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Retained surgical items (RSIs) are rare but serious events associated with significant morbidity and costs. We assessed the effectiveness of radiofrequency (RF) detection technology and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in reducing the incidence of RSIs.All RSIs reported to the New York Patient Occurrence Reporting and Tracking System at five large urban teaching hospitals from 2007 to 2017 were analyzed. In 2012, TeamSTEPPS training was provided to all perioperative staff at each site, and use of RF detection became required in all procedures. The incidence of events before and after the interventions were compared using odds ratios.A total of 997,237 operative procedures were analyzed. After the interventions, the incidence of RSIs decreased from 11.66 to 5.80 events per 100,000 operations (odds ratio [OR] [95% CI] = 0.50 [0.32 to 0.78]). The frequency of RSIs involving RF-detectable items decreased from 5.21 to 1.35 events per 100,000 operations (OR [95% CI] = 0.26 [0.11 to 0.60]). The difference in RSIs involving non-RF-detectable surgical items was not statistically significant.The incidence of RSIs was significantly lower during the time period after implementing RF detection technology and after TeamSTEPPS training, primarily driven by a decrease in retained RF-detectable items. RF detection technology may be worth pursuing for hospitals looking to decrease RSI frequency. The benefit of TeamSTEPPS training alone may not result in a reduction of RSIs.

Background The COVID-19 pandemic disrupted healthcare systems throughout the world. We examine whether appendectomy outcomes in 2020 and 2021 were affected by the pandemic. Methods We conducted a retrospective cohort study of 30-day appendectomy outcomes using the ACS-NSQIP database from 2019 through 2021. Logistic regression and linear regression analyses were performed to create models of post-operative outcomes. Results There were no associations between the time period of surgery and death, readmission, reoperation, deep incisional SSI, organ space SSI, sepsis, septic shock, rate of complicated appendicitis, failure to wean from the ventilator, or days from admission to operation. During the first 21 months of the pandemic (April 2020 through December 2021), there was a decreased length of hospital stay (p = 0.016), increased operative time (p Conclusions There were minimal differences in emergent appendectomy outcomes during the first 21 months of the pandemic when compared to 2019. Surgical systems in the US successfully adapted to the challenges presented by the COVID-19 pandemic.

Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs.Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time.A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P 0.001).Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Splenectomy, still a commonly performed treatment for splenic injury in trauma patients, has been shown to have a high rate of complications. The purpose of this study was to identify predictors, including race and insurance status, associated with adverse outcomes post-splenectomy in trauma patients. We discuss possible explanations and methods for reducing these disparities.The American College of Surgeons - Trauma Quality Improvement Program (ACS-TQIP) participant user database was queried from 2010 to 2015 and patients who underwent total splenectomy were identified. All mechanisms of injury, including both blunt and penetrating trauma, were included. Patients with advance directives limiting care or aged under 18 were excluded. Propensity score matching was used to control for age, preexisting medical conditions, and the severity of the traumatic injury. A chi-squared test was used to find significant associations between available predictors and outcomes for this cross-sectional study.The post-splenectomy mortality rate was 9.2% (n = 1047), 8.0% (n = 918) of patients had three or more complications, and 20.3% (n = 2315) had major complications. A primary race of white (OR 0.7, 95% Confidence Interval (CI) 0.6-0.9, p 0.01) and private insurance (OR 0.5, 95%CI 0.4-0.6, p 0.01) were associated with lower risks of mortality A primary race of neither Black nor white (OR 1.3, 95%CI 1.03-1.7, p = 0.03) and a lack of health insurance ("self-pay") (OR 1.6, 95%CI 1.3-1.9, p 0.01) were both correlated with mortality. When limited to hospitals of 600+ beds, there were no associations between race and mortality.The post-splenectomy mortality rate after trauma remains high. In U.S. trauma centers, a primary race of Black and payment status of "self-pay" are associated with adverse outcomes after splenectomy following a traumatic injury. These disparities are reduced when limiting analysis to larger hospitals. Efforts to reduce disparities in outcomes among trauma patients requiring a splenectomy should focus on improving resource availability and quality in smaller hospitals.

