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Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort.The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis.After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, Plt; .001), a higher 30-day mortality (38.6% vs 29.0%, Plt; .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, Plt; .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, Plt; .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, Plt; .001).Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population.

Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion.Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality.A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP2 (1,160 [12.6%]) (p0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]).Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement.Therapeutic/Care Management; Level IV.

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/m2 [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/m2) and obese (BMI ≥30kg/m2) 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 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.

ImportanceFor decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach.ObservationsThis review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome.Conclusions and RelevanceThe treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.

Background A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. Methods Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. Results Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. Conclusion Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach.

Introduction Intestinal-cutaneous fistulas (ICFs) constitute a major surgical challenge. Definitive surgical treatment of ICFs continues to be associated with significant morbidity. The purpose of this study was to utilize a nationwide database to define the morbidity associated with current treatment strategies in the surgical management of ICFs. Methods The 2006–2017 American College of Surgeon National Surgical Quality Improvement datasets (ACS-NSQIP) were used to assess 30-day morbidity and mortality after surgical repair of ICFs. Outcomes for emergent repair were compared to elective repair of ICFs. Results Overall, 4197 patients undergoing ICF-repair were identified. Mean age was 55.9 (SD 15.3). Patients were generally comorbid (62.9% were in ASA class III). The observed in-hospital mortality was 2.3%. However, the observed morbidity rate was 47.3%. Of the observed morbidity, 35.6% was due to post-operative infectious complications (superficial surgical site infections (SSI), deep SSI, organ/space SSI, wound disruption, pneumonia, urinary tract infection (UTI) sepsis or septic shock). The most common infectious complication was sepsis (13.1%). 30-day readmission rate was 15.3% and the 30-day reoperation rate was 11.0%. Emergent repair was associated with a sevenfold increase in mortality (11.9% vs 1.8%, P Conclusion The management of patients with ICFs is complex and is associated with significant morbidity. Half of patients undergoing surgical management of ICFs developed in-hospital complications.

Background In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. Methods Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. Results A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. Conclusion Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. Level of evidence Prognostic, Level III.

A minimally invasive step-up (MIS) approach for management of necrotizing pancreatitis (NP) has been associated with reduced morbidity and mortality compared with open surgical techniques. We sought to evaluate bleeding complications in NP patients treated with a MIS approach and to describe the management and outcomes of these events.An observational, cohort study was performed using a prospectively maintained NP database at a tertiary referral center from 2013 to 2019.Of 119 NP patients, 13% suffering bleeding events, and 18% underwent an intervention. There was a 6-fold higher mortality rate in patients with bleeding events (n = 3; 18.8%) compared with those without (n = 3; 2.9%) ( P = 0.031). The most common intervention for hemorrhage control was endovascular coil embolization (75%), which was successful 88% of the time. Seven patients underwent prophylactic vascular intervention, which was 100% successful in preventing bleeding events from the embolized vessel.Bleeding events in NP patients treated with a MIS approach are associated with a 6-fold increase in mortality. Endovascular intervention is an effective strategy for the management of bleeding events. Prophylactic embolization may be an effective technique for reducing bleeding complications.

BACKGROUND: We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts. METHODS: This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality. RESULTS: A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality. CONCLUSION: We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities. LEVEL OF EVIDENCE: Prognostic, level III.

Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.

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 surg...

A Man with Abdominal Pain, Joint Swelling, and Skin Lesions A 55-year-old-man with a history of neurofibromatosis and chronic necrotizing pancreatitis presented with abdominal pain and recurrent pa...

Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding.This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing.A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018).This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.

Background Western Trauma Association guidelines recommend admitting patients 65 years or older with two or more rib fractures diagnosed by chest radiograph to the intensive care unit (ICU). Increased use of computed tomography has led to identification of less severe, "occult" rib fractures. We aimed to evaluate current national trends in disposition of older patients with isolated rib cage fractures and to identify characteristics of patients initially admitted to the ward who failed ward management. Methods A retrospective cohort study of patients 65 years or older with isolated two or more blunt rib cage fractures using the 2010 to 2016 American College of Surgeons Trauma Quality Improvement Program database was performed. Ward failure was defined as patients initially admitted to the ward with subsequent need for unplanned ICU admission or intubation. Multivariable analyses were derived to study the independent predictors of failure of ward management. Propensity score matching sub-analysis was used to assess outcomes in patients admitted to the ward versus ICU. Results There were 5,021 patients included in the analysis. Of these patients, 1,406 (28.0%) were admitted to the ICU. On multivariable analysis, age was an independent predictor of ICU admission. Of the 3,577 patients admitted directly to the ward, 38 (1.1%) patients required unplanned intubation or ICU admission. Independent predictors of failure of ward management included chronic renal failure (odds ratio [OR], 7.20; p ≤ 0.001; 95% confidence interval [CI], 2.50-20.76), traumatic pneumothorax (OR, 8.70; p = 0.008; 95% CI, 1.76-42.93), concurrent sternal fracture (OR, 6.52; p ≤ 0.001; 95% CI, 2.53-16.80), drug use disorder (OR, 6.58; p = 0.032; 95% CI, 1.17-36.96), and emergency department oxygen requirement or oxygen saturation less than 95% (OR, 2.38; p = 0.018; 95% CI, 1.16-4.86). Mortality was higher in patients with delayed ICU care versus patients with successful ward disposition (21.1% vs. 0.8%; p Conclusion Our results suggest that the majority of isolated rib cage fractures in older patients are safely managed on the ward with exceedingly low ward failure rates (1.1%). Patients with failure of ward management have significantly higher mortality, and we have identified predictors of failing the ward. Level of evidence Therapeutic/Care Management, level IV; Prognostic III.

