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Intestinal ischemia-reperfusion (I/R) injury is a severe disease associated with high mortality. Stimulator of interferon genes (STING) is an intracellular protein that is activated by cytosolic DNA and is implicated in I/R injury, resulting in transcription of type I interferons (IFN-α and IFN-β) and other proinflammatory molecules. Extracellular cold-inducible RNA-binding protein (eCIRP), a damage-associated molecular pattern, induces STING activation. H151 is a small molecule inhibitor of STING that has not yet been studied as a potential therapeutic. We hypothesize that H151 reduces inflammation, tissue injury, and mortality after intestinal I/R. Methods: In vitro, RAW264.7 cells were pretreated with H151 then stimulated with recombinant murine (rm) CIRP, and IFN-β levels in the culture supernatant were measured at 24 hours after stimulation. In vivo, male C57BL/6 mice were subjected to 60-minute intestinal ischemia via superior mesenteric artery occlusion. At the time of reperfusion, mice were intraperitoneally instilled with H151 (10 mg/kg BW) or 10% Tween-80 in PBS (vehicle). Four hours after reperfusion, the small intestines, lungs, and serum were collected for analysis. Mice were monitored for 24 hours after intestinal I/R to assess survival. Results: In vitro, H151 reduced rmCIRP-induced IFN-β levels in a dose-dependent manner. In vivo, intestinal levels of pIRF3 were increased after intestinal I/R and decreased after H151 treatment. There was an increase in serum levels of tissue injury markers (lactate dehydrogenase, aspartate aminotransferase) and cytokine levels (interleukin 1β, interleukin 6) after intestinal I/R, and these levels were decreased after H151 treatment. Ischemia-reperfusion-induced intestinal and lung injury and inflammation were significantly reduced after H151 treatment, as evaluated by histopathologic assessment, measurement of cell death, chemokine expression, neutrophil infiltration, and myeloperoxidase activity. Finally, H151 improved the survival rate from 41% to 81% after intestinal I/R. Conclusions: H151, a novel STING inhibitor, attenuates the inflammatory response and reduces tissue injury and mortality in a murine model of intestinal I/R. H151 shows promise as a potential therapeutic in the treatment of this disease.

The purpose of this study was to implement a checklist monitoring system and identify critical surgical checklist items associated with post-colectomy surgical site infections (SSI). The relationship between checklist compliance, infection rates, and identification of non-compliant surgeons was explored.National Health Safety Network (NHSN) data were imported annually to establish baseline incidence of post-colectomy SSI from 2016 to 2019. A colectomy checklist was used to monitor compliance for 1694 random colectomies (1274 elective; 420 emergency). Reports were generated monthly to profile system, hospital, surgeon-specific infection, and checklist compliance rates.Checklist compliance improved in elective and emergent colectomies to 90% for all items except oral antibiotic and mechanical bowel prep in elective cases. Annualized total SSI and organ space infection rates in elective cases decreased by 33% and 45%, respectively. Elective and emergency SSI's were reduced for Superficial Incisional Primary (SIP), Deep Incisional Primary (DIP), and Intra-Abdominal Abscess (IAB) by 66%, 60.4%, and 78.3%, respectively. Checklist compliance between low ( 3%) and high ( 3%) infection rate surgeons demonstrated significantly lower utilization of oral antibiotic prep (p 0.03) and mechanical bowel prep (p 0.02) in high infection rate surgeons.Surgeons compliant with colectomy checklists decreased elective and emergency colectomy infection rates. Ceiling compliance rates 95% for bundle items are suggested to achieve optimal reductions in SSIs and efforts should be focused on surgeons with NHSN infection rates 3%. Oral antibiotic prep and mechanical bowel prep compliance rates in elective colectomy appeared to differentiate high infection rate surgeons from low infection rate surgeons.

Practice-Based Learning and Improvement, a core competency identified by the Accreditation Council for Graduate Medical Education, carries importance throughout a physician's career. Practice-Based Learning and Improvement is cultivated by a critical review of complications, yet methods to accurately identify complications are inadequate. Machine-learning algorithms show promise in improving identification of complications. We compare a manual-supplemented natural language processing (ms-NLP) methodology against a validated electronic morbidity and mortality (MM) database, the Morbidity and Mortality Adverse Event Reporting System (MARS) to understand the utility of NLP in MM review.The number and severity of complications were compared between MARS and ms-NLP of surgical hospitalization discharge summaries among three academic medical centers. Clavien-Dindo (CD) scores were assigned to cases with identified complications and classified into minor (CD I-II) or major (CD III-IV) harm.Of 7774 admissions, 987 cases were identified to have 1659 complications by MARS and 1296 by ms-NLP. MARS identified 611 (62%) cases, whereas ms-NLP identified 670 (68%) cases. Less than one-third of cases (299, 30.3%) were detected by both methods. MARS identified a greater number of complications with major harm (457, 46.30%) than did ms-NLP (P 0.0001).Both a prospectively maintained MM database and ms-NLP review of discharge summaries fail to identify a significant proportion of postoperative complications and overlap 1/3 of the time. ms-NLP more frequently identifies cases with minor complications, whereas prospective voluntary reporting more frequently identifies major complications. The educational benefit of reporting and analysis of complication data may be supplemented by ms-NLP but not replaced by it at this time.

