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BACKGROUND Down syndrome (DS) is a genetic condition associated with multiple comorbidities. While physicians may perceive that DS patients have more postoperative complications, the literature remains unclear. This study compared postoperative complications for children with and without DS who underwent abdominal and thoracic procedures. METHODS The National Surgical Quality Improvement Program Pediatric was queried for patients aged

The World Health Organization recommends including the parents in completion of the pediatric surgical safety checklist. At our hospital, the preinduction surgical safety checklist is conducted in the preoperative holding with anesthesia, nursing, and often with the parents of children undergoing an operative procedure. We hypothesized that adherence to the preinduction checklist is better when parents are engaged in surgical safety checklist performance.An observational study of adherence to the preinduction checklist for nonemergent pediatric operations was performed (2016-2017). Adherence was defined as verbalization of checkpoints. Only checkpoints (patient identification, procedure, site marking, weight, allergies, and NPO status) relevant to parental knowledge were evaluated. Parental engagement was based on: positive body language, eye contact, lack of distractions, and understanding of checkpoints.484 preinduction surgical safety checklists were observed (interrater reliability0.7). Partial completion occurred in 55% cases; only 41% checklists were fully completed. Parents were present for 81% of checklists, and more checkpoints were performed when parents were present (5, IQR 4-6) versus absent (2, IQR 1-3, P.001). Increased preinduction adherence was associated with increased parent engagement by linear regression analysis (1.20, 95%CI 1.05-1.33). Staff confirmed more checkpoints with engaged parents (28-78%) versus when parents were not engaged (1-9%, P.001 for all checkpoints).Overall preinduction surgical safety checklist performance was poor (less than half of checklists fully completed). In contrast, checklist adherence improved with parental presence and engagement during performance of the checklist.

The responsibilities of a mentee extend throughout all of the stages in a mentoring relationship or cycle. In the first phase, the mentee should prepare to be mentored which requires setting goals, identifying needs, researching potential mentors, and choosing a mentor. After selecting a mentor, the mentee should focus on getting acquainted, building the relationship, and setting shared goals and expectations. During the main phase of the relationship, the mentee and mentor work together to achieve the set goals. In the final phase, the mentee and mentor should reflect on their own and together on the successes of and lessons learned from the relationship. There are multiple tools that can be used during the mentorship cycle to aid in clarifying goals, strengths and weaknesses, expectations, and performance such as a gap analysis or a SWOT (strengths, weaknesses, opportunities, threats) analysis. Finally, frameworks have been proposed for formally evaluating the mentoring relationship. Ultimately, a successful mentoring relationship requires planning, active engagement, and accountability from both the mentee and the mentor.

Background Disparities in colon cancer survival have been reported to result from advanced stage at diagnosis and delayed therapy. We hypothesized that delays in treatment among medically underserved patients occur as a result of system-level barriers in a safety-net hospital system. Materials and methods Retrospective review and analysis of colon cancer patients treated in a large safety-net hospital system between May 2008 and May 2012. Data were collected on demographics, stage at diagnosis, time to surgery, time to adjuvant chemotherapy, and vital status. Regression analyses were performed to determine predictors of delays and failure to receive therapy. Results Of 248 patients treated for colon cancer, 56% (n = 140) had advanced disease at the time of presentation; furthermore, 29.1% of all colectomies for colon cancer were performed on an urgent or emergent basis. Thirty-six patients with stage III and IV disease did not receive chemotherapy (26%). Race, age, gender, and hospice care did not predict receipt of chemotherapy or delays to treatment. Patients with stage I colon cancer had a significantly longer interval between diagnosis and elective surgery when compared with patients with stage II, III, and IV colon cancer, with only 10% (n = 3) undergoing resection sooner than 6 wk after diagnosis. Conclusions One in three patients diagnosed with colon cancer in a large safety-net hospital system require urgent or emergent surgery, and one in two present with advanced disease. Reducing disparities should focus on earlier diagnosis of colon cancer and improving access to surgical specialists.

Background Ventral hernia repairs are one of the most common procedures performed by the general surgeon. They are also among the most complex procedures performed. We hypothesized that with each surgical failure, subsequent ventral hernia repair becomes more complicated and morbid. Study Design We assessed a multicenter database of patients who underwent an elective ventral hernia repair from 2000 to 2012 with at least 6 months of follow-up and elective repairs. Patients were evaluated by the number of previous ventral hernia repairs they had: primary ventral hernia repair (PVHR), first time incisional hernia repair (IHR1), second time incisional hernia repair (IHR2), or third time or greater incisional hernia repair (IHR3). The main outcomes measured were abdominal reoperation, operative duration, surgical site infection (SSI), and hernia recurrence. Complications were assessed and compared between the 4 groups. Time to recurrence was estimated using the Kaplan-Meier curve method by study cohort (PVHR, IHR1, IHR2, IHR3). Results A total of 794 patients were assessed; of these, 481 (60.6%) had PVHR, 207 (26.1%) had IHR1, 78 (9.8%) had IHR2, and 28 (3.5%) had IHR3. Patients with multiple repairs were more likely to undergo subsequent reoperation, have a longer operative duration, develop SSI, and have a recurrence. At 140 months of follow-up, 37% of primary ventral hernias and 64% of incisional hernias have recurred. The highest recurrence rates are seen in IHR3, with 73% recurring. Conclusions Previous ventral hernia repair increases the complication profile of repair, creating a vicious cycle of repair, complications, reoperation, and re-repair. Furthermore, long-term outcomes for ventral hernia repair are poor. Future studies should focus on hernia prevention and improving long-term outcomes after hernia repair.

