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This study aimed to determine whether surgical stabilization of rib fractures (SSRF) is associated with worse outcomes in individuals with multicompartmental injuries.A retrospective review of a prospective trauma registry was performed for adult blunt trauma patients (aged ≥ 18 y) with Injury Severity Score ≥ 15 and radiographic evidence of rib fractures (2015-2020). Individuals without concomitant head, abdomen/pelvis, or lower extremity Abbreviated Injury Scale scores ≥ 3 were excluded. Propensity match on demographic and clinical variables was performed comparing patients treated nonoperatively (NO) to those undergoing SSRF. A chart review was performed for additional data. Primary outcome was hospital length of stay (LOS). Secondary outcomes were in-hospital mortality, intensive care unit LOS, and duration of mechanical ventilation.One thousand nine hundred ninety three patients fit the inclusion criteria (NO = 1,951, SSRF = 42). After matching, there were 98 in the NO group and 42 in the SSRF group. Mean age was 51 y, 61.4% were male, and 71.4% were of White race. Median time to fixation was 5 d. The SSRF group had more severe chest trauma as evidenced by a higher RibScore (3.2 versus 1.7, P 0.001) and had a longer LOS (18 versus 9 d, P 0.001), intensive care unit LOS (13 versus 3 d, P = 0.007), and duration of mechanical ventilation (8 versus 2 d, P = 0.013) on univariate analysis. Multivariable regression analysis demonstrated no association between SSRF and these short-term outcomes.Despite delayed average time to intervention, SSRF in a trauma-patient population with multicompartmental injuries and competing management priorities is not associated with worse short-term outcomes.

Background The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. Methods Patients enrolled in the “Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS—to anastomose or not to anastomose” study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. Results There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy ( P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. Conclusion The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

Background Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons’ knowledge and perception of using AI-based tools in clinical decision-making processes. Methods An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society’s website and Twitter profile. Results 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. Discussion The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI.

Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both are performed simultaneously. Physicians performing them require knowledge of local anatomy, tissue and vascular relationships, along with advance bronchoscopy and endoscopy skills. Although PDTs and PEGs are considered relatively low-risk procedures, operators need to have the knowledge and skill to recognize and prevent adverse outcomes. Current published literature on post-procedural care and stoma wound management was reviewed. Available recommendations for the routine care of tracheostomy and PEG tubes are included in this review. Signs and symptoms of early PDT- and PEG-related complications and their management are discussed in detail. These include hemorrhage, infection, accidental decannulation, tube obstruction, clogging, and dislodgement. Rare, life-threatening complications are also discussed. Multidisciplinary teams are needed for improved patient care, and members should be aware of all pertinent care aspects and potential complications related to PDT and PEG placement. Each institute is strongly encouraged to have detailed protocols to standardize care. This review provides a state-of-the-art guidance on the care of patients with tracheostomies and gastrostomies specifically in the ICU setting.

Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient.This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers enrolled all adult patients undergoing emergency laparotomies and systematically collected preoperative, operative, and 30-day postoperative variables. For the purpose of this study, we defined unplanned readmission as a readmission occurring within 30 days from discharge and one that was immediately preceded by an emergency department visit. Patients were excluded if they died during the index admission, were discharged to hospice, or were transferred to other hospitals. Predictors of unplanned readmission were evaluated using a multivariable logistic regression model, adjusting for patient demographics, comorbidities, laboratory variables, and preoperative acuity of disease variables.A total of 1,347 patients were included, of which 234 (17.4%) had an unplanned readmission. The median patient age was 60 y, 49.4% were male, and 71.4% were white. The most common diagnoses were hollow viscus perforation (28.1%) and small bowel obstruction (24.5%). Predictors of unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, confidence interval: 1.35-3.64, P = .002], weight loss10% in the past 6 months [odds ratio: 1.65, confidence interval: 1.07-2.54, P = .023], dyspnea at baseline [odds ratio: 1.62, confidence interval: 1.06-2.48, P = .026], wound complications [odds ratio: 2.23, confidence interval: 1.55-3.19, P.001], and discharge to nursing homes [odds ratio: 1.68, confidence interval: 1.02-2.80, P = .044]).Unplanned readmission after emergency laparotomies are common, especially for patients with wound complications or requiring nursing homes. These system factors are potential quality improvement targets to reduce readmissions.

