Search

Background: Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemorrhage control in severe non-compressible torso trauma remains controversial, with limited data on patient selection and outcomes. This study aims to analyze the nationwide trends of its use in the emergency department (EDs)., Methods: A retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) from 2017 to 2022 was performed, focusing on REBOA placements in EDs., Results: The analysis included 3398 REBOA procedures. Majority patients were male (76 ​%) with a median age of 40 years (27-58) and injury severity score of 20 (20-41). The most common mechanism was collision (64 ​%), with emergency surgeries most frequently performed for pelvic trauma (14 ​%). Level 1 trauma centers performed 82 ​% of these procedures, with consistent low annual utilization (<200 facilities). Survival rates were 85 ​% at 1-h post-placement, decreasing significantly to 42 ​% by discharge., Conclusions: REBOA usage in remains limited but steady, primarily occurring at level 1 trauma center EDs. While short-term survival rates are favorable, they drop significantly by the time of discharge., Competing Interests: Declaration of competing interest Andrew D Fisher, Michael D April, Julie A Rizzo, Joseph D DuBose, and Steven G Schauer have all received funding from the Department of Defense in the form of grants to their institutions. However, there are no competing interests pertaining this particular publication., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Laparoscopic cholecystectomy (LC) at night remains controversial. Prior studies have not controlled for disease severity. We analyzed outcomes of LC performed day vs. night while controlling for the Parkland Grading Scale for Cholecystitis (PGS)., Methods: Analysis of the AAST multicenter evaluation of cholecystitis database was performed. Exclusion criteria included non-operative cases, open operations, and missing PGS. Cases were divided based on operation start time. PGS was used to control for disease severity. Outcomes included operative time, use of bailout techniques and complications., Results: Of 759 procedures identified, 16% were nighttime LC. No differences in demographics, comorbidities, physiologic variables and PGS were noted. Operative time (108.6 min vs 105.6), bailout techniques (8.3% vs 7.4%) and complications (9.9% vs 11.3%) were similar between groups., Conclusion: Regardless of severity, laparoscopic cholecystectomy is safe 24-h a day. Operations performed at night have a similar complication profile to those performed during the day., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Ambulatory surgery centers (ASCs) are frequently utilized; however some ambulatory procedures may be performed in hospital outpatient departments (HOPs). Our aim was to compare operating room efficiency between our ASC and HOP., Methods: We reviewed outpatient general surgery procedures performed at our ASC and HOP. Total case time was divided into five components: ancillary time, procedure time, exit time, turnover time, and nonoperative time., Results: Overall, 220 procedures were included (114 ASC, 106 HOP). Expressed in minutes, the mean turnover time (29.8 ± 9.6 vs. 24.5 ± 12.7; p < 0.01), ancillary time (32.2 ± 7.0 vs. 22.2 ± 4.5; p < 0.01), procedure time (77.4 ± 44.9 vs. 56.2 ± 23.0 p < 0.01), exit time (11.8 ± 4.4 vs. 8.5 ± 4.3; p < 0.01), and nonoperative time (62.9 ± 21.9 vs. 48.7 ± 15.0; p < 0.01) were longer at the HOP than at the ASC., Conclusion: ASC outpatient procedures are more efficient than those performed at our HOP. A system evaluation of our HOP operating room efficiency is necessary., (Copyright © 2019. Published by Elsevier Inc.)