Background The prevalence of burnout and depression are high among surgical trainees. This study examined the impact of program-driven initiatives to improve surgical trainee wellness. Methods A survey was administered to residents and fellows at all surgical training programs across an urban academic health system. The survey measured burnout, depressive symptoms, and perceptions of program-driven wellness initiatives. Results The response rate was 44% among 369 residents. Of these, 63.2% screened positively for burnout, and 36.7% for depression. Residents who were burned out were more likely to work >80 h per week, have greater clerical duties, and miss educational activities more frequently. Conversely, having opportunities for wellness activities, dedicated faculty and housestaff wellness champions, and assistance with clerical burden were all associated with lower rates of burnout and depression. Conclusion The presence of wellness support was associated with better outcomes, suggesting the value of initiatives to manage workload and support the well-being of surgical resident physicians.

ImportanceUnprofessional behaviors and mistreatment directed at trainees continue to challenge the learning environment. Academic medical institutions should encourage reports of inappropriate behavior and address such reports directly to create a safe learning environment.ObjectiveTo determine the feasibility of creating and implementing an online reporting system for receiving and reviewing complaints of unprofessional behavior directed toward or experienced by students, postdoctoral trainees, and residents.Design, Setting, and ParticipantsThis cohort study assessed implementation of an online reporting system (feedback form) with a method for triaging reports, providing both positive and negative feedback, as well as adjudication and transparent public disclosure of aggregate data. The system was launched at a large urban academic medical center with numerous trainees that is fully integrated with a health system of 8 hospitals. Participants included faculty who interact with trainees, medical students, graduate students and postdoctoral fellows, and residents and clinical fellows. Follow-up began in October 2019 (at the time of tool launch) and lasted through December 2021. Data were analyzed from January to March 2022.Main Outcomes and MeasuresThe primary outcomes were the numbers and types of reports according to the reporter and the person reported about.ResultsParticipants included 2900 faculty who interact with trainees, 600 medical students, more than 1000 graduate students and postdoctoral fellows, and 2600 residents and clinical fellows. Trainees submitted 196 reports, 173 (88.3%) of which described unprofessional interactions. Among the reports describing unprofessional behavior, 60 (34.7%) were from medical students, 96 (55.5%) were from residents and fellows, 17 (9.8%) were from graduate students or postdoctoral trainees, and 78 (45.1%) were from men. The majority of negative reports described behaviors by faculty (106 [61.3%]), followed by residents and fellows (24 [13.9%]). Twenty faculty (Conclusions and RelevanceIn this cohort study, the new reporting mechanism facilitated identification of the small number of individuals associated with unprofessional behaviors toward trainees and increased awareness of the school’s commitment to creating a safe learning environment.

Background Locally advanced pancreatic tumors may require vascular reconstruction for complete resection. However, pancreatoduodenectomy with vascular resection (PDVR) remains a subject of debate due to increased complications. Methods Patients were identified using the ACS NSQIP Participant User Data Files from 2014 to 2019. Results The 30-day mortality rate was 2.7%; major complications occurred in 32.2%. There is an increasing trend of PDVR in patients requiring pancreatectomy. There were no significant differences in mortality between PDVR with vein, artery, or venous and arterial resections. High BMI and postoperative biliary stent were risk factors for early complications. High BMI and COPD increased risk of early mortality. Chemotherapy and chemoradiotherapy were negative predictors for early morbidities and mortality, respectively. Conclusion This study identifies the predictors of early morbidity and mortality in PDVR. The results of this study may assist decision making in perioperative management to optimize overall survival and guide additional research., Highlights • Pancreaticoduodenectomy with concomitant vascular reconstruction (PDVR) for carcinoma is increasing in frequency for locally advanced pancreatic neoplasms. • Early morbidity and mortality rates are acceptable. • Patients with elevated body mass index (BMI) and underlying COPD have a higher mortality. • Elevated BMI and preoperative biliary stenting are associated with a higher incidence of early complications. • Neoadjuvant chemotherapy and chemoradiation may also improve resectability and post-operative outcomes.