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.

Dementia is a terminal illness that leads to progressive cognitive and functional decline. As the elderly population grows, the incidence of dementia in hospitalized older adults increases and is associated with poor short-term and long-term outcomes. Delirium is associated with an accelerated cognitive decline in hospitalized patients with dementia. The first step in the management of dementia is accurate and early diagnosis. Evidence-based management guidelines in the setting of critical illness and dementia are lacking. The cornerstone of management is defining goals of care early in the course of hospitalization and using palliative care and hospice when deemed appropriate.

Background The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients. Methods Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher's exact, Student's t, chi-squared, or Mann–Whitney U tests as appropriate. Results Thirty-seven patients with acute hemorrhage from nontrauma sources were identified. REBOA placement was primarily performed by trauma attendings (20/37, 54%) and vascular attendings (13/37, 35%). In seven patients (19%), balloons were positioned prophylactically but never inflated. In 24 (65%) of 37 patients, REBOA was placed in the operating room. 28/37 balloons (76%) were advanced to zone 1, 8/37 (22%) were advanced to zone 3, and there was one REBOA use in the inferior vena cava. Most common indications were gastrointestinal and peripartum bleeding. In the 30 cases of balloon inflation, 24 of 30 (80%) resulted in improved hemodynamics. Eleven of 30 patients (37%) died before discharge. One patient developed a distal embolism, but there were no reports of limb loss. Twelve patients (40% of all REBOA inflations and 63% of survivors) were discharged to home. Conclusions REBOA has been used in a range of acutely hemorrhaging emergency general surgery patients with low rates of access-related complications. Mortality is high in this patient population and further research is needed; however, appropriate patient selection and early use may improve survival in these life-threatening cases.

We investigated whether the COVID-19 pandemic affected rates of interpersonal violence (IV). A retrospective study was performed using city-wide crime data and the trauma registry at one high-volume trauma center pre-pandemic [PP] (March-October 2019) and during the pandemic [PA] (March-October 2020). The proportion of trauma admissions attributable to IV remained unchanged from PP to PA, but IV increased as a proportion of overall crime (34% to 41%, p

Background Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs). Methods A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality. Results Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, PConclusion While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.

Data on duration of antibiotics in patients managed with an open abdomen (OA) due to intra-abdominal infection (IAI) are scarce. We hypothesized that patients with IAI managed with OA rather than closed abdomen (CA) would have higher rates of secondary infections (SIs) independent of the duration of the antibiotic treatment.This was an observational, prospective, multicenter, international study of patients with IAI requiring laparotomy for source control. Demographic and antibiotic duration values were collected. Primary outcomes were SI (surgical site, bloodstream, pneumonia, urinary tract) and mortality. Statistical analysis included ANOVA, chi-square/Fisher's exact test, and logistic regression.Twenty-one centers contributed 752 patients. The average age was 59.6 years, 43.6% were women, and 43.9% were managed with OA. Overall mortality was 16.1%, with higher rates among OA patients (31.6% vs 4.4%, p0.001). OA patients had higher Sequential Organ Failure Assessment (4.7 vs 1.8, p0.001), American Society of Anesthesiologists Physical Status (3.6 vs 2.7, p0.001), and APACHE II scores (16.1 vs 9.4, p0.001). The mean duration of antibiotics was 6.5 days (8.0 OA vs 5.4 CA, p0.001). A total of 179 (23.8%) patients developed SI (33.1% OA vs 16.8% CA, p0.001). Longer antibiotic duration was associated with increased rates of SI: 1 to 2 days, 15.8%; 3 to 5 days, 20.4%; 6 to 14 days, 26.6%; and more than 14 days, 46.8% (p0.001).Patients with IAI managed with OA had higher rates of SI and increased mortality compared with CA. A prolonged duration of antibiotics was associated with increased rates of SI. Increased antibiotic duration is not associated with improved outcomes in patients with IAI and OA.

