings. CONCLUSIONS: Given the significant heterogeneity within our findings across multiple domains of impact, we advocate for a tailored approach to mitigating the impacts of rural hospital closures for policymakers. We also discuss crucial knowledge gaps in the evidence base-especially with respect to quality measures beyond mortality. The synthesis of these findings will permit policymakers and researchers to understand, and mitigate, the harms of rural hospital closure.

The PASS Course: Practical Anatomy and Surgical Skills Course as a Pragmatic Primer for Senior Medical Students Pursuing Surgical Residency.

The senior year of undergraduate medical education has been scrutinized for lacking emphasis from educators and value for students. Surgical residency program directors and medical students have reported different sets of perceived weaknesses as surgical trainees enter residency. With this in mind, we developed a novel rotation for senior medical students pursuing surgical residency. The rotation incorporates practical didactics, robust skill and simulation training, and an enriching anatomy experience that entails dissections and operations on embalmed and fresh tissue cadavers. To our knowledge, this is the first reported formal training experience for medical students that involves working with fresh tissue cadavers, which have been described as effective models for live human tissue in the operating room. We describe our multifaceted curriculum in detail, discuss its organization, and elaborate on its potential value. We also provide detailed explanations of the curriculum components so that other surgical educators may consider adopting them.

High-risk surgery among Medicare beneficiaries living in health professional shortage areas.

PURPOSE: Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures. METHODS: We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care. FINDINGS: Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5% vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2% vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively. CONCLUSIONS: Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

The Use of Whole Blood in Rural Trauma Leads to Decreased Resource Utilization.

BACKGROUND: Nearly 40% of trauma deaths result from uncontrolled hemorrhage. Most of these deaths occur within 24 hours, highlighting the importance of early resuscitation. Balanced component resuscitation has been shown to improve outcomes in hemorrhagic shock. However, hemostatic properties may then be decreased, leading to inadequate coagulopathy treatment or higher transfusion requirements. Data comparing the efficacy of component vs. whole blood (WB) resuscitation in early trauma is poor, particularly in the rural population. This study investigates WB use and resource utilization at a rural Level 1 trauma center. METHODS: A prospective cohort study with historical controls (HC) was performed using patients over age 17 presenting as the highest priority trauma. Two units of WB were available to patients with signs of hemorrhagic shock, with subsequent transfusions via massive transfusion protocol or thromboelastography guidance. Component utilization, time to hemorrhage control, complications, and transfer times were examined. RESULTS: Forty patients received WB vs. 153 HC. WB patients had lower complication rates (35% vs. 55.6%; P = .02), and a significant reduction in pRBC utilization in the emergency department (0 vs. 2; P < .0001) and throughout admission (2.0 vs. 4.0; P = .0003). All patients had prolonged transport times given the rural setting (1.42 hours HC vs. 2.03 hours WB; P = .002). DISCUSSION: Unlike most urban WB studies, this study occurred in a rural area with extended transportation times, when WB is inaccessible for patients. Despite this delay, WB patients demonstrated lower component utilization and complication rates. Further research is needed to characterize the impact of early WB access.

The "SHIFT" technique: Suprahepatic IntraFalciform tubing for placement of ventriculoperitoneal shunts.

Ventriculoperitoneal (VP) shunts in pediatric patients are an important aspect of management for patients with hydrocephalus and are fraught with complications. Surgical revision rates for VP shunts in the pediatric population are currently high, which necessitates innovation in operative techniques for placing VP shunts in attempt to decrease complication risks. Here we describe a novel approach for placement of VP shunts that we hypothesize can reduce potential morbidity among pediatric patients. By utilizing the falciform ligament of the liver and the suprahepatic recess to suspend and maintain the shunt, outcomes may portend fewer iatrogenic intra-abdominal injuries, enhanced ease of shunt removal, provide a large surface area for absorption of drained cerebrospinal fluid, and result in fewer adhesions secondary to device placement. We are referring to the operative technique as the "SupraHepatic IntraFalciform Tubing" (SHIFT) technique. In summary, the SHIFT shunt is fashioned by creating a window through the falciform ligament, inserting the shunt, and placing tubing in the suprahepatic recess.

The PEET procedure: Punch Excision of Epithelialized Tracts for gastrocutaneous fistula closure.

BACKGROUND: Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET). METHODS: The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract. RESULTS: Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care. CONCLUSION: Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.

Bilayer wound matrix dermal substitute allows survival of split-thickness skin graft in necrotizing fasciitis defects: A retrospective, uncontrolled case study.

BACKGROUND: Necrotizing fasciitis (NF) is a rapid infectious process involving the fascia and subcutaneous tissue. Current standards of care rely on surgical debridement, resulting in large defects, with limited reconstructive options. Wound management has evolved over the last decade, including use of bilayer wound matrices (BWM). The authors sought to assess the use of collagen-GAG bilayer wound matrices on STSG take for NF wounds. METHODS: A qualitative clinical evaluation (2016-2018) was performed to analyze the efficacy of BWM to aide in STSG take. Primary outcomes were 180-day bilayer matrix success, defined by progressing to split-thickness skin graft (STSG) and STSG take, determined by clinical evaluation. Wounds without a diagnosis of NF or reconstruction with BWM were excluded. RESULTS: Ten patients with 11 NF wounds were identified. Average BMI was 32 kg/m2. Comorbidities included hypertension (70%), diabetes (40%), and peripheral vascular disease (40%). Average wound size was 542cm2 (range: 49cm2 -1050cm2) and average wound age was 19 days at BWM placement. Matrices were applied to the lower extremity (64%), upper extremity (27%), and perineum (9%). One-hundred percent (n = 11) of wounds were deemed successful by receiving a STSG. Average time to STSG was 44 days (21d -108d). Complications consisted of delayed healing (n = 1, 8%) and partial necrosis (n = 1). No instances of infection or STSG graft loss occurred. CONCLUSION: Complex defects caused by soft tissue necrotizing infections remain a reconstructive challenge. We highlight the benefit of a BWM as a treatment modality for reconstruction by priming the wound bed for a definitive STSG.