BACKGROUND The association between psychiatric illness and outcomes in trauma patients in general has only recently been investigated. The aim of this study was to describe the unique characteristics, risk factors, and outcomes of patients with comorbid psychiatric illness and penetrating abdominal and pelvic injuries. MATERIALS AND METHODS This was a retrospective review of trauma patients with open injuries to the abdomen and pelvis identified in the 2010-2015 the American College of Surgeons Trauma Quality Improvement Program database. Baseline variables extracted included demographics, comorbidities, including a discrete "psychiatric illness" variable that preexisted in the database, and injury information. Outcome variables collected included in-hospital mortality, length of stay and intensive care unit stay, and complications. Categorical variables were analyzed using chi-square and Fisher's exact test. Logistic regression was used to assess independent predictors for mortality with odds ratios (ORs) and 95% confidence intervals (CIs) constructed about group differences. RESULTS There were 22,053 patients identified, 6.1% of whom were diagnosed with a psychiatric comorbidity. Patients with psychiatric illnesses were more likely to be aged ≥65 y (5.4% versus 3.2%, P

Introduction Mitral valve repair has been established as the preferred treatment option in the management of degenerative mitral valve disease. Compared with other surgical treatment options, mitral valve repair is associated with increased survival and decreased rates of both complications and reoperations. However, among patients undergoing mitral valve repair, little is known about the predictors of postoperative outcomes. The purpose of this study is to identify preoperative patient risk factors associated with postoperative morbidity and mortality within 30 days of mitral valve repair. Methods Data was derived from the American College of Surgeons National Surgical Quality Improvement Program database to assess patients who underwent mitral valve repair from 2011 through 2017. Preoperative risk factors were analyzed to determine their association with a variety of postoperative 30-day outcome measures. Results One thousand three hundred and sixty-six patients underwent mitral valve repair; 849 (62.2%) males and 517 (37.8%) females. Ages ranged from 18 to 90 years, with a mean age of 64 years. The overall 30-day mortality was 3.1% (43 patients). Among the 12 identified risk factors associated with increased mortality on univariate analysis, pre-operative hematocrit level was the only variable significantly correlated with mortality after undergoing multivariate analysis. 259 patients (19.1%) were discharged to a location other than home, an outcome associated with 22 identified risk factors. Among these risk factors, female gender, age, dialysis, pre-operative serum sodium, pre-operative serum albumin, and partial or full living dependency remained statistically significant following multivariate analysis. 126 patients (9.2%) experienced unplanned readmission. This outcome was associated with five risk factors, of which only dyspnea upon mild exertion was significant on multivariate analysis. Reoperation occurred in 105 patients (7.7%). Of the seven identified variables associated with reoperation, patient age, pre-operative platelet count, dyspnea upon mild exertion were independent predictors on multivariate analysis. 53 patients (3.9%) underwent reintubation, which was associated with 11 identified risk factors. Among them, patient age and pre-operative INR value were predictive of reintubation on multivariate analysis. 26 patients (1.9%) experienced stroke, of whom age was the only associated risk factor on both univariate and multivariate analysis. 31 patients (2.3%) experienced acute renal failure, which correlated with 11 risk factors on univariate analysis. Of these, only patient age and pre-operative hematocrit were identified as independent predictors on multivariate analysis. Conclusions Outcomes are good following mitral valve repair. Although a substantial number of risk factors were found to be associated with adverse outcomes, only a small subset remained statistically significant following multivariate analysis. Identification of these risk factors may help guide clinical decision making with respect to which patients are the best candidates to undergo mitral valve repair., Highlights • There is minimal literature on adverse 30-day outcomes following mitral valve repair. • This study identified independent predictors of mortality, discharge location, readmission, reoperation, and reintubation. • Management of these risk factors may help guide clinical decision making., Article SummaryThe literature is limited regarding predictors of adverse 30-day outcomes following mitral valve repair. Through the use of the ACS NSQIP database, this study identified independent predictors of mortality, discharge location, readmission, reoperation, and reintubation. Management of the identified patient risk factors may help guide clinical decision making prior to undergoing surgery.

Background Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately. Results Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035–0.106) and (OR 0.052 CI 0.024–0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026–0.185) and (OR 0.059, CI 0.015–0.229), respectively. Conclusions Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.

Background and Objectives: With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately. Results: Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P