Background The objective of this study was to characterize variations in packed red blood cell (PRBC) transfusion practices in critically ill patients and to identify which factors influence such practices. We hypothesized that significant variation in transfusion triggers exists among acute care surgeons. Methods A survey of PRBC transfusion practices was administered to the American Association for the Surgery of Trauma members. The scenarios examined hemoglobin thresholds for which participants would transfuse PRBCs. Results A hemoglobin threshold of less than or equal to 7 g/dL was adopted by 45% of respondents in gastrointestinal bleeding, 75% in penetrating trauma, 66% in sepsis, and 62% in blunt trauma. Acute care surgeons modified their transfusion trigger significantly in the majority of the modifications of these scenarios, often inappropriately so. Conclusions This study documents continued evidence-practice gaps and wide variations in the PRBC transfusion practices of acute care surgeons. Numerous clinical factors altered such patterns despite a lack of supporting evidence (for or against).

Surgical wound class (SWC) is used to risk-stratify surgical site infections (SSI) for quality reporting. We previously demonstrated only 8% agreement between hospital-based SWC and diagnosis-based SWC for acute appendicitis. We hypothesized that education and process-based interventions would improve hospital-based SWC reporting and the validity of SSI risk stratification.Patients (18 years old) who underwent appendectomies for acute appendicitis between January 2011 and December 2013 were included. Interventions entailed educational workshops regarding SWC for perioperative personnel and inclusion of SWC as a checkpoint in the surgical safety checklist. Thirty-day postoperative SSIs were recorded. Chi-square, Fisher's exact test, and kappa statistic were utilized.995 cases were reviewed (pre-intervention=478, post-intervention=517). Weighted interrater agreement between hospital-based and diagnosis-based SWC improved from 50% to 81% (p0.01), and weighted kappa increased from 0.16 (95% CI 0.004-0.03) to 0.29 (95% CI 0.25-0.34). Hospital-based dirty wounds were significantly associated with SSI in the post-intervention period only (p0.01).Agreement between hospital-based SWC and diagnosis-based SWC significantly improved after simple interventions, and SSI risk stratification became consistent with the expected increase in disease severity. Despite these improvements, there were still substantial gaps in SWC knowledge and process.

BACKGROUND Nonoperative multidisciplinary management for severe (American Association for the Surgery of Trauma Grades IV and V) liver injury has been used for two decades. We have previously shown that Damage Control Resuscitation (DCR) using low-volume, balanced resuscitation improves survival of severely injured trauma patients; however, little attention has been paid to organ-specific outcomes. We wanted to determine if implementation of DCR has improved survival and successful nonoperative management after severe blunt liver injury. METHODS A retrospective study was performed on all adult trauma patients with severe blunt liver injury who were admitted from 2005 to 2011. Patients were divided into pre-DCR (2005-2008) and DCR (2009-2011) groups. Patients who died before leaving the emergency department (ED) were excluded. Outcomes (resuscitation products used, survival, and length of stay) were then compared by univariate and multivariate analyses. RESULTS Between 2005 and 2011, 29,801 adult trauma patients were admitted, and 1,412 (4.7%) experienced blunt liver injury. Of these, 244 (17%) sustained Grade IV and V injuries, with 206 patients surviving to leave the ED. The pre-DCR group (2005-2008) was composed of 108 patients, and the DCR group (2009-2011) had 98 patients. The groups were not different in demographics as well as prehospital and ED vital signs or Injury Severity Score (ISS). No change in operative or interventional radiology techniques occurred in this time frame. The DCR cohort had an increase in successful nonoperative management (from 54% to 74%, p < 0.01) as well as a reduction in initial 24-hour packed red blood cell (median, from 13 U to 6.5 U; p < 0.01), plasma (median, from 13 U to 8 U; p < 0.01), and crystalloid (median, from 5,800 mL to 4,100 mL; p < 0.01) administration. The DCR treatment was associated with improved survival, from 73% to 94% (p < 0.01). CONCLUSION In patients with severe blunt liver injury, DCR was associated with less crystalloid and blood product use, a higher successful nonoperative management rate, and improved survival. Resuscitation technique may improve outcomes after severe liver injury. LEVEL OF EVIDENCE Therapeutic/care management, level III.

© 2015 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education. Journal clubs have an extensive history that dates back to the time of Sir William Osler. They provide a venue to discuss the latest medical literature among groups of peers and are an innovative method for translating knowledge into practice within individual institutions. With advances in social media, journal clubs are poised to take an evolutionary step by harnessing digital connectivity. Online journal clubs are uniting hundreds of medical practitioners from around the world under the banner of one cause: enhancing knowledge translation of the medical literature without the limitations of geography. This article describes 10 steps for creating online journal clubs based on the experiences of a multidisciplinary team of clinicians and medical educators.

Background Discordance exists between author self-disclosure and the Open Payments Database in various surgical fields, but the effects of this discordance on study design and presentation are unknown. We hypothesized that, among ventral hernia publications, discordance exists between industry and physician self-reported conflicts of interest (COIs); authors disclose relevant COIs; and disclosure and relevant COIs affect study favorability. Study Design We conducted a double-blinded, prospective, observational study of published articles. PubMed was searched in reverse chronological order for clinical articles pertaining to ventral hernias. Authors' self-disclosed conflicts were compared with those on the Open Payments Database. Two reviewers blinded to article disclosure status determined jointly whether the COIs were relevant to the article. Three blinded referees independently voted whether each article was favorable to discussed subject matter. The primary end point was study favorability. Secondary outcomes included disclosure status and relevance. Results One hundred articles were included. Compared with authors with no COIs, authors with a COI, self-disclosed or not, were twice as likely to write results favorable to industry. Of those with a COI, most of the articles had a relevant COI (37 of 45 [82.2%]), and 25% of relevant COIs were not disclosed by authors. Among authors with a relevant COI, study favorability remained unchanged at 68.5% (control: no COI 33.3%; p Conclusions Within the ventral hernia literature, 70% of articles have a COI. Self-reporting of COI is discordant in 63% of articles. Twenty-five percent of relevant COI are not disclosed. Having a COI increases the chances that an article will cast a favorable impression on the company paying the authors by 200%.