Background Percutaneous drainage as the initial procedure for severe pancreatitis (SP) may not always be optimal. Our aim was to identify the characteristics of patients who failed percutaneous drainage and compare their outcomes with patients who underwent surgical intervention as the initial approach. Methods A retrospective review of a prospectively collected emergency general surgery registry of patients admitted to a tertiary-care, academic center with the diagnosis of SP who underwent an intervention was performed (2010-2018). Patients were divided into successful drainage (SD), drainage failure (DF), and surgery first (SF) groups. DF was defined as the need for surgical intervention. Results The study included 129 patients. Fifty (38.8%) patients underwent SF as their initial management modality. Among 79 patients who underwent drainage, 34 (43.0%) were in the DF group and progressed to surgical intervention. Within that group, 19 (55.9%) underwent open necrosectomy. The DF group was more likely to have lower rates of peripancreatic fluid collections, a higher rate of necrotizing pancreatitis, and a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score when compared with the DS group. Mortality was higher in the DF and SF groups, and total length of stay and ICU length of stay were highest in the DF group. Discussion Patients who experience failure of drainage for SP have high morbidity and mortality rates and fare worse overall than patients who undergo surgery as the primary intervention. Patients with necrotizing pancreatitis and a higher APACHE II score might warrant surgical intervention over a drainage-first approach.

Patients supported with venovenous extracorporeal membrane oxygenation are at risk for intra-abdominal hypertension and abdominal compartment syndrome. Flow through the return cannula may be compromised in these patients, resulting in inadequate support and end-organ malperfusion. Early decompressive laparotomy can mitigate these complications and potentially improve outcomes. Here we review a series of nine patients undergoing early decompressive laparotomy for abdominal compartment syndrome at a single institution and propose an algorithmic approach to the management of these patients.

Background Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. Methods Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition. Results Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups ( P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups ( P = .04). Conclusion Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.

Background Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. Methods A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values ( P < .05) were significant. Results Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. Conclusion These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Appendicitis is the most common general surgery problem in pregnant patients, but patients can present with vague symptoms making diagnosis difficult. Misdiagnosis and delayed diagnosis can lead to complications such as perforation, which can result in dire outcomes, including fetal and maternal demise. A high level of clinical suspicion should be maintained to identify the diagnosis and progress to operative intervention quickly. Here we present a case highlighting prompt recognition of perforated appendicitis leading to fetal and maternal distress with emergent operative intervention leading to good outcomes for both mother and baby.

Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors’ clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.

The ACGME work hour restrictions facilitated increased utilization of service-based advanced practice providers (APPs) to offset reduced general surgery resident work hours. Information regarding attending surgeon perceptions of APP impact is limited. The aim of this survey was to gauge these perceptions with respect to workload, length of stay (LOS), safety, best practice, level of function, and clinical judgment. Attending surgeons on surgical teams that employ service-based APPs at an urban tertiary referral center responded to a survey at the completion of academic year 2016. Perceptions regarding APP impact on workload, LOS, safety, best practice, level of function, and clinical judgment were examined. Twenty-two attending surgeons (40%) responded. Respondents agreed that APPs always/usually decrease their workload (77%), decrease LOS (64%), improve safety (68%), contribute to best practice (82%), and decrease near misses (71%). They also agreed that APPs decrease resident workload (87%), but fewer agreed that APPs contribute to resident education (68%). The majority perceived APPs function at the PGY1/2 (43%) or PGY3 (39%) level and always/usually trust their clinical judgment (72%), and felt there was variability in level of function among APPs (56%). This single-center study illustrates that attending surgeons perceive a positive impact on patient care by service-based APPs.

