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Objective: There are no guidelines for adequate postoperative pain control while lowering the risk of morphine overuse. To optimize the utilization of morphine derivatives, the proportions of patients and morphine amounts prescribed postoperatively have been studied worldwide. The present study reviewed the number of patients receiving morphine and the amounts administered at the Department of Acute Care Surgery. Materials and Methods: The use of postoperative oral morphine derivatives by patients undergoing common emergency general surgeries was retrospectively reviewed. Electronic data were collected of patients undergoing open appendectomy, laparoscopic appendectomy, laparoscopic cholecystectomy, open cholecystectomy, and open hernia surgery. The rates and amounts of the morphine derivatives prescribed during hospitalization and at discharge were analyzed. The amounts of the derivatives were converted to morphine milligram equivalents (MME). Results: Opioid derivatives were prescribed postoperatively for 22 patients (3.8%), with an average of 2.4 MME. Eighteen patients (3.1%) received intrahospital morphine derivatives (mean: 30 MME), while thirteen (2.2%) obtained them as a home medication (mean: 67 MME). The overall length of stay was 3.2 days (1 to 33), and the mean last pain score was 0.5 (0 to 7). A multiple logistic regression revealed that patients aged <60 years and with a BMI <25 had a higher proportion of morphine prescriptions. Conclusion: On case-by-case adjustments, a trivial amount of morphine derivatives was sufficiently prescribed to deal with postoperative pain following common general emergencies. The proportions of morphine prescriptions were higher among younger patients and those with average BMIs. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: Transmural bowel necrosis (TBN) is an uncommon surgical emergency that represents an endpoint of occlusive acute mesenteric ischemia (AMI), nonocclusive AMI and small bowel obstruction (SBO). According to limited evidence, each etiology of TBN might demonstrate a different CT finding. This investigation aimed to 1) identify overall CT findings of TBN, and 2) compare CT findings of TBN in each etiology., Materials and Methods: Forty-nine consecutive adults (mean age, 64.6 years; 26 men) with occlusive AMI, nonocclusive AMI or SBO, and pathologically proven TBN were enrolled. All had a CT scan within 24 h before surgery. Clinical information was compiled from medical records. CT examinations were re-reviewed by two radiologists with disagreements resolved by the third radiologist. Data were analyzed and compared., Results: Transmural bowel necrosis were secondary to arterial AMI, venous AMI, combined arterial and venous AMI, nonocclusive AMI, and SBO in 6, 5, 2, 10, and 26 patients, respectively. The CT findings were ascites (93.9%), abnormal wall enhancement (91.8%), bowel dilatation (89.8%), mesenteric fat stranding (89.8%), abnormal wall thickness (71.5%), pneumatosis (46.9%) and intrinsic hyperattenuation of bowel walls (22.5%). Portovenous gas, mesenteric venous gas, and pneumoperitoneum were present in 4 patients (8.2%). Bowel wall thickness was the only CT findings that showed a statistically significant difference among the 5 etiologies of TBN (P = 0.046)., Conclusions: Most common CT findings of TBN were ascites, abnormal bowel wall enhancement, dilatation, and mesenteric fat stranding. Wall thickness differentiated five etiologies, being most thickened in venous AMI and normal in arterial AMI., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Objectives: Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery., Methods: A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated., Results: Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P  = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P  = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P  = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47-100%, and 54-100%, which increased to 53-100%, and 60-100%, respectively, when considering only radiologists' reinterpretations., Conclusions: In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

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: Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery., Methods: All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC., Results: Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC., Conclusions: We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team., (© 2022 Wiley Periodicals LLC.)