Surgical site infections (SSIs) remain prevalent after ventral hernia repair (VHR). In 2013-2014, a safety-net academic hospital initiated a two-pronged quality-improvement (QI) project: (1) Development and implementation of evidence-based guidelines; and (2) creation of a specialized hernia clinic to manage challenging patients and complex ventral hernias. Our objective was to decrease SSI rates after elective VHR.The primary outcome was SSI 30 days post-operatively, which was assessed in aggregate and with a stratified analysis based on case complexity using the χA total of 399 patients in the pre-QI period and 390 patients in post-QI period (178 patients in general surgery clinics; 212 patients in the specialty hernia clinic) underwent VHR. Patients treated in the post-QI period were less likely to experience an SSI (13.5% vs. 1.5%; p 0.001). On subgroup analysis of the post-QI clinics, specialty hernia clinic patients had an even lower risk of SSI than those in general surgery clinics (1.4% versus 1.7%).The QI initiatives of evidence-based guidelines and the specialty hernia clinic were associated with lower SSI rates. Differences in peri-operative management included differences in patient selection and pre-operative preparation and increased use of synthetic mesh and laparoscopy. Future studies must investigate the long-term outcomes of these initiatives.

Social media use has increased both in the general public and in the surgical profession. A variety of social media platforms have been used, with Twitter being one of the most common and interactive platforms. Common uses by surgeons and scientists for social media include dissemination of information, information exchange, education, research recruitment, community consultation for clinical trials, and hospital or surgeon ratings. As social media use increases, a new language as well as metrics has been developed to track impact and reach of research incorporating social media platforms. All surgeons should be encouraged to familiarize themselves with social media, regardless of whether or not they choose to actively engage in it.

The modified Activities Assessment Scale (AAS) is a 13-question abdominal wall quality of life (AW-QOL) survey validated in patients undergoing ventral hernia repair (VHR). No studies have assessed AW-QOL among individuals without abdominal wall pathology. The minimal clinically important difference (MCID) of the modified AAS and its implications for the threshold at which VHR should be offered also remain unknown. Our objectives were to (1) establish the AW-QOL of patients with a clinical abdominal wall hernia versus those with no hernia, (2) determine the MCID of the modified AAS, and (3) identify the baseline quality of life (QOL) score at which patients derive little clinical benefit from VHR. Patient-centered outcomes data for all patients presenting to General Surgery and Hernia Clinics October–December 2016 at a single safety-net institution were collected via a prospective, cross-sectional observational study design. Primary outcome was QOL measured using the modified AAS. Secondary outcome was the MCID. Patients with no hernia had modified AAS scores of 81.6 (50.4–94.4), while patients with a clinically apparent hernia had lower modified AAS scores of 31.4 (12.6–58.7) (p

Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis.Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial.According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship.Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.

Background In an effort to reduce surgical site infection (SSI) rates, a large number of infection control practices (ICPs), including operating room attire policies, have been recommended. However, few have proven benefits and many are costly, time-consuming, and detrimental to provider morale. The goal of this multi-institution study was to determine which ICPs are associated with lower postoperative SSI rates. Study Design Twenty American College of Surgeons NSQIP and Texas Alliance for Surgical Quality-affiliated hospitals completed this Quality Improvement Assessment Board-approved study. Surgeon champions at each hospital ranked current surgery, anesthesia, and nursing adherence to 38 separate ICPs in 6 categories (attire, preoperative, intraoperative, preoperative, intraoperative, antibiotics, postoperative, and reporting) on 4-point scales for general surgery cases. These data were compared with the risk-adjusted general surgery SSI odds ratios contained in the July 2016 American College of Surgeons NSQIP hospital-level, risk-adjusted reports. Compliance rates were compared between the 7 best (median SSI odds ratio, 0.64; range, 0.56 to 0.70) and 7 worst (median SSI odds ratio, 1.16; range, 0.94 to 1.65) performers using ANOVA. Results Nearly all hospitals reported maximal adherence to hair removal with clippers (Surgical Care Improvement Project measure Inf-6) and to best-practice prophylactic antibiotic metrics (Surgical Care Improvement Project measure Inf-1-3). Variable adherence was identified across many ICPs and more frequent compliance with 8 ICPs correlated with lower SSI odds ratios, including preoperative shower; skin preparation technique; using clean instruments, gowns, and gloves for wound closure and dressing changes; and transparent internal reporting of SSI data. Operating room attire ICPs, including coverage of nonscrubbed provider head and arm hair, did not correlate with SSI rates. Conclusions This analysis suggests that the subset of ICPs that focus on perioperative patient skin and wound hygiene and transparent display of SSI data, not operating room attire policies, correlated with SSI rates. Implementation of this subset of evidence-based ICPs may improve SSI rates at lower-performing hospitals.

