Search

Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS)15 defines major anatomic injury and Revised Trauma Score (RTS)7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.Prognostic, level IV.

Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure. A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction. A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P

A soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database. The targeted pancreas module of the American College of Surgeons–National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses. A total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p

Objectives The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. Methods Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p Results Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. Conclusions This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Post-operative pancreatic fistulas remain a significant source of morbidity following pancreatic surgery. Few studies have evaluated the effect of neoadjuvant chemotherapy and radiation on this adverse outcome. This study aims to evaluate the effects of neoadjuvant therapy on 30-day morbidity and mortality following pancreaticoduodenectomy. A retrospective analysis was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Project (NSQIP) from 2014 to 2015 for patients undergoing pancreaticoduodenectomy with pancreaticojejunal reconstruction. A fistula was defined according to the NSQIP definition. Patient demographics, operative variables, and 30-day outcomes were compared between those who received no neoadjuvant therapy, chemoradiation, chemotherapy alone, and radiation alone. Univariate analysis was completed using chi-square, Fisher exact test, Student’s t test, and Mann-Whitney U test where appropriate. Independent predictors of fistula formation were established using multivariable regression. A P value

Introduction: Platelet dysfunction following traumatic brain injury (TBI) is associated with worse outcomes. The efficacy of platelet transfusion to reverse antiplatelet medication (APM) remains unknown. Thrombelastography platelet mapping (TEG-PM) assesses platelet function. We hypothesize that platelet transfusion can reverse the effects of APM but does not improve outcomes following TBI.Methods: An observational study at six US trauma centres was performed. Adult patients on APM with CT evident TBI after blunt injury were enrolled. Demographics, brain CT and TEG-PM results before/after platelet transfusion, length of stay (LOS), and injury severity score (ISS) were abstracted.Results: Sixty six patients were enrolled (89% aspirin, 50% clopidogrel, 23% dual APM) with 23 patients undergoing platelet transfusion. Transfused patients had significantly higher ISS and admission CT scores. Platelet transfusion significantly reduced platelet inhibition due to aspirin (76.0 ± 30.2% to 52.7 ± 31.5%, p

High-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma.A retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection.A total of 4,098 patients had a pancreatic injury of which 15.9% (n=653) had a grade III and 6.7% (n=274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0-19.9) vs. 18.4% (95% CI 14.6-22.6), p=0.32 and grade IV: 24.0% (95% CI: 16.2-33.4) vs. 27.1% (95% CI: 20.5-34.4), p=0.68.Resection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS.

Percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) placements provide enteral access to patients unable to tolerate oral feeds. Limited data comparing PEG and LG outcomes is available in adults. This study compares complications between PEG and LG placements. A retrospective chart review was completed for patients undergoing PEG or LG placement at a single academic center between 2007 and 2014. Patient demographics, comorbidities, and Charlson Comorbidity Index (CCI) were compared. Logistic regression was utilized to identify independent predictors for complication. Two hundred and twenty-four patients (164 PEGs and 60 LGs) were evaluated. Patients undergoing LG had a higher incidence of prior surgery (42 vs 20%; P

To date there exists no published study examining the safety and efficacy of the EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler. We compared outcomes between the robotic and comparable laparoscopic stapler in robotic-assisted colorectal procedures.We conducted a retrospective review of 93 patients who underwent robotic-assisted colorectal surgery at our institution from 2012 to 2014. Surgeries included left, sigmoid, subtotal and total colectomies, and low anterior rectal resections. Indications were malignancy and diverticular and inflammatory bowel disease. Preoperative demographics, intraoperative data, and postoperative outcomes were examined. Student's t-test and Fischer's exact used were appropriate.Forty-five millimeters laparoscopic staplers were used in 58 cases, while the 45 mm robotic stapler was used in 35 cases. There was no difference in age (P = .651), gender (P = .832), or body mass index (P = .204) between groups. There was no difference in estimated blood loss (P = .524), operative time (P = .769), length of stay (P = .895), or complication rate (P = .778). The robotic stapler group had one anastomotic leak, while the laparoscopic stapler group had six (P = .705). There were more laparoscopic stapler fires (2.69) per patient than robotic stapler fires (1.86) (P = .001). The cost per patient for the laparoscopic group was $631.45 versus $473.28 for the robotic group (P = .001).This is the first study to evaluate the robotic stapler. Advantages of the robotic stapler include large range of motion and 90° of articulation, which may provide a benefit when using the stapler in difficult areas like the pelvis. The robotic stapler has a comparable level of safety as a 45 mm laparoscopic stapler and is more cost effective.

Introduction Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). Methods This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. Results 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. Conclusion This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. Level of evidence Prognostic/Epidemiologic retrospective multicenter trial, level III.

Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients.Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors.A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR.In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.

The use of anticoagulation in the prevention of strokes due to atrial fibrillation or the treatment of venous thromboembolic disease has been on the rise. With the advent and proliferation of direct oral anticoagulation medications, the management of anticoagulation reversal has become increasingly complex, especially when urgent or emergent reversal is required. This review details the commonly used parenteral and oral anticoagulants, the treatment strategies necessary for their reversal, and therapies still in development.

