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Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death.This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection.This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database.The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2).A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection.Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention.The incidence of C difficile infection in the 30 days after surgery was measured.The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966-3.711); p0.001), smoking (OR = 1.520 (95% CI, 1.063-2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005-2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437-3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period.The study was limited because it was a retrospective database review with observational bias.Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.

BACKGROUND Laparoscopic colectomies are associated with reduced perioperative morbidity and mortality compared with open surgery. Nevertheless, many surgeons continue to utilize an open surgical approach due to the perceived benefits of shorter operative times. This study aims to compare the outcomes of laparoscopic versus open colectomies of equal or shorter operative duration. METHODS All patients undergoing elective laparoscopic or open colectomy in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) were identified from the years 2005 through 2012. Patients were stratified first by operative procedure including partial colectomy, total colectomy, or low anterior resection. Each surgical group was then divided into 4 groups according to operative time

BACKGROUND The complex nature of current morbidity and mortality predictor models do not lend themselves to clinical application at the bedside of patients undergoing emergency general surgery (EGS). Our aim was to develop a simplified risk calculator for prediction of early postoperative mortality after EGS. METHODS EGS cases other than appendectomy and cholecystectomy were identified within the American College of Surgeons National Surgery Quality Improvement Program database from 2005 to 2014. Seventy-five percent of the cases were selected at random for model development, whereas 25% of the cases were used for model testing. Stepwise logistic regression was performed for creation of a 30-day mortality risk calculator. Model accuracy and reproducibility was investigated using the concordance index (c statistic) and Pearson correlations. RESULTS A total of 79,835 patients met inclusion criteria. Overall, 30-day mortality was 12.6%. A simplified risk model formula was derived from five readily available preoperative variables as follows: 0.034*age + 0.8*nonindependent status + 0.88*sepsis + 1.1 (if bun ≥ 29) or 0.57 (if bun ≥18 and < 29) + 1.16 (if albumin < 2.7), or 0.61 (if albumin ≥ 2.7 and < 3.4). The risk of 30-day mortality was stratified into deciles. The risk of 30-day mortality ranged from 2% for patients in the lowest risk level to 31% for patients in the highest risk level. The c statistic was 0.83 in both the derivation and testing samples. CONCLUSION Five readily available preoperative variables can be used to predict the 30-day mortality risk for patients undergoing EGS. Further studies are needed to validate this risk calculator and to determine its bedside applicability. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III.

Femoral hernias occur less frequently than inguinal hernias, but are often more challenging to repair surgically. Femoral hernias constitute between 2% and 8% of groin hernias, with the majority afflicting women. Because of the narrow neck and unyielding surrounding structures, femoral hernias are more likely to incarcerate or strangulate than their inguinal counterparts. They commonly present with incarceration of fat or intra-peritoneal contents. There has been extensive controversy in the last several decades concerning optimal approaches to femoral hernia repair, beginning with inguinal vs femoral approaches initially, to current debates about open vs laparoscopic and mesh vs tissue. Annandale is credited with the first inguinal approach to femoral hernia repair. Many other techniques have been described, but the contributions of Chester McVay established the fundamental basis for understanding femoral hernia repair. The McVay repair requires a relaxing incision to obtain a tension-free repair. Since Lichtenstein and colleagues described the use of prosthetic mesh for tension-free herniorrhaphy, many have turned to mesh to address the difficulties of femoral hernia repair, obviating the need for a relaxing incision. The use of prosthetic mesh is not universally applicable to femoral or inguinal hernia repair due to the incidence of strangulation and necrosis causing a potentially contaminated field. In addition, mesh can lead to other complications, such as chronic pain, infection, migration, and erosion. An effective primary tissue repair for femoral hernia is a useful procedure in the armamentarium of the general surgeon. During two recent humanitarian missions to Guatemala, surgeons from the George Washington University Department of Surgery encountered an unusually large incidence of femoral hernias. A technique developed at George Washington University, which combines a classic McVay (Cooper’s ligament [CL]) repair with a

Observational studies have reported conflicting results with primary fascial closure (PFC) versus bridged repair during laparoscopic ventral hernia repair (LVHR).The aim of the study was to determine whether when evaluated in a randomized controlled trial (RCT), PFC compared to bridged repair would improve patient quality of life (QoL).In this blinded, multicenter RCT, patients scheduled for elective LVHR (hernia defects 3 to 10 cm on computed tomography scan) were randomized to PFC versus bridged repair. Primary outcome was change in QoL after LVHR using a validated, hernia-specific survey (1 = poor QoL and 100 = perfect QoL) that measures pain, function, cosmesis, and satisfaction. Secondary outcomes were postoperative surgical site occurrences (including hematoma, seroma, surgical site infection, and wound dehiscence), abdominal eventration, and hernia recurrence. The trial was powered to detect a difference in change in QoL of 7 points between the study groups. Outcomes were compared with Mann-Whitney U test or chi-square.A total of 129 patients underwent LVHR and 107 (83%) completed follow-up at 2 years. Patients from both groups were similar at baseline. On median follow-up of 24 months (range: 9-42), patients treated with LVHR-PFC had on average a 12-point higher improvement in QoL compared to bridged repair (improvement in QoL, 41.3 ± 31.5 vs 29.7 ± 28.7, P value = 0.047). There were no differences in surgical site occurrence, eventration, or hernia recurrence between groups.Among patients undergoing elective LVHR, the fascial defect should be closed. This is the first RCT demonstrating that PFC with LVHR significantly improves patient QoL.This trial was registered with clinicaltrials.gov (NCT02363790).