Despite the importance of defect size, there are no standardized recommendations on how to measure ventral hernias. Our aims were to determine (1) if any significant differences existed between various methods of measuring ventral hernias and (2) the effect of these methods of measurement on selection of mesh size. A prospective study of all patients enrolled in a randomized trial assessing laparoscopic ventral hernia repair at a single institution from 3/2015 to 7/2016 was eligible for inclusion. Abdominal wall hernia defect size was determined by multiplying defect length and width obtained separately using each of five methods: radiographic (CT), intraoperative with abdomen desufflated, intraoperative with abdomen insufflated to 15 mmHg (intra-abdominal aspect), intraoperative with abdomen insufflated to 15 mmHg (extra-abdominal aspect), and clinical. The primary outcome was intraclass correlation between the five different methods of measurement for each patient. Secondary outcome was changes in mesh selection assuming a 5 cm overlap in each direction. Fifty patients met inclusion criteria for assessment. The five different measurement methods had an intraclass correlation for each patient of 0.533 (95% CI 0.373–0.697) (weak correlation) for length; 0.737 (95% CI 0.613–0.844) (moderate correlation) for width; and 0.684 (95% CI 0.544–0.810) (moderate correlation) for area. Different types of measurements affected mesh selection in up to 56% of cases. Among five common methods of measuring abdominal wall hernia defect, sizes are only weakly to moderately correlated. Further studies are needed to determine which method results in optimally sized abdominal wall prostheses and superior ventral hernia repair.

Background Damage control laparotomy (DCL) is used widely in the management of patients with traumatic injuries but carries significant morbidity. Surgical-site infection (SSI) also carries potential morbidity, increased costs and prolonged hospital stay. The aim of this study was to determine whether primary skin closure after DCL increases the risk of SSI. Methods This was a retrospective institutional review of injured patients undergoing DCL between 2004 and 2012. Outcomes of patients who had primary skin closure at the time of fascial closure were compared with those of patients whose skin wound was left open to heal by secondary intention. The association between skin closure and SSI was evaluated using propensity score-adjusted multivariable logistic regression. Results Of 510 patients who underwent DCL, primary fascial closure was achieved in 301. Among these, 111 (36·9 per cent) underwent primary skin closure and in 190 (63·1 per cent) the skin wound was left open. Fascial closure at the initial take-back surgery was associated with having skin closure (P < 0·001), and colonic injury was associated with leaving the skin open (P = 0·002). On multivariable analysis, primary skin closure was associated with an increased risk of abdominal SSI (P = 0·020), but not fascial dehiscence (P = 0·446). Of patients receiving skin closure, 85·6 per cent did not develop abdominal SSI and were spared the morbidity of managing an open wound at discharge. Conclusion Primary skin closure after DCL is appropriate but may be associated with an increased risk of SSI.

Background Laparoscopic cholecystectomies can be performed at night in high-volume acute care hospitals. We hypothesized that nonelective nighttime laparoscopic cholecystectomies are associated with increased postoperative complications. Study Design We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected on demographics, operative time, time of incision, length of stay, 30-day postoperative complications (ie, bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, and bleeding) and death. Statistical analyses were performed using STATA software (version 12; Stata Corp). Results During 8 months, 356 patients had nonelective laparoscopic cholecystectomies. A majority were female (n = 289 [81.1%]) and Hispanic (n = 299 [84%]). There were 108 (30%) nighttime operations. There were 29 complications in 18 patients; there were fewer daytime than nighttime patients who had at least 1 complication (4.0% vs 7.4%; p = 0.18). On multivariate analysis, age (odds ratio = 1.06 per year; 95% CI, 1.02–1.10; p = 0.002), case duration (odds ratio = 1.02 per minute; 95% CI, 1.01–1.02; p = 0.001), and nighttime surgery (odds ratio = 3.33; 95% CI, 1.14–9.74; p = 0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs 2 days; p Conclusions Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.

Background This study sought to identify the incidence, indications, and predictors of abdominal reoperation and mesh explantation following open ventral hernia repair with mesh (OVHR). Methods A retrospective cohort study of all patients at a single institution who underwent an OVHR from 2000 to 2010 was performed. Patients who required subsequent abdominal reoperation or mesh explantation were compared with those who did not. Reasons for reoperation were recorded. The 2 groups were compared using univariate and multivariate analysis (MVA). Results A total of 407 patients were followed for a median (range) of 57 (1 to 143) months. Subsequent abdominal reoperation was required in 69 (17%) patients. The most common reasons for reoperation were recurrence and surgical site infection. Only the number of prior abdominal surgeries was associated with abdominal reoperation on MVA. Twenty-eight patients (6.9%) underwent subsequent mesh explantation. Only the Ventral Hernia Working Group grade was associated with mesh explantation on MVA. Conclusions Abdominal reoperation and mesh explantation following OVHR are common. Overwhelmingly, surgical complications are themost common causes for reoperation and mesh explantation.

Laparoscopic ventral hernia repair (LVHR) has grown in popularity. Typically, this procedure is performed with a mesh bridge technique that results in high rates of seroma, eventration (bulging), and patient dissatisfaction. In an effort to avoid these complications, there is growing interest in the role of laparoscopic primary fascial closure with intraperitoneal mesh placement. This systematic review evaluated the outcomes of closure of the central defect during LVHR. A literature search of PubMed, Cochrane databases, and Embase was conducted using PRISMA guidelines. MINORS was used to assess the methodologic quality. Primary outcome was hernia recurrence. Secondary outcomes were surgical-site infection, seroma formation, bulging, and patient-centered items (satisfaction, chronic pain, functional status). Eleven studies were identified, eight of which were case series (level 4 data). Three comparative studies examined the difference between closure and nonclosure of the fascial defect during laparoscopic ventral incisional hernia repairs (level 3 and 4 data). These studies suggested that primary fascial closure (n = 138) compared to nonclosure (n = 255) resulted in lower recurrence rates (0-5.7 vs. 4.8-16.7 %) and seroma formation rates (5.6-11.4 vs. 4.3-27.8 %). Follow-up periods for both groups were similar (1-108 months). Only one study evaluated patient function and clinical bulging. It showed better outcomes with primary fascial closure. Closure of the central defect during LVHR resulted in less recurrence, bulging, and seroma than nonclosure. Patients with closure were more satisfied with the results and had better functional status. The quality of the data was poor, however. A randomized controlled trial to evaluate the role of closure of the central defect during LVHR is warranted.