Background We examined and compared APP versus surgical resident perceptions of the role of APPs in surgical subspecialty teams. Methods Residents/first year surgical critical care fellows and inpatient service-specific APPs responded to a survey that examined perceptions about the APP-resident/fellow relationship. Statistical analysis compared responses using a Pearson chi-square test. Results Thirty-two resident/fellows (48%) and 10 APPs (42%) responded. There was consensus that having an APP on service decreases workload, contributes to continuity of care and enhances resident-patient coordination education and agreement that there was clear communication and adequate collaboration. Both groups differed with respect to APPs contribution to resident/fellow clinical education, role definition and chain of command. The majority of trainees felt that APPs function at a PGY2 level (51.7%) compared to APPs, who felt that they functioned at a PGY4/5 (22%) or Fellow (44%) level. Conclusion APPs and resident/fellows agree that APPs impact resident workload, continuity of care and patient-coordination education.

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume ( P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume ( P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.

BACKGROUND Limited data exist for long-term outcomes after emergency general surgeries (EGSs) in the United States. This study aimed to characterize the incidence of inpatient readmissions and additional operations within 6 months of an EGS procedure. METHODS In this retrospective observational study, we identified adults (≥18 years old) undergoing one of seven common EGS procedures (appendectomies, cholecystectomies, small bowel resections, large bowel resections, control of gastrointestinal [GI] ulcers and bleeding, peritoneal adhesiolysis, and exploratory laparotomies) who were discharged alive in the 2010-2015 National Readmissions Database. Outcomes included the rates of all-cause inpatient readmissions and of undergoing a second EGS procedure, both within 6 months. Multivariable logistic regression models identified risk factors of reoperation, adjusting for patient, clinical, and hospital factors. RESULTS Of 706,678 patients undergoing an EGS procedure 131,291 (18.6%) had an inpatient readmission within 6 months. Among those readmitted, 15,178 (11.6%) underwent a second EGS procedure, occurring at a median of 45 days (interquartile range, 15-95). After adjustment, notable predictors of reoperation included male sex (adjusted odds ratio [aOR], 1.06 [95% confidence interval, 1.01-1.10]); private, nonprofit hospitals (aOR, 1.09 [1.02-1.17]); private, investor-owned hospitals (aOR, 1.09 [1.00-1.85]); discharge to short-term hospital (aOR, 1.35 [1.04-1.74]); discharge with home health care (aOR, 1.19 [1.13-1.25]); and index procedure of control of GI ulcer and bleeding (aOR, 9.38 [8.75-10.05]), laparotomy (aOR, 7.62 [6.92-8.40]), or large bowel resection (aOR, 6.94 [6.44-7.47]). CONCLUSION One fifth of patients undergoing an EGS procedure had an inpatient readmission within 6 months, where one in nine of those underwent a second EGS procedure. As half of all second EGS procedures occurred within 6 weeks of the index procedure, identifying patients with the highest health care needs (index procedure type and discharge needs) may identify patients at risk for subsequent reoperation in nonemergency settings. LEVEL OF EVIDENCE Epidemiological, level III.

Objective Emergency general surgery (EGS) patients presenting with sepsis remain a challenge. The Surviving Sepsis Campaign recommends a 30 mL/kg fluid bolus in these patients, but recent studies suggest an association between large volume crystalloid resuscitation and increased mortality. The optimal amount of pre-operative fluid resuscitation prior to source control in patients with intra-abdominal sepsis is unknown. This study aims to determine if increasing volume of resuscitation prior to surgical source control is associated with worsening outcomes. Methods We conducted an 8-year retrospective chart review of EGS patients undergoing surgery for abdominal sepsis within 24 h of admission. Patients in hemorrhagic shock and those with outside hospital index surgeries were excluded. We grouped patients by increasing pre-operative resuscitation volume in 10 ml/kg intervals up to > 70 ml/kg and later grouped them into Results Of the 301 patients included, the mean age was 55, 51% were male, 257 (85%) survived to discharge. With increasing fluid per kg (p = 0.004). Patients who received 30 ml/kg (p = 0.02). These groups had median qSOFA scores (1.0 vs. 1.0, p = 0.06). There were no differences in time to operation (6.1 vs 4.9 h p = 0.11), ventilator days (1 vs 3, p = 0.08), or hospital LOS (8 vs 9 days, p = 0.57). Relative risk regression correcting for age and physiologic factors showed no significant differences in mortality between the fluid groups. Conclusions Greater pre-operative resuscitation volumes were initially associated with significantly higher mortality, despite similar organ failure scores. However, fluid volumes were not associated with mortality following adjustment for other physiologic factors in a regression model. The amount of pre-operative volume resuscitation was not associated with differences in time to operation, ventilator days, ICU or hospital LOS.