Purpose: The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S., Patients: We aimed to prospectively validate ESS in a Greek patient population., Methods: All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901., Results: A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67-0.90] and 0.83 [95% CI 0.74-0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76-0.91] and 0.79 [95% CI 0.69-0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81-0.96] and 0.84 [95% CI 0.77-0.91]) in both Greek and U.S., Conclusion: The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Body mass index (BMI) does not reliably predict Surgical site infections (SSI). We hypothesize that abdominal wall thickness (AWT) would serve as a better predictor of SSI for patients undergoing emergency colon operations., Methods: We retrospectively evaluated our Emergency Surgery Database (2007-2018). Emergency colon operations for any indication were included. AWT was measured by pre-operative CT scans at 5 locations. Only superficial and deep SSIs were considered as SSI in the analysis. Univariate then multivariable analyses were used to determine predictors of SSI., Results: 236 patients met inclusion criteria. The incidence of post-operative SSI was 25.8% and the median BMI was 25.8kg/m 2 [22.5-30.1]. The median AWT between patients with and without SSI was significantly different (2.1cm [1.4, 2.8] and 1.8cm [1.2, 2.5], respectively). A higher BMI trended toward increased rates of SSI, but this was not statistically significant. In overweight (BMI 25-29.9kg/m 2 ) and obese (BMI ≥30kg/m 2 ) patients, SSI versus no SSI rates were (50.0% versus 41.9% and 47.4% versus 36.4%, P = 0.365 and 0.230) respectively. The incidence of SSI in patients with an average AWT < 1.8cm was 20% and 30% for patients with average AWT ≥1.8cm. On multivariable analysis, AWT ≥1.8cm at 2cm inferior to umbilicus was an independent predictor of SSI (OR 2.98, 95%CI 1.34-6.63, P = 0.007)., Conclusions: AWT is a better predictor of SSI than BMI. Preoperative imaging of AWT may direct intraoperative decisions regarding wound management. Future clinical outcomes research in emergency surgery should include abdominal wall thickness as an important patient variable., (Copyright © 2021. Published by Elsevier Inc.)

Background: In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA versus GA., Methods: We conducted a post hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. All patients ≥ 16 years-old who underwent an open appendectomy between October 2016 and March 2017 in one of the 14 participating hospitals were included. Patients were stratified into two groups: NA-defined as spinal or epidural-and GA. All-cause morbidity, hospital length of stay (LOS), and pain severity were assessed using univariate analysis followed by multivariable logistic regression adjusting for the following preoperative characteristics: age, gender, body mass index (BMI), smoking, history of opioid use, emergency status, and country., Results: A total of 655 patients were included, 353 of which were in the NA group and 302 in the GA group. The countries operating under NA were Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Overall, NA patients were younger (mean age (SD): 34.5 (14.4) vs. 40.7 (17.9), p-value < 0.001) and had a lower BMI (mean (SD): 23.5 (3.8) vs. 24.3 (5.2), p-value = 0.040) than GA patients. On multivariable analysis, NA was independently associated with less postoperative complications (OR, 95% CI: 0.30 [0.10-0.94]) and shorter hospital LOS (LOS > 3 days, OR, 95% CI: 0.47 [0.32-0.68]) compared to GA. There was no difference in postoperative pain severity between the two techniques., Conclusions: Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery., (© 2021. Société Internationale de Chirurgie.)

Background: 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., Methods: 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., Results: 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 loss >10% 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])., Conclusion: 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., (Copyright © 2020. Published by Elsevier Inc.)

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., (Copyright © 2020. Published by Elsevier Inc.)

Background: The Emergency Surgery Score (ESS) has been previously validated as a reliable tool to predict postoperative outcomes in emergency general surgery (EGS). The purpose of this study is to assess the differential performance of the ESS in specific EGS procedures., Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing EGS between 2007 and 2017. Patients who underwent the following EGS procedures were identified: laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction (SBO), colectomy, and incarcerated ventral or inguinal hernia repair. The performance of the ESS in predicting mortality in each procedure was assessed using receiver operating characteristic analyses., Results: A total of 467,803 patients underwent EGS (mean age 50 ± 19.9 y, females 241,330 [51.6%]), of which 191,930 (41%) underwent laparoscopic appendectomy, 40,353 (8.6%) underwent laparoscopic cholecystectomy, and 35,152 (7.5%) patients underwent surgery for SBO. The ESS correlated extremely well with mortality for patients who underwent laparoscopic appendectomy (area under the curve (AUC) 0.91), laparoscopic cholecystectomy (AUC 0.91), lysis of adhesions for SBO (AUC 0.83), colectomy (AUC 0.83), and incarcerated hernia repair (AUC 0.85)., Conclusions: ESS performance accurately predicts mortality across a wide range of EGS procedures, and its use should be encouraged for preoperative patient counseling and for nationally benchmarking the quality of care of EGS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI)., Methods: This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication., Results: Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09)., Conclusion: In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL)., Methods: This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method., Results: From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively., Conclusion: Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking., Level of Evidence: Prognostic and epidemiological, level III., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients., Methods: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality., Results: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality., Conclusion: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality., Level of Evidence: Therapeutic study, level IV.