Background The incidence of incisional hernias after stoma reversal is not well reported. The aim of this study was to systematically review the literature reporting data on incisional hernias after stoma reversal. We evaluated both the incidence of stoma site and midline incisional hernias. Methods A systematic review identified studies published between January 1, 1980, and December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies were excluded. Assessment of risk of bias, detection method, and essential study-specific characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done. Results Sixteen studies were included in the analysis; 1613 patients had 1613 stomas formed. Fifteen studies assessed stoma site hernias and five studies assessed midline incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3% (range 0%–33.9%) and for midline incisional hernias was 44.1% (range 8.7%–58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. Conclusion Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed.

Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence.From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized.Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P.001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P.001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3-5) to 11 (10-12) to 14 (13-14; P.001).A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.

Background Intrahepatic cholangiocarcinoma (ICC) is often diagnosed at advanced stage and few patients qualify for resection. Effects of barriers to access on outcomes are unknown. We hypothesized that income and rural residence account for delays in treatment and decreased survival. Methods Texas Cancer Registry was queried for ICC patients from 2000 to 2008. Median household income (MHI) and urban/rural status were analyzed. Regression analyses were performed for (1) time-to- treatment (TTT), and (2) overall survival (OS). Results Among 1,089 patients, 20.2% patients resided in rural areas and MHI ranged $24,497–$81,113/year. Primary treatment included surgery for 9.5%, radiation 5.4% and chemotherapy 21.0%. Median TTT was 29 (range 0–235) days. Patients from low-income areas were less likely to receive treatment (below median MHI, 29.7% vs. above median MHI, 37.5%%; P = 0.007). MHI was associated with TTT (per $10,000/year: hazard ratio (HR) = 1.05; 95% CI: 1.01–1.09). Adjusting for stage, MHI was associated with OS (per $10,000/year: HR = 0.97; 95%CI: 0.94–0.99). Rural residence was neither associated with TTT nor OS. Conclusion Overall treatment rates for ICC patients are low. Regional income, not urbanization was associated treatment and survival independent of stage. Further research is needed to determine how regional prosperity relates to care access. J. Surg. Oncol. 2014; 110:416–421. © 2014 Wiley Periodicals, Inc.

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons, and the American Society of Colorectal Surgeons Evidence Based Reviews in Surgery : Colorectal Surgery

The U.S. Centers for Disease Control requires 90 days after surgery using an implant to diagnose or show the absence of a surgical site infection (SSI). However, many databases only track outcomes up to 30 days. The cost and effort to increase follow-up to 90 days after surgery is high and the benefit is unclear. We hypothesize that the majority of SSIs after ventral hernia repair occur within 30 days of surgery.All patients who underwent ventral hernia repair (with or without mesh) from 2010-2015 at a single institution were evaluated for evidence of SSI. The duration between surgery and the diagnosis of a post-operative SSI was assessed. Baseline and operative characteristics were compared between patients with an early SSI (within 30 days of surgery) and those with a late SSI (more than 30 days after surgery).Among 1,635 patients who underwent ventral hernia repair, 117 (7.2%) developed an SSI. The median (range) of days between surgery and SSI was 15 days (range, 2-763). There were 20 (17.1%) late SSIs diagnosed; of these, 17 were diagnosed between 31-90 d and three were diagnosed later than 90 days. Patients with a late SSI were more likely to have had a prior ventral hernia repair and have had biologic mesh (p = 0.001).Whereas the majority of SSIs after ventral hernia repair occurred within the first 30 days, a substantial number of late SSIs occurred. It is worthwhile to follow patients for at least 90 days post-operative in order to capture a more accurate picture of the true rate of SSI.

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).

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro–con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.