Contains fulltext : 238976.pdf (Publisher’s version ) (Open Access) On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Thoracic trauma continues to cause at least 25% of traumatic deaths in the USA, and many of these injuries cause death within the first minutes to hours following trauma. Mortality of thoracic injuries is second only to head injuries. Many deaths are preventable by prompt diagnosis and treatment given the vital structures that reside within the thoracic cavity. Injuries from chest trauma range from rib fractures requiring only pain control to cardiac lacerations with tamponade or exsanguinating hemorrhage. Given the range of injuries, acuity and clinical presentation, multiple diagnostic modalities, and treatment options exist for thoracic trauma. Thoracoscopic techniques have evolved from simple cavity washout through an existing chest tube site with evaluation of diaphragmatic injury to the currently used video-assisted thoracic surgery (VATS). Management of critical injuries by means of sternotomy or thoracotomy remains valuable procedures.

Introduction We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). Methods This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65–74, 75–84, ≥85 years old). Results 715 patients were included, of which 52% were 65–74, 34% were 75–84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%–60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65–74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). Conclusion ESS is an accurate predictor of outcome in the elderly EL patient 65–85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.

Background The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. Methods This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. Results A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). Conclusion This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. Level of evidence Prognostic study, level III.

Blunt abdominal aortic injury is an infrequent occurrence after blunt trauma. The majority of these injuries result from deceleration forces sustained in motor vehicle collisions. Effects of these forces on the thoracic aorta are well described, but associated spinal compression or distraction can also lead to injury of the affixed abdominal aorta. We present a case of multifocal blunt thoracic and abdominal aortic injury with circumferential abdominal aortic dissection, resulting in aortoaortic intussusception associated with a thoracolumbar spinal injury. The unique diagnostic challenge and subsequent successful endovascular management of a rare nonocclusive abdominal aortic intussusception are herein discussed.

IntroductionThoracic aortic injury is a leading cause of death after blunt trauma, but the effect of trauma system organization on outcomes is undefined. This was an analysis of thoracic aortic injury in a state with a comprehensive trauma system.MethodsThis was a retrospective study of thoracic aortic injury in Maryland between 2009 and 2014 using a statewide inpatient admission database. Presence of thoracic aortic injury and open or endovascular aortic interventions were identified by International Classification of Diseases version 9 codes. Patients were compared by admitting hospital status, categorized as Level I or non-Level I trauma centers. Outcomes were overall inpatient mortality and death after aortic repair.ResultsOf 774,211 injured patients, 168 (0.02%) had thoracic aortic injury. Patients with thoracic aortic injury were younger, more often male, and were more severely injured than patients without thoracic aortic injury. The majority of patients (136, 81%) were admitted to Level I trauma centers; Level I and non-Level I patients had similar characteristics. Most patients (110, 65%) were managed non-operatively, but patients admitted to Level I facilities were more likely to undergo aortic repair. Overall and post-operative mortality rates were lower at Level I hospitals (22% versus 31% and 6% versus 17%, respectively), but these differences did not reach statistical significance.ConclusionThis novel analysis indicates thoracic aortic injury management in Maryland is highly concentrated at Level I trauma centers, which was associated with mortality below previously reported national rates. Although limited by small sample size, these findings suggest a benefit to regionalized care for patients with thoracic aortic injury and support transfer to high-volume facilities for definitive management.

BACKGROUNDPatients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency g

Objective The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. Methods A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death. Results Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0). Conclusions The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and—similar to emergency general surgery—may benefit from dedicated training and practice models.

Background: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the t...

The original article [1] contained a typo in author, Federico Coccolini’s name. This has now been corrected.