It is presently considered the standard of care to perform many routine intra-abdominal operations using a minimally invasive approach. The authors recently identified a racial disparity in access to a laparoscopic approach to inguinal hernia repair, cholecystectomy, appendectomy, and colectomy. The present study further evaluates this patient cohort to assess the relationship between the race and postoperative complications and test the mediating effect of the selected surgical approach.After institutional review board approval, patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent inguinal hernia repair, cholecystectomy, appendectomy, or colectomy in 2016 were identified. Patient demographics, including the self-reported race and ethnicity, as well as clinical, operative, and postoperative variables were recorded. After the exclusion of cases associated with diagnoses of cancer, a 4:1 propensity score matching algorithm generated a clinically balanced cohort of patients of white and black self-reported race. The mediating effect of an open approach to surgery on the relationship between black self-reported race and postoperative complications was evaluated via a series of regressions.There were 41,340 unilateral inguinal hernia repairs, 3182 bilateral inguinal hernia repairs, 60,444 cholecystectomies, 50,523 appendectomies, and 58,012 colectomies included in the database in 2017. Exclusion of cases associated with cancer and subsequent propensity score matching returned 17,540 unilateral hernia repairs, 890 bilateral hernia repairs, 23,865 cholecystectomies, 11,660 appendectomies, and 12,320 colectomies. On mediation analysis, any complication, severe complication, and death were significant when regressed on black self-reported race (any: odds ratio [OR] = 1.210, 95% confidence interval [CI] = 1.132-1.291, P 0.001; severe: OR = 1.352, 95% CI = 1.245-1.466, P 0.001; death: OR = 1.358, 95% CI = 1.000-1.818, P = 0.044), and open surgery was a significant mediator in the incidence of any complication and severe complication (any: OR = 1.180, 95% CI = 1.105-1.260, P 0.001 and severe: OR = 1.307, 95% CI = 1.203-1.418, P 0.001).These findings underscore the importance of access to a minimally invasive approach to surgery. However, other factors may contribute to racial disparities in postoperative complications after common abdominal operations.

This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene.We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality.5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age 65 (P 0.0001), independent functional status prior to admission (P 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693).LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

Background Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. Study design This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. Results Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p 3(OR 12.0, 95%CI 8.5–16.9,p 1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit 240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p, Highlights • Cardiac events following general and vascular surgery were associated with a mortality rate of 55%. • Underlying risk factors for cardiac events following general and vascular surgery include COPD, hypertension on medication, and renal failure. • Return to the OR, deep wound infection, unplanned intubation and ventilator dependence are also associated with a post-op cardiac event.

Formal training in leadership development has become increasingly popular among physicians. There is a growing interest to provide this educational content to medical students and residents so that they will have these skills upon the start of their clinical or academic medical practice. It is possible to provide the proper management skills to medical trainees so they will have the opportunity to utilize and master these competences during their education. This chapter provides an overview of the available content and the literature to support the integration of this curriculum into formal undergraduate and graduate medical education. This chapter provides a template for the development of a longitudinal experience and the necessary proficiencies to allow trainees to develop as effective clinical leaders.

Background Endovascular approaches to aortoiliac disease are becoming increasingly frequent due to decreases in recovery time, bleeding, and discomfort. Despite this trend, little is known about the predictors of complications. This study was designed to identify risk factors for major 30-day morbidity and mortality after endovascular repair. Methods Data were derived from the 2015–2016 Participant User Files and Procedure Targeted databases of the American College of Surgeons National Surgical Quality Improvement Program. Demographics and comorbidities of patients undergoing repair were assessed. Preoperative risk factors were analyzed using univariate and multivariate analysis. Results Twelve hundred and nine patients underwent endovascular aortoiliac repair, including 532 females (44.0%) and 677 males (56.0%). The 30-day mortality rate was 0.7%. Diabetes mellitus requiring medication, chronic steroid use, dialysis, pre-existing open wound, age, and low serum albumin and hematocrit increased mortality. After logistic regression, 30-day mortality was correlated with low serum albumin (survivors = 3.77, nonsurvivors = 2.60; P = .003) and chronic steroid use (P = .020). Multivariate analysis identified high preoperative white blood cell count as a risk factor for amputation. Diabetes, smoking history, and low serum sodium were risk factors for return to the operating room. Female sex and steroid use were risk factors for myocardial infarction and stroke. Open wounds and high platelets were risk factors for the need for an operative bypass after endovascular intervention. Preprocedural statin use was protective against need for a later operative bypass and reintervention. Conclusions Open wound, smoking, preprocedural steroid use, diabetes, female sex, high platelet and white blood cell count, and low serum albumin are the most strongly associated risk factors for adverse 30-day postoperative outcomes. Mortality rates remain low after endovascular aortoiliac revascularization.