Recently, gastric electrical stimulation (GES) has been used to treat gastroparesis. This study analyzes a cohort of gastroparetic patients after GES.All patients undergoing GES from October 2003 to July 2007 were included. Pre- and postoperative assessments were performed for frequency and severity of gastrointestinal symptoms and gastric retention. The values were compared using a paired t-test for patients at 6 and 12 months. Statistical significance was defined as p0.05.Fifty gastroparetic patients were enrolled (20 diabetic, 25 idiopathic, 2 postsurgical, and 3 connective tissue disorder patients). All patients underwent laparoscopic implantation with GES (Medtronic, Inc). Median followup was 28 months (range 3 to 51 months). Thirty-five patients were available for followup at 6 months, and 30 patients were available at 12 months. The total symptom severity score (19.05+/-8.04) decreased significantly at 6 months (12.92+/-7.41, p0.001) and 12 months (14.05+/-8.28, p0.01). Similarly, total frequency score (20.39+/-8.08) decreased significantly at 6 months (15.01+/-7.37, p0.01) and 12 months (15.71+/-7.40, p0.05). At 12 months (n=27), gastric retention at 2 hours was decreased significantly from 66% +/- 21% to 50% +/- 22% (p0.04) and normalized in 11 of 27 patients. The severity of symptoms was reduced in all patients with normal gastric retention postoperatively. Finally, gastric retention at 4 hours was reduced by 14%, but the difference was not significant.Gastroparetic symptoms at 6 months were improved and sustained at 12 months after GES. Gastric emptying at 2 hours was reduced significantly after GES. Longterm followup of this cohort is required to confirm the short-term effects of GES.

BACKGROUND: Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of self-reported height and weight and HCP estimations of height, weight, and body mass index (BMI) classification when compared with measured height, weight, and calculated BMI. STUDY DESIGN: Attending physicians, residents, and nurses provided height and weight estimates along with BMI categorizations for 110 trauma patients at a large, teaching hospital with a Level I trauma center. Patients provided reports of their heights and weights. Measured heights and weights were obtained with appropriate calibrated devices, and BMIs were calculated. Estimates and categorizations were then compared with measured and calculated values. RESULTS: HCPs were 41% and 53% accurate in estimating height and weight, respectively. Self-reports had higher accuracy (69% and 92%, respectively) but still resulted in a BMI misclassification of 32%. Twenty-two percent of patient self-reports were unobtainable. When HCPs attempted to categorize a patient into a BMI group, the accuracy was 56%. Functioning, calibrated instruments for measuring height and weight were frequently unavailable in relevant hospital locations. CONCLUSIONS: This study demonstrated that HCPs' estimates of height, weight, and BMI category are highly inaccurate. Patient self-reports are better, but are unavailable at times. Objective measurements with calibrated instruments are necessary for accuracy in research studies and for patient safety in clinical practice. Efforts to ensure the availability of calibrated instruments may be necessary in the hospital setting.

Cystic lymphangiomas are rare, benign anomalies of the lymphatic system. More than 95% of cystic lymphangiomas occur in the head, neck, and axilla with only 1% in the retroperitoneum. Most of these cases are diagnosed by the second year of life with only a handful of adult cases. Once a symptomatic cystic lesion of the abdomen or retroperitoneum is diagnosed, treatment usually consists of surgical excision. Traditionally, surgery requires a laparotomy. This paper describes a patient with a retroperitoneal cyst who underwent a successful laparoscopic resection. The etiology and management of adult retroperitoneal cysts are reviewed as well.

2 previously healthy 41-year-old woman fell off a horse nto her left side. She was not trampled and was able to emount and ride home. She later became lightheaded nd presented to our trauma center. Physical examinaion revealed left lower quadrant and left flank tenderess. A Foley catheter was inserted and hematuria was oted. CT of the abdomen with intravenous contrast emonstrated a urinoma tracking over the left psoas uscle. Delayed CT image (Fig. 1) and volumeendered CT reconstruction (Fig. 2) of the kidneys deict ureteropelvic junction (UPJ) injury (Figs. 1A, 2A, rrow) with preferential drainage into the urinoma (Figs. B, 2B). Rigid cystourethroscopy with a left retrograde yelogram confirmed the laceration of the left renal pelis. A double J ureteral stent was placed. Hematuria esolved on hospital day 4 and the patient was disharged home. Ureteropelvic junction injury resulting from blunt rauma is an uncommon and often elusive injury with freuent delays in diagnosis. Approximately two-thirds of the PJ injuries occur in children, more commonly on the ight side. The pathogenesis of this injury is not well estabished. Theories of injury include avulsion caused by severe ateral flexion of the torso and cephalad distraction of the idney, and disruption caused by compression of the UPJ gainst the ribs, or transverse processes. Severe lateral flex1

RESULTS: Weight estimates by HCPs were 49% accurate ( 10%) and ranged from 74 lbs under to 100 lbs over measured weight. BMI classification by HCPs was 54% accurate. Estimates were most likely to be correct when BMI was in normal range. Selfreports were 68% accurate, however 28% were unavailable due to language or injury. Patient reports had the lowest margin of error, but resulted in BMI misclassification of 32%.