Background: Sentinel lymph node biopsy (SLNB) has replaced axillary node dissection for staging clinically node negative breast cancer patients. Previously, other investigators have found disparities in the rate of SLNB in African Americans. Therefore, we hypothesized that African Americans and Hispanics are offered SLNB less frequently than Caucasians in a large safety-net hospital. Methods: A retrospective review of female patients who underwent breast cancer surgery from 2002-2011 at a safety-net hospital was completed. Data was collected from the institutional cancer registry and medical record for: age at diagnosis, patient demographics, pathologic and clinical stage at presentation, and receipt of SLNB. Patients with clinically negative nodes (N0) were determined to be appropriate for SLNB. Patients with clinically positive nodes, biopsy proven nodal involvement, or stages IIIC or IV were deemed not appropriate for SLNB. Results: Of 566 patients, the mean age at diagnosis was 53 years (range: 28-79); 46% (n = 269) were Hispanic, 31% African American (n = 174), 17% Caucasian (n = 95) and 5% Asian/Other (n = 28). Based on clinical stage, which was available for 561 patients, 64% were eligible for SLNB. Of those, 95% received appropriate SLNB. Race was not a predictor of eligibility for or receipt of appropriate SLNB. TotalCaucasianAfrican AmericanHispanicOtherp-value %(n = 566)%(n = 95)%(n = 95)%(n = 269)%(n = 28) Clinical Stage 0.70010.4 (59)7.4 (7)10.9 (19)11.2 (30)10.7 (3) 123.5 (133)25.3 (24)24.7 (43)22.7 (61)17.9 (5) 2A28.3 (160)29.5 (28)24.7 (43)11.5 (31)35.7 (10) 2B15.4 (87)18.9 (18)19.0 (33)7.1 (19)17.9 (5) 3A6.0 (34)5.3 (5)5.7 (10)7.8 (21)0 3B7.6 (43)8.4 (8)6.9 (12)7.8 (21)7.1 (2) 3C3.4 (19)1.1 (1)1.7 (3)5.2 (14)3.6 (1) 44.6 (26)3.2 (3)5.7 (10)4.5 (12)3.6 (1) Unknown0.9 (5)1.1 (1)5.7 (10)0.7 (2)3.6 (1) Appropriate for SLNB64.0 (362)67.4 (64)61.5 (107)63.2 (170)75.0 (21)0.48Received appropriate SLNB94.7 (343)93.8 (60)92.5 (99)95.9 (163)100.0 (21)0.28 Conclusions: There was no difference in the rate of SLNB between racial and ethnic minority patients at a large safety-net hospital. The previously reported disparity likely resulted from more advanced presentation of disease rather than lack of appropriate care. Efforts to improve disparities seen in medically underserved patients should be focused on earlier detection and treatment of breast cancer. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-12-09.

Introduction: Racial and ethnic minority breast cancer patients present with later clinical stage at diagnosis, which may be due to lack of access to care due to poor socioeconomic status (SES). Our hypothesis was that the racial gap in clinical stage at breast cancer presentation would be eliminated after adjustment for SES. Methods: Retrospective review was performed of breast cancer (excluding ductal carcinoma in situ) patients from 10 hospitals in Harris County Texas between 2002 and 2011. Demographic and clinical information was recorded. Clinical stage was calculated based on data from the institutional tumor registry and electronic medical record. Zip code-based SES data, including mean household income and percentage of households receiving social support, were downloaded from www.census.gov. A multivariate ordered logistic regression clustered by hospital was used to identify predictors of clinical stage. Results: Of 3084 breast cancer patients, the mean age at diagnosis was 59 ± 14 years. The cohort included 1873 Caucasian (61%), 519 African-Americans (17%), 353 Hispanics (11%), and 339 Asian/others (11%). Age, race, mean household income, and percentage of household receiving social support were predictive of clinical stage at presentation (p Ordered Logistic RegressionVariableOdds RatioSEp-value95% CIMean Income0.998.2 e-060.0010.98 - 0.99% Social Support1.010.0020.0021.00 - 1.01Age0.980.0020.0410.97- 0.99Race African-American4.581.220.0002.72 - 7.72Hispanic1.991.260.2730.58 - 6.89Asian/other1.450.760.4730.52 - 4.04Caucasian = referent value for Race, SE = standard error, CI = confidence interval The largest racial gap was observed between African-Americans and Caucasians. African Americans from areas with a mean income up to $180K still had a lower predicted probability of presenting with clinical stage 1a disease than the Caucasians from the poorest mean income areas ( $305K) still had a higher probability of presenting with clinical stage 4 disease as Caucasians from areas with a mean income as low as $100K. Conclusion: Both African-American race and residence in a low SES zip code contribute independently to late clinical stage at presentation among breast cancer patients. Both genetic and social factors may play a role in this disparity. Addressing factors related to just race or low SES status alone is unlikely to improve outcomes for African-Americans from low SES zip codes. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-14.

Background The aim of this study was to evaluate the incidence, indications, and predictive factors of hospital readmission after open ventral hernia repair. Methods A retrospective review of all open ventral hernia repairs at a single institution from 2000 to 2010 was performed to assess readmissions between 1 to 30, 1 to 90, and 91 to 365 days. Multivariate analysis was performed to identify independent predictors of 30-day readmission. Results Of the 888 patients, 75 (8%) were readmitted between 1 and 30 days, 97 (11%) between 1 and 90 days, and 78 (9%) between 91 and 365 days. Unplanned readmissions related to the surgery constituted the majority of 1-day to 30-day and 1-day to 90-day readmissions (82% and 74%, respectively) but not between 91 and 365 days (32%). Prior superficial or deep surgical-site infection (odds ratio, 2.39; 95% confidence interval, 1.32 to 4.32) and duration of surgery (odds ratio, 1.35; 95% confidence interval, 1.05 to 1.73) were associated with 30-day readmission. Conclusions Efforts to reduce readmissions should be directed at modifiable risk factors for surgical-site infection and other surgical complications, particularly among those with prior skin infections and longer durations of surgery.