Objective: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world., Summary of Background Data: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic., Methods: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients., Results: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ± 13.9 in US and 183.5 ± 133.7 mg versus 0.8 ± 3.9 and 4.6 ± 27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001)., Conclusions: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.

Background: Early diagnosis and prompt debridement of necrotizing soft tissue infection (NSTI) improves the outcome. We sought to determine whether failure to admit NSTI patients to acute care surgery (ACS) departments delays treatment and increases the mortality rate. Methods: Patients with NSTI were identified using the 2007-2018 institutional emergency surgery database at a tertiary care hospital. The diagnosis was confirmed by the operative/pathology reports. Patients who developed NSTI during hospitalization or underwent initial debridement at an outside hospital were excluded. Patients admitted to a non-ACS service (e.g., medicine, gynecology) were compared with those admitted to the ACS service with respect to co-morbidities, clinical presentation, time to surgery, and mortality rate. Multi-variable linear and logistic analyses were performed to determine whether admission to a non-ACS service predicts a delay in surgery or an increase in the mortality rate. Results: Of 132 patients, 91 met the inclusion criteria. The mean age was 53 years; 56% were male. Twenty patients (22%) were admitted to a non-ACS service, two thirds of them with an initial misdiagnosis (e.g., cellulitis). The demographics, co-morbidities, and clinical presentation were similar in the two groups except that the non-ACS group more often had human immunodeficiency virus infection (15.0% versus 2.8%; p = 0.04) and less often presented with erythema (70% versus 94.4%; p = 0.01). The median time to incision in non-ACS patients was significantly longer (24.8 versus 3.9 hours; p < 0.001). The mortality rates were 20.0% for the non-ACS group and 7.0% for the ACS group (p = 0.086). Multi-variable analyses revealed that absence of erythema is independently associated with a non-ACS admission (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.3-25.6; p = 0.02), and non-ACS admissions correlated independently with delayed surgery (OR 35.20; 95% CI 3.86-321.20; p = 0.002). Conclusions: Admission of patients with NSTI to a non-ACS service often occurs because of initial misdiagnosis, especially in the absence of skin erythema; correlates with significantly delayed surgery; and might lead to more deaths.