Background: Surgical training is under scrutiny for the effect increased resident autonomy may have on patient outcomes. We hypothesize that as laparoscopic cholecystectomy (LC) difficulty increases, there will be increased involvement by senior residents and attending physicians with no differences in complications., Methods: Ten acute care surgeons were asked to fill out a postoperative questionnaire regarding surgical difficulty after every LC between 11/9/2016 and 3/30/2017. Either the Jonckheere-Terpstra test, Mantel-Haenzel chi square test, or ANOVA was used to test for the association between perioperative data and surgical difficulty., Results: A total of 190 LCs were analyzed. PGY level, percent of surgery time with attending surgeon involvement, partial cholecystectomy rate, and length of operation all significantly rose with increasing level of difficulty (p < 0.001) with no significant differences in 60-day emergency room bounce-backs, readmission, or complication rates., Conclusions: We found that as LC difficulty increases, so does attending surgeon and/or senior resident involvement, without increased morbidity., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes., Methods: Eleven surgeons took pictures of and prospectively graded the initial view of 317 GBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fisher's Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade., Results: ICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICC = 0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade., Conclusions: PGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. TABLE OF CONTENTS SUMMARY: The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The main objective of this study was to compare detection rates of clinically significant thoracolumbar spine (TLS) fracture between computed tomography (CT) imaging of the chest, abdomen, and spine (CT CAP) and CT for the thoracolumbar spine (CT TL)., Methods: We retrospectively identified patients at our institution with a TLS fracture over a two-year period that had both CT CAP and reformatted CT TL imaging. The sensitivity of CT CAP to identify fracture was calculated for each fracture type., Results: A total of 516 TLS fractures were identified in 125 patients using reformatted CT TL spine imaging. Overall, 69 of 512 fractures (13%) were missed on CT CAP that were identified on CT TL. Of those, there were no clinically significant missed fractures., Conclusions: CT CAP could potentially be used as a screening tool for clinically significant TLS injuries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Gallbladders (GBs) with severe inflammation have longer operative times and an increased risk for complications. We propose a grading system using intraoperative images to better stratify GB inflammation., Methods: After reviewing the intraoperative images of GBs obtained during several hundred laparoscopic cholecystectomies, we developed a five-tiered grading system based on anatomy and inflammatory changes. Fifty intraoperative photographs were taken prior to dissection and then distributed to 11 surgeons who rated each GB's severity per the grading system. The two-way random effects Intraclass Correlation Coefficient (ICC) was used to assess the reliability among the raters., Results: The ICC among the raters of GB severity was 0.804 (95% CI: 0.733 to 0.867; p = 0.0001). Nineteen GB images had greater than 82% agreement and 16 were clustered around GBs with severe inflammation (grades 3-5)., Conclusion: This study proposes a simple, reliable grading system that characterizes GB complexity based on inflammation and anatomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The push for public reporting of outcomes necessitates relevant benchmarks for disease states across different settings. This study establishes benchmarks for choledocholithiasis management in a safety net hospital setting., Methods: We reviewed all patients admitted to our acute care surgery service with biochemical evidence of choledocholithiasis who underwent same-admission cholecystectomy (CCY) between July 2012 and December 2013., Results: During this 18-month period, 915 patients were admitted with biochemical evidence of choledocholithiasis. Descriptive statistics for the cohort are provided, which include a 51% rate of obesity and 95% rate of pathologic cholecystitis. Conversion rates of 4% and complication rates of 6% were found. The majority had a CCY without biliary imaging (n = 630, 68.9%)., Conclusions: Relevant benchmarks are characterized, and results of a practice pattern of omitting pre- or intraoperative biliary tree imaging are described. These findings serve as a first benchmark of choledocholithiasis management for urban safety net hospitals., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: No consensus exists for the timing and utility of biliary imaging in patients with preoperative concern for choledocholithiasis., Methods: Admissions to an acute care surgery service with evidence of choledocholithiasis undergoing same-admission cholecystectomy without preoperative or intraoperative imaging were identified. One-way analysis of variance on the log-transformed outcomes, with the Tukey-Kramer multiple comparison procedure, were used to compare means between groups., Results: A total of 668 patients with elevated but downtrending liver enzymes underwent cholecystectomy without preoperative or intraoperative imaging. Thirty-eight patients (5.7%) had postoperative biliary imaging, of whom 22 (3.3%) had definite choledocholithiasis. One case of postoperative cholangitis occurred which required readmission and endoscopic retrograde cholangiopancreatography with no long-term morbidity. Presenting liver enzymes were significantly higher in the group found to have retained stones postoperatively than those without retained stones., Conclusions: Patients presenting with biochemical evidence of choledocholithiasis who downtrend preoperatively can be safely managed by cholecystectomy with omission of biliary tract imaging., (Copyright © 2015 Elsevier Inc. All rights reserved.)