Background The impact of quality measures in health care and reimbursement is growing. Ensuring the accuracy of quality measures, including any risk-stratification variables, is necessary. Surgical site infection rates, risk stratified by surgical wound classification (SWC) among other variables, are increasingly considered as quality measures. We hypothesized that hospital-documented and diagnosis-based SWCs are frequently discordant and that diagnosis-based SWCs better predict surgical site infection rates. Study Design All pediatric patients (ie, younger than 18 years old) at a single institution who underwent an appendectomy for appendicitis between October 1, 2010 and August 31, 2011 were included. Each chart was reviewed to determine the hospital-documented SWC, which is recorded by the circulating nurse (options included clean, clean-contaminated, contaminated, and dirty); SWC based on the surgeons' postoperative diagnosis, including contaminated (ie, acute nonperforated, nongangrenous appendicitis), dirty (ie, gangrenous and perforated appendicitis), and 30-day postoperative surgical site infections. Results Of the 312 evaluated appendicitis cases, the diagnosis-based and circulating nurse–based SWCs differed in 288 (92%) cases. The circulating nurse–based and diagnosis-based SWCs differed by more than one SWC in 176 (56%) cases. Surgical site infections were associated with worsening diagnosis-based SWC, but not with circulating nurse–based SWC. Conclusions Significant discordance exists between hospital documentation by the circulating nurse- and surgeon diagnosis-based SWCs. Inconsistency in risk-stratified quality measures can have a significant effect on outcomes measures, which can lead to misdirection of quality-improvement efforts, incorrect inter-hospital rating, reduced reimbursements, and public misperceptions about quality of care.

Background Current risk-assessment tools for surgical site occurrence (SSO) and surgical site infection (SSI) are based on expert opinion or are not specific to open ventral hernia repairs. We aimed to develop a risk-assessment tool for SSO and SSI and compare its performance against existing risk-assessment tools in patients with open ventral hernia repair. Study Design A retrospective study of patients undergoing open ventral hernia repair (n = 888) was conducted at a single institution from 2000 through 2010. Rates of SSO and SSI were determined by chart review. Stepwise regression models were built to identify predictors of SSO and SSI and internally validated using bootstrapping. Odds ratios were converted to a point system and summed to create the Ventral Hernia Risk Score (VHRS) for SSO and SSI, respectively. Area under the receiver operating characteristic curve was used to compare the accuracy of the VHRS models against the National Nosocomial Infection Surveillance Risk Index, Ventral Hernia Working Group (VHWG) grade, and VHWG score. Results The rates of SSO and SSI were 33% and 22%, respectively. Factors associated with SSO included mesh implant, concomitant hernia repair, dissection of skin flaps, and wound class 4. Predictors of SSI included concomitant repair, dissection of skin flaps, American Society of Anesthesiologists class ≥3, wound class 4, and body mass index ≥40. The accuracy of the VHRS in predicting SSO and SSI exceeded National Nosocomial Infection Surveillance and VHWG grade, but was not better than VHWG score. Conclusions The VHRS identified patients at increased risk for SSO/SSI more accurately than the National Nosocomial Infection Surveillance scores and VHWG grade, and can be used to guide clinical decisions and patient counseling.

Radical resection is the primary treatment for rectal cancer. When anastomosis is possible, a temporary ileostomy is used to decrease morbidity from a poorly healed anastomosis. However, ileostomies are associated with complications, dehydration, and need for a second operation. We sought to evaluate the impact of ileostomy-related complications on the treatment of rectal cancer. We conducted a retrospective study of patients who underwent sphincter-preserving surgery between January 2005 and December 2010 at a tertiary cancer center. The primary outcome was the overall rate of ileostomy-related complications. Secondary outcomes included complications related to ileostomy status, ileostomy closure, anastomotic complications at primary resection, rate of stoma closure, and completion of adjuvant chemotherapy assessed by multivariate logistic regression. Of 294 patients analyzed, 32 % (n = 95) were women. Two hundred seventy-one (92 %) received neoadjuvant chemoradiation. The median tumor distance from the anal verge was 7 cm (interquartile range 5–10 cm). Two hundred eighty-one (96 %) underwent stoma closure at a median of 7 months (interquartile range 5.4–8.3 months). The most common complication related to readmission was dehydration (n = 32–11 %). Readmission within 60 days of primary resection was associated with delay in initiating adjuvant chemotherapy (odds ratio 3.01, 95 % confidence interval 1.42–6.38, p = 0.004). Diverting ileostomies created during surgical treatment of rectal cancers are associated with morbidity; however, this is balanced against the risk of anastomosis-related morbidity at rectal resection. Given the potential benefit of fecal diversion, patient-oriented interventions to improve ostomy management, particularly during adjuvant chemotherapy, can be expected to yield marked benefits.

Stress hyperglycemia is associated with increased risk of surgical site infections (SSIs). Use of strict or tight glycemic control with intensive insulin therapy to prevent SSIs is controversial.Review of pertinent English-language literature.There is a large body of literature supporting an association between stress hyperglycemia and SSIs. The quality of evidence from randomized controlled trials and meta-analyses that strict glycemic control reduces SSIs or any infections is low, and the strength of recommendation for strict glycemic control is weak due to the associated increase in moderate and severe hypoglycemia.Current recommendations for glycemic control in surgical patients are informed primarily by trials using intensive insulin therapy in critically ill patients. Further research is necessary to ascertain the optimal glycemic target for non-critically ill patients, to determine if subsets of patients may benefit from strict glycemic control, and to identify alternative methods for treating stress hyperglycemia and explaining the mechanisms by which it increases infectious risk.