Background Fenoldopam is a short-acting dopamine A1 receptor agonist which mediates vasodilation of the renal arteries, thereby increasing urine output. The objective of this study was to compare the effects of fenoldopam and its synergistic effect on furosemide for improving the urine output in postoperative critically ill patients with acute kidney injury (AKI). Methods This is a retrospective study of postoperative critically ill patients with AKI. Patients who received furosemide (control group) were compared with those who received furosemide plus fenoldopam (treatment group) and evaluated at 12 and 24 hours post-treatment. Patients with oliguria and AKI were included in the study, while patients with chronic kidney disease (CKD) were excluded. Glomerular filtration rate, serum creatinine, blood pressure, calculated fluid accumulation, fluid intake, urine output, and total fluid output were used as variables to assess the medication effect. Results Of the 126 patients who met the inclusion and exclusion criteria, 87 patients received furosemide alone, and 39 patients received furosemide plus fenoldopam during their first 24 hours of admission to the surgical intensive care unit (SICU). Although not statistically significant, the addition of fenoldopam demonstrated an increase in mean urine output of 1525ml (IQR; 1530-2095) in the first 24 hours (P=0.06). There was also noted an increase in the urine output (p= 0.07) and a decrease in the total fluid accumulation when fenoldopam was co-administered with furosemide when compared to the patients who were only treated with furosemide (p=0.06). There was no significant change in creatinine clearance from baseline in either group. Conclusion Fenoldopam may increase urine output in postoperative critically ill patients with acute kidney injury when administered within the first 24 hours of presentation. Based on our results, fenoldopam appears to have a synergistic effect with furosemide in our study population.

Background Laparoscopic cholecystectomy is the most common laparoscopic procedure performed in the United States. Our aim was to determine if increased operative time (OT) is associated with increased morbidity following laparoscopic cholecystectomy. Methods Using ACS NSQIP from 2006 to 2015, we identified all adult (≥18 years) patients that underwent laparoscopic cholecystectomy for cholecystitis performed within 3 days of admission. Our analysis was limited to cases with OT ≥15 minutes and ≤360 minutes. Outcome variables included postoperative surgical site infections (SSI), dehiscence, pneumonia, reintubation, failure to wean from ventilator, pulmonary embolism, renal failure, urinary tract infection, cardiac arrest, myocardial infarct, bleeding, deep vein thrombosis, sepsis, septic shock, return to the operating room, and death. Results 7,031 cases met inclusion criteria. Median OT was 63 minutes, first quartile was 46 minutes and third quartile was 87 minutes. Logistic regression analysis showed that increased OT (third vs first quartile) was an independent risk factor for superficial SSI (OR 1.75, 95% CI 1.36-2.25, P < .0001), organ-space SSI (OR 1.77, 95% CI 1.33-2.35, P < .0001), dehiscence (OR 2.03, 95% CI 1.01-4.07, P = 0.0470), and septic shock (OR 1.81, 95% CI 1.06-3.09, P = 0.0286). Increased OT was independently associated with increased LOS (fourth vs 1st quartile: IRR 1.53, P < 0.0001; third vs 1st quartile: IRR 1.29, P < .0001; 2nd vs 1st quartile: IRR 1.16, P < 0.0001). Conclusion Increased OT is independently associated with morbidity and increased LOS following laparoscopic cholecystectomy for cholecystitis. Prospective studies are warranted to determine which factors contribute to increased OT and why.

We report the successful treatment of a moribund patient as a result of amniotic fluid embolism with cardiopulmonary bypass and open pulmonary artery thromboembolectomy. Review of the literature indicates that this is the first reported case of treatment of amniotic fluid embolism with cardiopulmonary bypass and pulmonary thromboembolectomy.

Liver surgery for colorectal liver metastasis has dramatically changed in recent years. A better knowledge of the natural history and biology of the primary tumor and a more thorough understanding of segmental liver anatomy are the major conceptual advancements. Also more effective diagnostic tools, such as serial carcinoembryonic antigen (CEA), preoperative and intraoperative ultrasound (US), CT scan, CT angioportography, and magnetic resonance imaging (MRI), have all contributed to earlier diagnosis and improved patient selection. Liver-sparing surgery (segmental approaches) using ultrasonic dissection techniques have also significantly decreased morbidity and mortality while still achieving improved radicality in the surgical resection of metastatic liver disease.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to l-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primary carcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

A case of an unusually large cystic renal cell carcinoma demonstrated on plain film, CT, and magnetic resonance (MR) is presented. Though the origin of huge abdominal tumors can be difficult to determine, the CT and MR findings were able to correctly diagnose the mass as a malignant cystic kidney tumor.

Presented is the case of a patient with inguinal endometriosis adjacent to a hernia sac in whom laparoscopy revealed no evidence of pelvic endometriosis.