Background: Patients in the US receive disproportionally higher amounts of opioids after operations compared with their non-US counterparts. We aimed to assess the relationship between perceived pain severity after operation and the amount of opioid medications prescribed at discharge in US vs non-US patients., Methods: We conducted a post-hoc analysis of the International Patterns of Opioid Prescribing multicenter study. Patients 16 years and older who underwent appendectomy, cholecystectomy, or inguinal herniorrhaphy in 1 of 14 participating hospitals across 8 countries between October 2016 and March 2017 were included. In hospitals where pain severity was assessed using a 0 to 10 visual analog scale before hospital discharge, patients were stratified into the following groups, depending on the pain severity: none, mild (1 to 3), moderate (4 to 6), and severe (7 to 10). The number of opioid prescriptions, total number of pills, and oral morphine equivalents prescribed were calculated for each group and US and non-US patients were compared., Results: A total of 2,024 patients were included. Eighty-three percent of US patients without pain were prescribed opioids compared with 8.7% of non-US patients without pain (p < 0.001). The number of opioid prescriptions, number of pills, and oral morphine equivalents prescribed were similar across the 4 pain severity groups in US patients (p > 0.05). In contrast, the number of opioid prescriptions, number of opioid pills, and oral morphine equivalents prescribed among non-US patients were incrementally higher as the pain severity progressed from no pain to severe pain (all, p < 0.05)., Conclusions: US patients are prescribed opioids at high rates and doses regardless of pain severity. Additional efforts should be directed toward tailoring opioid prescriptions to patients' needs., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to examine the prevalence of, and describe factors associated with, firearm-related injuries in American households., Methods: Using the 2010-2016 ACS-TQIP database, all ICD-9/10 external causes of injury for firearm-related injuries were queried with the place of occurrence designated as "home". Causes of injury were identified as assault, intentional self-injury, and unintentional injury. Univariate then multivariable regression analyses were performed to identify factors associated with each injury type., Results: 12,657 firearm-related injuries in households were identified. Of those, 49.9% were victims of assault, 35.7% were intentional self-injury, and 14.4% were unintentional. Mortality was highest among self-inflicted injuries (52.4%), followed by assault (12.9%), and unintentional injuries (5.9%). On multivariable analysis, age <45 years, African-American race, and drug use were independently associated with an injury secondary to assault. Age >65 years, White race, psychiatric illness, and alcohol use disorder were independently associated with intentional self-injury. White and American-Indian race were independently associated with unintentional injuries., Conclusions: Assault is the most common cause of home-related firearm injury requiring hospitalization, while intentional self-injury is the most lethal., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The performance of the Emergency Surgery Score (ESS), a validated risk calculator, in the elderly emergency general surgery (EGS) patient remains unclear. We hypothesized that ESS accurately predicts outcomes in elderly EGS patients, including octogenarians and nonagenarians., Methods: Using the 2007-2017 National Surgical Quality Improvement Program (NSQIP) database, we included all EGS patients ≥65 years old. The correlation between ESS, mortality and morbidity was assessed in the 3 patient cohorts (>65, octogenarians and nonagenarians), using the area under the curve (AUC)., Results: A total of 124,335 patients were included, of which 34,215 (28%) were octogenarians and 7239 (6%) were nonagenarians. In patients ≥65 years, ESS accurately predicted mortality (AUC 0.81). For octogenarians and nonagenarians, ESS predicted mortality moderately well (AUC 0.77 and 0.69, respectively., Conclusion: ESS accurately predicts mortality and morbidity in the elderly EGS patient, but its accuracy in predicting morbidity decreases for nonagenarians., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES., Methods: Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed., Results: A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES., Conclusion: Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively., Level of Evidence: Prognostic study, Level IV.

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.

Background: Outcome data on the very elderly patients undergoing emergency general surgery (EGS) are sparse. We sought to examine short- and long-term mortality in the 80 plus years population following EGS., Methods: Using our institutional 2008-2018 EGS Database, all the 80 plus years patients undergoing EGS were identified. The data were linked to the Social Security Death Index to determine cumulative mortality rates up to 3 years after discharge. Univariate and multivariable logistic regression analyses were used to determine predictors of in-hospital and 1-year cumulative mortality., Results: A total of 385 patients were included with a mean age of 84 years; 54% were female. The two most common comorbidities were hypertension (76.1%) and cardiovascular disease (40.5%). The most common procedures performed were colectomy (20.0%), small bowel resection (18.2%), and exploratory laparotomy for other procedures (15.3%; e.g., internal hernia, perforated peptic ulcer). The overall in-hospital mortality was 18.7%. Cumulative mortality rates at 1, 2, and 3 years after discharge were 34.3%, 40.5%, and 43.4%, respectively. The EGS procedure associated with the highest 1-year mortality was colectomy (49.4%). Although hypertension, renal failure, hypoalbuminemia, hyperbilirubinemia, and elevated liver enzymes predicted in-hospital mortality, the only independent predictors of cumulative 1-year mortality were hypoalbuminemia (odds ratio, 2.17; 95% confidence interval, 1.10-4.27; p = 0.025) and elevated serum glutamic pyruvic transaminase (SGOT) level (odds ratio, 2.56; 95% confidence interval, 1.09-4.70; p = 0.029) at initial presentation. Patients with both factors had a cumulative 1-year mortality rate of 75.0%., Conclusion: More than half of the very elderly patients undergoing major EGS were still alive at 3 years postdischarge. The combination of hypoalbuminemia and elevated liver enzymes predicted the highest 1-year mortality. Such information can prove useful for patient and family counseling preoperatively., Level of Evidence: Prognostic, Level III.