Objectives To determine if there is a correlation between the numbers of evaluations submitted by faculty and the perception of the quality of feedback reported by trainees on a yearly survey. Method 147 ACGME-accredited training programs sponsored by a single medical school were included in the analysis. Eighty-seven programs (49 core residency programs and 38 advanced training programs) with 4 or more trainees received ACGME survey summary data for academic year 2013–2014. Resident ratings of satisfaction with feedback were analyzed against the number of evaluations completed per resident during the same period. R-squared correlation analysis was calculated using a Pearson correlation coefficient. Results 177,096 evaluations were distributed to the 87 programs, of which 117,452 were completed (66%). On average, faculty submitted 33.9 evaluations per resident. Core residency programs had a greater number of evaluations per resident than fellowship programs (39.2 vs. 27.1, respectively, p = 0.15). The average score for the “satisfied with feedback after assignment” survey questions was 4.2 (range 2.2–5.0). There was no overall correlation between the number of evaluations per resident and the residents' perception of feedback from faculty based on medical, surgical or hospital-based programs. Conclusions Resident perception of feedback is not correlated with number of faculty evaluations. An emphasis on faculty summative evaluation of resident performance is important but appears to miss the mark as a replacement for on-going, data-driven, structured resident feedback. Understanding the difference between evaluation and feedback is a global concept that is important for all medical educators and learners., Highlights • Residents and fellows do not perceive that regular evaluations are the same as feedback. • The quantity of faculty evaluations does not correlate the resident perception of quality feedback. • A greater emphasis is necessary to instruct faculty on providing regular, timely and data-driven feedback to residents and fellows with specific comments on performance. • Faculty summative evaluation of resident performance is important but this is not a replacement for structured feedback.

Background Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. Methods A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. Results In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. Conclusion After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Background: Sepsis is an uncommon occurrence after appendectomy, but the morbidity and mortality of patients who develop sepsis after appendectomy remains exceedingly high. The purpose of ...

This study analyzed trends in laparoscopic inguinal hernia repair over time, rates of laparoscopic repair in women, and subsequent postoperative outcomes.Data for 237,503 patients undergoing repair of an initial, reducible inguinal hernia were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2006-2017. Data were analyzed by univariate and multivariate analysis.Since 2006, there was an increased proportion of laparoscopic inguinal hernia surgeries, from 20.49% in 2006 to 36.36% in 2017 (p .001). The percentage of women with bilateral inguinal hernias that underwent laparoscopic repair was less than the percentage of men (31.58% vs. 41.43%, p .001). Based on multivariate analysis, women were less likely to have laparoscopic hernia repair (OR 0.74, CI 0.71-0.76). Postoperative complications were overall low.A greater proportion of inguinal hernia repairs are performed laparoscopically. Women with bilateral inguinal hernias are more likely than men to undergo open rather than laparoscopic inguinal hernia repair.

Background: Diaphragmatic hernia is a complication of trauma that may lead to significant morbidity and mortality if unrecognized. The clinical sequelae following missed traumatic diaphragmatic hernia (TDH) diagnoses have not been well-defined. Methods: The 2005–2015 ACS-NSQIP databases were accessed to identify patients ≥18 years old who underwent operative repair of acute and chronic TDH. Patient demographics, health characteristics, pertinent complications, and 30-day outcomes were collected. Categorical variables were analyzed using chi-square and Fisher’s Exact Test. Logistic regression was used to perform multivariate analyses with odds ratios (OR) and 95% confidence intervals (CI) constructed about group differences. Results: From 2005–2015, 1000 patients underwent operative repair for TDH, of which 285 (28.5%) were acute and 715 (71.5%) were chronic. Patients undergoing acute repairs had a greater percentage of emergency procedures (29.8% vs. 10.2%, p 2 (51.2% vs 43.2%, p = 0.02). Acute TDH patients were more likely to develop postoperative wound infection (1.40% vs 0.28%, p = 0.05), infectious process (11.2% versus 7.0%, p = 0.03), failure to wean from mechanical ventilation (8.1% vs 3.4%, p = 0.0015), and remain hospitalized at 30 days (4.3% vs 0.9%, p = 0.0058). Conclusions: Patients with acute TDH repair are more likely to develop postoperative complications. Further study is necessary to determine the optimal timing of surgery for TDH discovered following initial resuscitation and evaluation.