Background Large databases provide a wealth of information for researchers, but identifying patient cohorts often relies on the use of current procedural terminology (CPT) codes. In particular, studies of stoma surgery have been limited by the accuracy of CPT codes in identifying and differentiating ileostomy procedures from colostomy procedures. It is important to make this distinction because the prevalence of complications associated with stoma formation and reversal differ dramatically between types of stoma. Natural language processing (NLP) is a process that allows text-based searching. The Automated Retrieval Console is an NLP-based software that allows investigators to design and perform NLP-assisted document classification. In this study, we evaluated the role of CPT codes and NLP in differentiating ileostomy from colostomy procedures. Methods Using CPT codes, we conducted a retrospective study that identified all patients undergoing a stoma-related procedure at a single institution between January 2005 and December 2011. All operative reports during this time were reviewed manually to abstract the following variables: formation or reversal and ileostomy or colostomy. Sensitivity and specificity for validation of the CPT codes against the mastery surgery schedule were calculated. Operative reports were evaluated by use of NLP to differentiate ileostomy- from colostomy-related procedures. Sensitivity and specificity for identifying patients with ileostomy or colostomy procedures were calculated for CPT codes and NLP for the entire cohort. Results CPT codes performed well in identifying stoma procedures (sensitivity 87.4%, specificity 97.5%). A total of 664 stoma procedures were identified by CPT codes between 2005 and 2011. The CPT codes were adequate in identifying stoma formation (sensitivity 97.7%, specificity 72.4%) and stoma reversal (sensitivity 74.1%, specificity 98.7%), but they were inadequate in identifying ileostomy (sensitivity 35.0%, specificity 88.1%) and colostomy (75.2% and 80.9%). NLP performed with greater sensitivity, specificity, and accuracy than CPT codes in identifying stoma procedures and stoma types. Major differences where NLP outperformed CPT included identifying ileostomy (specificity 95.8%, sensitivity 88.3%, and accuracy 91.5%) and colostomy (97.6%, 90.5%, and 92.8%, respectively). Conclusion CPT codes can identify effectively patients who have had stoma procedures and are adequate in distinguishing between formation and reversal; however, CPT codes cannot differentiate ileostomy from colostomy. NLP can be used to differentiate between ileostomy- and colostomy-related procedures. The role of NLP in conjunction with electronic medical records in data retrieval warrants further investigation.

Background Undocumented immigrants have been shown to be predisposed to worse clinical outcomes than the general population. This study examines survival in socioeconomically disadvantaged Hispanic documented and undocumented breast cancer patients. Methods Analysis of a prospective breast cancer database of patients treated in a safety-net hospital system. Overall survival was the primary outcome, and advanced stage at diagnosis (regional and metastatic) was a secondary outcome. Survival analysis and multivariate regression modeling were performed. Results Seven hundred fifty-one breast cancer patients were identified. Undocumented patients presented at an earlier age and were likely to present with advanced stage. After adjusting for covariates, undocumented status was not associated with increased mortality. The diagnosis-to-treatment interval was significantly longer in undocumented patients. Conclusions Despite undocumented patients presenting at a younger age, they have similar mortality compared with documented patients. This finding is partly explained by the local treatment afforded by undocumented patients, further studies are necessary to detail the reasons for these differences in presentation and outcome.

Breast cancer survival disparities by race are likely multifactorial. In a small pilot cohort, we demonstrated a statistical interaction between age and race. The purpose of this study was to validate earlier findings in a larger, more diverse cohort and to test the hypothesis that breast cancer survival is influenced by the dependent relationship of age and race. We conducted a retrospective analysis of a multi-institutional breast cancer database for patients treated between 1999 and 2009. Study variables included age and disease stage at diagnosis, race, treatment (surgery, chemotherapy, radiotherapy, hormone therapy) and overall survival. Statistical analysis and regression models were performed by Stata software. A total of 9,249 patients were included in this study. African American, Hispanic, and Asian patients were more likely to present at a younger age with metastases. African American and Hispanic race were associated with increased mortality after adjusting for stage, age, and treatment. A 2-way interaction between age and race was identified in the Cox regression model (p

Appendicitis is a common problem; there are more than 300,000 hospital discharges for appendicitis in the United States per year. Although the clinical scenario of periumbilical pain migrating to the right lower quadrant is classically associated with acute appendicitis, the presentation is rarely typical and the diagnosis cannot always be based on history and physical examination alone. Diagnostic errors are common, with over-diagnosis leading to negative appendectomies and with delays in diagnosis leading to perforations. The misdiagnosis of appendicitis has significant economic ramifications; in a nationwide study of administrative data over a 1-year period in the late 1990s, a negative appendectomy rate of 15% resulted in more than $740 million in hospital charges. Diagnostic strategies for evaluating patients with abdominal pain and for identifying patients with suspected appendicitis should all start with a thorough history and physical examination. The Surgical Infection Society (SIS) and Infectious Diseases Society of America (IDSA) published guidelines that recommend the establishment of local pathways for the diagnosis and management of acute appendicitis. The guidelines note that the combination of clinical and laboratory findings of characteristic abdominal pain, localized tenderness, and laboratory evidence of inflammation will identify most patients with suspected appendicitis. Other diagnostic strategies may include radiologic imaging or the use of scoring systems with or without computer support. Ultimately, the ‘‘gold standard’’ for a positive diagnosis is the histopathologic confirmation of appendicitis, although standard criteria are lacking. A negative diagnosis may be confirmed by intra-operative findings or clinical follow-up or both. There are different measures for evaluating a diagnostic test or strategy (Table 1). Sensitivity refers to the proportion of true positive tests among all patients who have the disease (A/[AþC]). Specificity refers to the proportion of true negatives among all patients who do not have the disease (D/[BþD]). Highly sensitive tests rule disease out, whereas highly specific tests rule disease in. Accuracy refers to the proportion of true positives and negatives among all patients tested ([AþD]/ [AþBþCþD]). The positive predictive value of a test refers to the proportion of true positives among all patients who test positive (A/[AþB]), whereas the negative predictive value refers to the proportion of true negatives among all patients who test negative (D/[CþD]). The predictive values of a test should be applied with caution to local patients as they depend upon the incidence