Background: Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient., Study Design: This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality., Results: Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p < 0.05)., Conclusions: A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Indications for nonoperative management (NOM) after penetrating renal injury remain ill-defined. Using a national database, we sought to describe the experience of operative and nonoperative management in the United States and retrospectively examine risk factors for failure of NOM., Materials and Methods: The TQIP database 2010-2016 was used to identify patients with penetrating renal trauma. Outcomes of patients treated with an immediate operation (IO) and NOM are described. Failure of NOM was defined as the need for a renal operation after 4 h from arrival. Univariate then multivariable regression analyses were performed to identify predictors of NOM failure., Results: Out of 8139 patients with kidney trauma, 1,842 had a penetrating mechanism of injury and were included. Of those, 89% were male, median age was 28 years, and 330 (18%) were offered NOM. Compared to IO, NOM patients were less likely to have gunshot wound (59% vs 89% p < 0.001) or high-grade renal injuries [AAST 4-5] (48% vs 76%, p < 0.001). Lower rates of in-hospital complications and shorter ICU and hospital stays were observed in the NOM group. NOM failed in 26 patients (8%). Independent predictors of NOM failure included a concomitant abdominal injury (OR = 3.99, 95% CI 1.03-23.23, p = 0.044), and every point increase in AAST grade (OR = 2.43, 95% CI 1.27-5.21, p = 0.005)., Conclusions: NOM is highly successful in selected patients. Concomitant abdominal injuries and higher grade AAST injuries predict NOM failure and should be considered when selecting patients for IO or NOM., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Hospital length of stay (LOS) is currently recognized as a key quality indicator. We sought to investigate how much of the LOS variation in the high-risk group of patients undergoing Emergency general surgery could be explained by clinical versus nonclinical factors., Methods: Using the 2007 to 2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we included all patients who underwent an emergency appendectomy, cholecystectomy, colectomy, small intestine resection, enterolysis, or hernia repair. American College of Surgeons National Surgical Quality Improvement Program defines emergency surgery as one that is performed no later than 12 hours after admission or symptom onset. Using all the ACS-NSQIP demographic, preoperative (comorbidities, laboratory variables), intraoperative (e.g., duration of surgery, wound classification), and postoperative variables (i.e., complications), we created multivariable linear regression models to predict LOS. LOS was treated as a continuous variable, and the degree to which the models could explain the variation in LOS for each type of surgery was measured using the coefficient of determination (R)., Results: A total of 215,724 patients were included. The mean age was 47.1 years; 52.0% were female. In summary, the median LOS ranged between 1 day for appendectomies (n = 124, 426) and cholecystectomies (n = 21,699) and 8 days for colectomies (n = 19,557) and small intestine resections (n = 7,782). The R for all clinical factors ranged between 0.28 for cholecystectomy and 0.44 for hernia repair, suggesting that 56% to 72% of the LOS variation for each of the six procedures studied cannot be explained by the wide range of clinical factors included in ACS-NSQIP., Conclusion: Most of the LOS variation is not explained by clinical factors and may be explained by nonclinical factors (e.g., logistical delays, insurance type). Further studies should evaluate these nonclinical factors to identify target areas for quality improvement., Levels of Evidence: Epidemiological study, level III.