To evaluate the efficacy of international normalized ratio (INR) reversal using four-factor prothrombin complex concentrate (4F-PCC) in nonmedication-induced coagulopathy. We performed a single-site, retrospective cohort study of patients receiving off-label use of 4F-PCC. Cohorts included liver dysfunction if they had acute liver decompensation or cirrhosis without other causative factors of liver failure such as sepsis, coagulopathy of acute sepsis (CAS) if they had documentation of sepsis and no underlying liver disorder, known factor deficiencies, or medication-induced coagulopathy, or warfarin if they were taking warfarin. Patients with unknown medication or direct oral anticoagulant usage were excluded. 4F-PCC was administered 32 times in 26 patients for nonvitamin-K antagonist related coagulopathy (11 CAS and 21 liver dysfunction) and 47 administrations were in warfarin patients. Liver dysfunction patients had a mean model for end-stage liver disease score of 28 ± 10. CAS and warfarin patients had significant INR reductions (ΔINR 1.9, P < 0.01; ΔINR 3.9, P < 0.01, respectively). Liver dysfunction patients mean change in INR trended toward significance (ΔINR 0.7, P = 0.09). Patients who received 4F-PCC based upon previously established dosing guidelines for moderate elevations in INR (20-30 IU/kg) doing demonstrated similar reductions in INR between CAS and warfarin patients (ΔINR 1.3, P = 0.03, ΔINR 1.0 P < 0.01, respectively). 4F-PCC significantly reduces the INR in CAS patients and trended toward significant reductions in liver dysfunction patients. Adequately powered, prospective trials are needed to demonstrate 4F-PCC efficacy in reversal of these coagulopathies.

BACKGROUND Work-hour restrictions have reduced operative experience for residents. The Advanced Surgical Skills for Exposure in Trauma (ASSET) course fills this training gap. Cadaver use has limitations including cost and availability. Hyper-realistic synthetic models may provide an alternative to cadavers. We compared same surgeon performance between synthetic and cadaveric models to determine interchangeability for formative evaluation. METHODS Forty residents (

Perhaps the most invigorating and daunting challenge to the modern day surgeon is the continual drive to push the envelope of what is innovative, fast, and cost effective. Likewise, surgeons must at all times maintain patient safety and provide treatments that are as efficacious as the current standard of care. As surgery began forming into a cogent specialty in the late nineteenth and early twentieth century, foundational strides were made in advancing antisepsis and sterility along with updating the current body of anatomic knowledge. Around this same time, the developing interest in the basic sciences lead to the birth of the surgeon scientist who formally set to define the pathological basis for surgical disease. William Stewart Halsted was one of the key figures in removing the general surgeon from the paradigm of the surgeon barber of the 1800s into the surgeon scientist of the twentieth century. This was part and parcel to his pursuit of the scientific basis of surgical diseases, and in many respects set the tone of translational research from the laboratory bench to the operating room. Of course, his achievements were built upon meticulous and often tireless efforts of the great surgeons that came before him. Physicians who explored nearly every cavity, crevice, and orifice of the human body and for whom so many eponyms exist.

The expansion of Medicaid eligibility under the Affordable Care Act is a state-level decision that affects how patients with traumatic injury (trauma patients) interact with locoregional health care systems. Washington, DC; Maryland; and Virginia represent 3 unique payer systems with liberal, moderate, and no Medicaid expansion, respectively, under the Affordable Care Act. Characterizing the association of Medicaid expansion with hospitalization after injury is vital in the disposition planning for these patients.To determine the association between expanded Medicaid eligibility under the Affordable Care Act and duration of hospitalization after injury.This retrospective cohort study included patients admitted from Virginia, Maryland, and Washington, DC, to a single level I trauma center. Data were collected from January 1, 2013, through March 6, 2016, in Virginia and Washington, DC, and from May 1, 2013, through March 6, 2016, in Maryland. All patients with Medicare or Medicaid coverage and all uninsured patients were included. Patients with private insurance, patients with severe head or pelvic injuries, and those who died during hospitalization were excluded.Hospital length of stay (LOS) and whether its association with patient insurance status varied by state of residence.A total of 2314 patients (1541 men [66.6%] and 773 women [33.4%]; mean [SD] age, 52.9 [22.8] years) were enrolled in the study. The uninsured rate in the Washington, DC, cohort (190 of 1699 [11.2%]) was significantly lower compared with rates in the Virginia (141 of 296 [47.6%]) or the Maryland (106 of 319 [33.2%]) cohort (P .001). On multivariate regression controlling for injury severity and demographic variables, the difference in LOS for Medicaid vs non-Medicaid recipients varied significantly by state. For Medicaid recipients, mean LOS in Washington, DC, was significantly shorter (2.57 days; 95% CI, 2.36-2.79 days) than in Maryland (3.51 days; 95% CI, 2.81-4.38 days; P = .02) or Virginia (3.9 days; 95% CI, 2.79-5.45 days; P = .05).Expanded Medicaid eligibility is associated with shorter hospital LOS in mildly injured Medicaid recipients.

Transanal hemorrhoidal dearterialization (THD) is a relatively new, minimally invasive approach for the treatment of hemorrhoid disease. Despite increasing use of this procedure, there remains scarce United States-based data on the perioperative variables affected by this surgical technique. This article details the experience with THD at a single institution. This is a single-institution study that includes consecutive patients that underwent THD at George Washington University from November 2011 to April 2014. After Institutional Review Board approval, retrospective chart review was performed. Patient demographic information, preoperative management of hemorrhoid disease, and quality of life indicators after THD were collected for all patients. A total of 96 patients underwent THD during the period of investigation. A majority of the patients were male and all patients had grade II or III hemorrhoids. Most patients who underwent THD presented with rectal bleeding. Four patients required postoperative admission to the hospital for pain control, eight patients experienced constipation postoperatively, and one patient had recurrence of their hemorrhoid disease at 30-day follow-up. No patients required admission to the hospital for postoperative hemorrhage and none experienced urinary retention or incontinence of flatus or stool. THD is a feasible alternative to Ferguson hemorrhoidectomy for the surgical treatment of grade II and III hemorrhoidal disease. Future prospective studies are needed to help improve patient selection for each respective surgical approach.