Laparoscopy has become the standard of care for the majority of cases for inguinal hernia repair, cholecystectomy, appendectomy, and colectomy due to the shortened patient recovery time compared to open surgery. This study sought to determine if there exists racial disparity in access to a laparoscopic approach to these common surgeries. This was an IRB-approved retrospective study utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Individuals who underwent inguinal hernia repair, cholecystectomy, appendectomy, and colectomy in 2016 were identified. Information on self-reported race and ethnicity and other demographic and pre-operative clinical covariates were recorded. Propensity matching was conducted to evaluate the association between race and a laparoscopic approach to surgery. There were 44,522, 60,444, 50,523, and 58,012 cases of inguinal hernia repair, cholecystectomy, appendectomy, and colectomy identified, respectively. Of these patients, 8.38, 8.76, 6.69, and 9.02% self-identified as black, respectively. Confounding effects of variables other than race were balanced by propensity matching. After propensity matching, there were 7460, 10,574, 10,470, and 6758 cases of hernia repair, cholecystectomy, colectomy, and appendectomy, respectively. On univariate (Chi square) analysis with laparoscopic surgery as the primary outcome, black race was significantly associated with lower likelihood of undergoing a minimally-invasive surgical approach in all four surgical procedures under investigation (33.86% of white patients and 21.69% of black patients, p

Background Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock. Methods Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an “investigational use only” study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods. Results 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p, Highlights • Finger-stick capillary lactate correlates with blood gas and core lab values. • Capillary lactate trends closely over time with arterial lactate. • Rising or falling capillary lactate reflects the adequacy of global perfusion. • Capillary lactate measurements require a fraction of the time and blood to process. • Preliminary results imply capillary lactate may be used in lieu of invasive methods.

Background A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infections. Such infections increase morbidity, length of stay, and overall cost. This study evaluates the correlation between elevated pre-operative glycosylated hemoglobin (HbA1c) and post-operative infections. Study design Adult patients undergoing non-emergent procedures across all surgical subspecialties from January 2010 to July 2014 had a preoperative HbA1c measured as part of their routine pre-surgical assessment. 2200 patient charts (1100, Highlights • This study reviews the impact of pre-operative HbA1c across many specialties undergoing elective surgery. • The risk factors of post-operative infection are multiple and likely synergistic. • Elevated serum HbA1c is not independently associated with an increased risk of post-operative infection.

Background Components separation technique emerged several years ago as a novel procedure to improve durability of repair for ventral abdominal hernias. Almost twenty-five years since its initial description, little comprehensive risk adjusted data exists on the morbidity of this procedure. This study is the largest analysis to date of short-term outcomes for these cases. Methods The ACS-NSQIP database identified open ventral or incisional hernia repairs with components separation from 2005 to 2012. A data set of cohorts without this technique, matched for preoperative risk factors and operative characteristics, was developed for comparison. A comprehensive risk-adjusted analysis of outcomes and morbidity was performed. Results A total of 68,439 patients underwent open ventral hernia repair during the study period (2245 with components separation performed (3.3%) and 66,194 without). In comparison with risk-adjusted controls, use of components separation increased operative duration (additional 83 min), length of stay (6.4 days vs. 3.8 days, p, Highlights • The repair of large abdominal wall hernias is more frequently performed using components separation. • While this technique appears to reduce recurrence, morbidity has not been previously studied. • When compared to a large cohort, components separation has a higher complication rate than traditional open hernia repair.

Introduction: When evaluating the cost of a lifesaving operation, one must consider the economic value, which can be defined as the relative cost per additional year of life lived. This evaluation might provide useful information for the application of costly procedures. The objective of this study was to determine the cost per year of life saved for the costliest operations performed at an urban academic medical center. Methods: Total hospital expenditures were categorized by diagnosis related group (DRG) between January 1, 2015 and December 31, 2016. Average cost and patient age for each procedure were calculated. Average lifespan following successful outcome was determined based upon published benchmarks. Cost per year of life saved was calculated for each procedure. Only those elective procedures necessary to prolong life and enhance health were analyzed. Results: 114,448 hospital admissions were reviewed. The 12 costliest procedures were identified and ranked according to cost per year of life saved: Coronary bypass ($1,345.45), portacaval shunt procedure ($2,261.70), cardiac valve/other major cardiothoracic procedure ($2,733.78), major bladder procedure ($2,733.78), cardiac defibrillator implant ($5,047.65), bone marrow transplant ($5,181.80), intracranial vascular procedures ($8,572.05), kidney transplant ($9,024.87), liver transplant ($11,112.73), endovascular cardiac valve replacement ($12,842.25), simultaneous pancreas/kidney transplant ($14,087.50), and heart transplant ($20,472.11). Conclusion: Among the costliest procedures, coronary bypass was the most economic, having the lowest cost per year of life saved ($1,345.45) and longest post-procedure life expectancy (17.6 years). These findings combined with further analysis of the identified procedures may allow us to better determine their relative value.