Background: Recent small randomized trials suggest that primary anastomosis with a diverting loop ileostomy (PADLI) is a safe alternative to Hartmann's procedure (HP) for patients with acute diverticulitis necessitating emergent operation. We sought to examine the 30-day outcomes of patients undergoing emergent HP vs PADLI., Method: Using the American College of Surgeons NSQIP Colectomy Procedure Targeted Database from 2012 to 2016, all patients with acute diverticulitis who underwent emergent HP or PADLI were identified. Multivariable logistic models were constructed to compare the 30-day mortality, overall morbidity, and individual postoperative complications (eg surgical site infection, bleeding, sepsis) of the 2 procedures, controlling for all preoperative variables (eg demographics, comorbidities, laboratory values, illness severity), as well as intraoperative and procedure-specific variables (eg wound classification)., Results: Of 130,963 patients, 2,729 patients were included. Median age was 64 years, 48.5% were male; the majority of patients underwent HP and only 208 (7.6%) underwent PADLI. Hartmann's procedure patients had more comorbidities (eg COPD: 9.8% vs 4.8%; p = 0.017), were more functionally dependent (6.3% vs 2.4%; p = 0.025), and were sicker (eg septic shock: 11.1% vs 5.3%; p = 0.015) compared with PADLI patients. The mortality rates for HP vs PADLI were 7.6% and 2.9%, respectively (p = 0.011). The morbidity rates were 55.4% and 48.6%, respectively (p = 0.056). In multivariable analyses, compared with HP, PADLI did not result in increased rates of mortality (odds ratio 0.21; 95% CI 0.03 to 1.58; p = 0.129) or morbidity (odds ratio 0.96; 95% CI 0.63 to 1.45; p = 0.834). The odds of most major postoperative complications were also similar for HP and PADLI overall., Conclusions: Currently, surgeons perform HP more frequently than PADLI. When controlling for patient population differences, PADLI appears to be at least a safe alternative to HP for select patient populations needing emergent surgical management of acute diverticulitis., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Recent studies suggest that obesity is a risk factor for Clostridium difficile infection, possibly due to disruptions in the intestinal microbiome composition. We hypothesized that body mass index (BMI) is associated with increased incidence of C. difficile infection in surgical patients., Methods: In this nationwide retrospective cohort study in 680 American College of Surgeons National Surgical Quality Improvement Program participating sites across the United States, the occurrence of C. difficile infection within 30 days postoperatively between different BMI groups was compared. All American College of Surgeons National Surgical Quality Improvement Program patients between 2015 and 2016 were classified as underweight, normal-weight, overweight, or obese class I-III if their BMI was less than 18.5, 18.5 to 25, 25 to 30, 30 to 35, 35 to 40 or greater than 40, respectively., Results: A total of 1,426,807 patients were included; median age was 58 years, 43.4% were male, and 82.9% were white. The postoperative incidence of C. difficile infection was 0.42% overall: 1.11%, 0.56%, 0.39%, 0.35%, 0.33% and 0.36% from the lowest to the highest BMI group, respectively (p < 0.001 for trend). In univariate then multivariable logistic regression analyses, adjusting for patient demographics (e.g., age, sex), comorbidities (e.g., diabetes, systemic sepsis, immunosuppression), preoperative laboratory values (e.g., albumin, white blood cell count), procedure complexity (work relative unit as a proxy) and procedure characteristics (e.g., emergency, type of surgery [general, vascular, other]), compared with patients with normal BMI, high BMI was inversely and incrementally correlated with the postoperative occurrence of C. difficile infection. The underweight were at increased risk (odds ratio, 1.15 [1.00-1.32]) while the class III obese were at the lowest risk (odds ratio, 0.73 [0.65-0.81])., Conclusion: In this nationwide retrospective cohort study, obesity is independently and in a stepwise fashion associated with a decreased risk of postoperative C. difficile infection. Further studies are warranted to explore the potential and unexpected association., Level of Evidence: Prognostic/Epidemiologic, Level IV.

Background: The decision to emergently operate on nonagenarian patients (NONAs) can be complex due to the uncertainty about outcomes and goals of care at this advanced age. We sought to study: (1) the outcomes and predictors of mortality for NONAs undergoing emergency general surgery (EGS) and (2) the accuracy of ACS-NSQIP mortality risk calculator in this special population., Methods: Using the 2007 to 2015 ACS-NSQIP database, we included all patients older than 90 years of age who underwent an emergent operation with a Current Procedural Terminology (CPT) code for "digestive system." Multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. NONAs' mortality rates for different combinations of risk factors were also studied and compared to the ACS-NSQIP calculator-predicted mortality rates., Results: Out of a total of 4,456,809 patients, 4,724 NONAs were included. The overall 30-day patient mortality and morbidity rates were 21% and 45%, respectively. In multivariable analyses, several independent predictors of 30-day mortality were identified, including recent history of weight loss, history of steroid use, smoking, functional dependence, hypoalbuminemia and sepsis or septic shock. The mortality among NONAs with a history of steroid use and a recent history of weight loss was 100%. Similarly, the mortality of NONAs with recent history of weight loss who presented with preoperative septic shock was 93%. The ACS-NSQIP calculator significantly and consistently underestimated the risk of mortality in all NONAs undergoing EGS., Conclusion: Most NONAs undergoing EGS survive the hospital stay and the first 30 postoperative days, even in the presence of significant preexisting comorbidities. However, the combination of recent weight loss with either steroid use or septic shock nearly ensures mortality and should be used in the discussions with patients and families before a decision to operate is made. The ACS-NSQIP surgical risk calculator should be used with caution in these high-risk patients., Level of Evidence: Prognostic study, level III.

Background: The emergency surgery score (ESS) is a preoperative risk calculator recently validated as a mortality predictor in emergency surgery (ES) patients. We sought to evaluate the utility of ESS as an ICU admission triage tool., Methods: A four-step methodology was designed. First, the 2007-2015 ACS-NSQIP database was examined to identify all ES patients using the "emergent" variable and CPT codes for "digestive system". Second, we created a composite variable called ICUneed, defined as death or the development of one or more postoperative complication warranting critical care (e.g. unplanned intubation, ventilator dependent ≥48 h, cardiac arrest, septic shock and coma ≥24 h). Third, for each patient, ESS was calculated. Fourth, the correlation between ESS and ICUneed was assessed by calculating the model c-statistics (AUROC)., Results: Out of a total of 4,456,809 patients, 65,989 patients were included. The mean population age was 56 years; 51% were female, and 71% were white. The overall 30-day postoperative mortality and morbidity were 8.2% and 31.7%, respectively. ESS gradually and accurately predicted ICUneed, with 1%, 40% and 98% of patients with ESS of 2, 9 and 16 requiring critical care, respectively. Only 6.2% of patients with ESS ≤7 had an ICUneed, while 97.2% of patients with ESS ≥15 had an ICUneed. The c-statistic of the predictive model was 0.90., Conclusions: ESS accurately predicts the need for postoperative critical care and ICU admission. In resource-limited settings, ESS may prove useful as an ICU triage tool ensuring a prompt rescue of the clinically deteriorating patient without unnecessary and burdensome ICU admissions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients., Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics., Results: Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively., Conclusion: The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.

Background: Diversion of unused prescription opioids is a major contributor to the current United States opioid epidemic. We aimed to study the variation of opioid prescribing in emergency surgery., Methods: Between October 2016 and March 2017, all patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, or inguinal hernia repair in the acute care surgery service of 1 academic center were included. For each patient, we systematically reviewed the electronic medical record and the prescribing pharmacy platform to identify: (1) history of opioid abuse, (2) opioid intake 3 months preoperatively, (3) number of opioid pills prescribed, (4) prescription of nonopioid pain medications (eg, acetaminophen, ibuprofen), and (5) the need for opioid prescription refills. The mean and range of opioid pills prescribed, as well as their oral morphine equivalent, were calculated., Results: A total of 255 patients were included (43.5% laparoscopic appendectomy, 44.3% laparoscopic cholecystectomy, and 12.1% inguinal hernia repair). The mean age was 47.5 years, 52.1% were female, 11.4% had a history of opioid use, and 92.5% received opioid prescriptions upon hospital discharge. Only 70.9% of patients were instructed to use nonopioid pain medications. The mean and range of opioid pills prescribed were 17.4; 0-56 (laparoscopic appendectomy), 17.1; 0-75 (laparoscopic cholecystectomy), and 20.9; 0-50 (inguinal hernia repair), while the range of prescribed oral morphine equivalent was 0-600 mg for laparoscopic appendectomy/laparoscopic cholecystectomy and 0-375 mg for inguinal hernia repair. No patients required any opioid medication refills., Conclusion: Even within the same surgical service, wide variation of opioid prescription was observed. Guidelines that standardize pain management may help prevent opioid overprescribing., (Copyright © 2018 Elsevier Inc. All rights reserved.)