Background Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. Methods Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. Results A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). Conclusions While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Background Limited health literacy has been associated with poorer health outcomes and increased morbidity and mortality. Though caring for surgical patients requires communication about complex topics, there is limited literature on health literacy competency in this population. The objective of this study was to assess health literacy in an adult surgical outpatient clinic population, to explore potential determinants of adequate health literacy, and to assess patient satisfaction with physician-patient communication. Materials and methods A prospective cross-sectional study was performed and anonymous data including health literacy, demographics, and patient satisfaction with provider communication were collected. The study population included adult patients who visited an outpatient surgical practice over a one-month period. Health literacy was assessed using the Newest Vital Sign while the satisfaction questions came from the Outpatient Satisfaction Survey (Press-Ganey Associates, Chicago, IL). Results 148 patients participated in the study. The mean age was 49 years, 41% of those who gender identified were male, and 76% were White/Caucasian. 34 (27%) of those who answered the question had received a four-year undergraduate/university degree. 55 (37%) of the patients were identified as having low health literacy. More years of education was significantly associated with adequate health literacy and those patients who were more educated and had adequate health literacy were more satisfied with provider communication. Conclusion Patients on average were highly satisfied with provider communication in this outpatient surgical clinic. Higher education levels were associated with better health literacy and patients with both characteristics were more satisfied with provider communication.

Introduction: Adhesive small bowel obstruction (SBO) is a disease process that has been difficult to prevent. Mechanical barriers and chemical agents exist to disrupt the formation of adhesions following surgery but each associated with medical risk and financial burden. Identifying risk factors for developing SBO in patients post laparotomy would aid in the appropriate use of such agents. We hypothesize that there might be additional risk factors that are associated with a higher likelihood of SBO. Methods: A retrospective analysis from 2008 to 2012 was performed. Cases of SBO following previous laparotomy were compared to those without SBO. Results: 468 medical records were reviewed (57% male). Operations that caused the highest risks for SBO included gynecological, colorectal and hernia operations with prosthetic materials. 66% percent of patients underwent a prior abdominal or pelvic high-risk procedure. The average time from surgery to the development of SBO was 24 months (median 19 months). Patients who developed SBO had a median age of 58.4 years on initial surgery, average previous operative time of 4.3 hours, and an av-erage of two prior operations. For every hour of operative time, the odds of developing SBO increased by 33% (p 3 decreased the odds of SBO (p = 0.05). Conclusions: Longer operative times are associated with post-operative adhesive small bowel obstruction. Patients with an ASA score greater than or equal to 3 appear to have a reduced risk of adhesive small bowel obstruction.

Objective To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). Summary of Background Data Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values Results A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). Conclusions The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. Mini abstract This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.

Background The surgical management of patients with morbid obesity (body mass index ≥ 40) is notable for a relatively high risk of complications. To address this problem, a perioperative care map was developed using precautions and best practices commonly employed in bariatric surgery. It requires additional medical assessments, sleep apnea surveillance, more stringent guidelines for anesthetic management, and readily available bariatric operating room equipment, among other items. This care map was implemented in 2013 at 4 major urban teaching hospitals for use in patients undergoing all types of nonambulatory surgery with a body mass index greater than 40 kg/m2. The impact on patient outcomes was evaluated. Methods The American College of Surgeons National Surgical Quality Improvement Program database was used to compare 30-day outcomes of morbidly obese patients before the year 2013 and after the years 2015 care-map implementation. In addition, trends in 30-day outcomes for morbidly obese patients were compared with those for non-obese patients. Results Morbidly obese patients, between 2013 and 2015, saw an adjusted decrease in the rate of unplanned return to the operating room (OR = 0.49; P = .039), unplanned readmission (OR = 0.57; P = .006), total duration of stay (−0.87 days; P = .009), and postoperative duration of stay (−0.69 days; P = .007). Of these, total duration of stay (−0.86 days; P = .015), and postoperative duration of stay (−0.69 days; P = .012) improved significantly more for morbidly obese patients than for nonmorbidly obese patients. Conclusion Outcomes in morbidly obese patients improved from 2013 to 2015. Implementation of a perioperative care map may have contributed to these improvements. The care map should be further investigated and considered for more widespread use.

Teamwork in the operating room decreases the risk of preventable patient harm. Observation in the operating room allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote operating room teamwork.Video and audio cameras were installed in 2014 into all operating rooms at an 875-bed, urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPS skills during surgical briefs and debriefs.A total of 1,410 briefs were evaluated: 325 (23%) through live observation and 1,085 (77%) through video; 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs 44%, P.001), anticipation of complex procedural events (61% vs 45%, P.001), and monitoring of resources (58% vs 42%, P.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs 60%, P.001), establishment of a leader (70% vs 51%, P.001), postoperative planning (77% vs 48%, P.001), case review and feedback (49% vs 33%, P.001), team engagement (64% vs 41%, P.001), and check back (61% vs 46%, P.001) compared to video.Video observations may not be as effective as evaluating live performance in promoting teamwork in the OR. Live observation enables immediate feedback, which may improve behavior and decrease barriers to compliance with surgical safety practices.

In recent years, medical educators have been making meaningful attempts to rethink how premedical students are prepared for medical school, and how medical students are prepared for residency. Among the many challenges to redesigning premedical and medical school curricula, one that stands out is the constraint imposed by our current methods of assessing aptitude, particularly our use of the Medical College Admissions Test (MCAT) and the United States Medical Licensing Examination (USMLE). For much of the past century, medical school and residency admissions committees have relied heavily on MCAT and USMLE scores to evaluate and rank candidates to their programs. These high-stakes exams determine to a large extent what is taught, and what is stressed, in preparation for and during medical school-despite the fact that scores have limited ability to predict future success in clinical medicine or biomedical research. Additionally, evidence indicates that students from disadvantaged and minority backgrounds do not fare as well on these exams and, as a result, may be disproportionately excluded from the medical profession. While medical school admissions committees have made limited incremental gains in holistic review, residency programs appear to be increasingly focused on USMLE Step scores and veering away from the spirit of holistic review. The authors propose that substantive change will remain slow in coming unless members of the medical education community radically rethink how we report scores from these exams, and how we use them in our selection of future medical students and residents.

Breast conservation therapy (BCT) has a reported incidence of positive margins ranging widely in the literature from 20% to 70%. Efforts have been made to refine standards for partial mastectomy and to predict which patients are at highest risk for incomplete excision. Most have focused on histology and demographics. We sought to further define modifiable risk factors for positive margins and residual disease. A retrospective study was conducted of 567 consecutive partial mastectomies by 21 breast and general surgeons from 2009 to 2012. Four hundred fourteen cases of neoplasm were reviewed for localization, intraoperative assessment, excision technique, rates, and results of re-excision/mastectomy. Histologic margins were positive in 23% of patients, 25% had margins 0.1-0.9 mm, and 7% had tumor within 1-1.9 mm. Residual tumor was identified at-in 61 cases: 38% (disease at margin), 21% (0.1-0.9 mm), and 14% (1-1.9 mm). Ductal carcinoma in situ (DCIS) was present in 85% of residual disease on re-excision and correlated to higher rates of re-excision (p =

Colon capsule endoscopy (CCE) was first put into clinical practice for the evaluation of the small bowel in patients presenting with a gastrointestinal bleed unsuccessfully diagnosed by upper GI endoscopy and colonoscopy. With the recent advent of new technology, there is improved visualization of the intestinal mucosa and subsequently a higher sensitivity for identification of mural pathology, as seen in many recent prospective studies. CCE has now been studied both in the US and in Europe as a modality for colon cancer screening as well as for the diagnosis of inflammatory bowel disease. When compared to conventional colonoscopy, CCE has been shown to have a sensitivity of greater than 88% for identifying 6 mm colonic polyps and over 90% for 1 cm polyps. Therefore its use as a screening tool for colon cancer must be evaluated. In patients suspected to have colitis secondary to inflammatory bowel disease (IBD), it has been shown to have 89% sensitivity for identifying active colonic inflammation. For higher risk patients that requiring urgent colonoscopy, CCE offers an attractive alternative with the potential for a reduced risk on iatrogenic injury. Colon capsule endoscopy may also play an important role in the diagnosis and surveillance of IBD with colonic manifestations. Colonoscopy during active severe disease is associated with an increased risk of perforation due to mucosal inflammation and friability, allowing us to consider CCE as a potentially safer alternative. CCE appears to be most useful for patients with acute lower GI bleeding, inflammatory bowel disease, colonic ischemia or other mucosal-based lesions.