Background A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared with open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis. We sought to determine whether transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage, endoscopic transgastric necrosectomy, video-assisted retroperitoneal debridement, sinus tract endoscopic necrosectomy, or a combination of techniques, with selective use of OSN. Study Design We conducted an observational cohort study with retrospective comparison at a single tertiary referral center (2006 through 2019). Eighty-eight patients were treated with OSN and 91 were treated with an MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary end point was 90-day mortality. Results There was no difference in baseline characteristics. Ninety-day mortality was 2% with MIS compared with 10% with OSN (p = 0.03). One-year mortality was 3% with MIS compared with 15% with OSN (p = 0.012). The rate of organ failure was lower with MIS (30% vs 45%; p = 0.029), but there was a higher bleeding rate (19% vs 9%; p = 0.064). In the MIS group, 9% were treated with percutaneous drainage, 32% with endoscopic transgastric necrosectomy, 8% with video-assisted retroperitoneal debridement, 15% with sinus tract endoscopic necrosectomy, and 27% with a combination of techniques. Conclusions Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN.

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 Conclusions A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios.

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.

Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE).All adults (age16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups.Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03).Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

Background Abdominal wall hernias represent a common problem that can present as surgical emergencies with increased morbidity and mortality. The data examining outcomes in elderly patients with hernia emergencies is scant. Methods The 2007-2017 ACS-NSQIP database was queried. Patients ≥65 years old with a diagnosis of acute complicated abdominal wall hernia were included. Univariable and multivariable analyses were used to identify independent predictors of 30-day mortality and surgical site infection (SSI). Results Main predictors of 30-day mortality were admission from nursing home or chronic care facility (OR = 1.62, 95% CI: 1.10-2.38, P = .014), transfer from outside ED (OR = 1.81, 95% CI: 1.31-2.51, P < .001), days from admission to operation (OR = 1.05, 95% CI: 1.02-1.08, P = .002), recent significant weight loss (OR = 1.95, 95% CI: 1.12-3.37, P = .018), pre-operative septic shock (OR = 4.13, 95% CI: 2.44-6.99, P < .001), ventilator dependence (OR = 2.50, 95% CI: 1.29-4.81, P = .006), and ASA status. When compared to open repair, laparoscopic repair emerged as protective against SSI (OR = .34, 95% CI: .17-.66, P = .001). Bowel resection (OR = 2.15, 95% CI: 1.63-2.84, P < .001) and increasing wound class were risk factors for SSI. Conclusion In the elderly patient presenting with an acute complicated abdominal wall hernia, time to surgery is crucial for survival, and comorbidities influence outcome. Laparoscopy is an option in management due to its decreased risk of surgical site infection without increased mortality, whenever patient factors are favorable for this approach.

As hospital systems plan for health care utilization surges and stress, understanding the necessary resources of a trauma system is essential for planning capacity. We aimed to describe trends in high-intensity resource utilization (operating room [OR] usage and intensive care unit [ICU] admissions) for trauma care during the initial months of the COVID-19 pandemic. Trauma registry data (2019 pre-COVID-19 and 2020 COVID-19) were collected retrospectively from 4 level I trauma centers. Direct emergency department (ED) disposition to the OR or ICU was used as a proxy for high-intensity resource utilization. No change in the incidence of direct ED to ICU or ED to OR utilization was observed (2019: 24%, 2020 23%; P = .62 and 2019: 11%, 2020 10%; P = .71, respectively). These results suggest the need for continued access to ICU space and OR theaters for traumatic injury during national health emergencies, even when levels of trauma appear to be decreasing.

Background COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution’s surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. Methods All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. Results Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. Conclusion Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.

Background The mortality rate from mesenteric ischemia is reported to be as high as 80%. The goal of our study was to identify demographic and clinical predictors of post-operative mortality and discharge disposition among elderly patients with mesenteric ischemia. Methods All patients 65 years and older who underwent emergency surgery (ES) for the management of mesenteric ischemia in the American College of Surgeons–National Surgical Quality Improvement Program database from 2007 to 2017 were included. Univariate analyses and logistic regressions were used to identify independent predictors of mortality and discharge disposition. Results A total of 2438 patients met inclusion criteria, with a median age of 77 years and 60.8% being female. The 30-day mortality of the overall cohort was 31.5% and the 30-day morbidity was 65.3%. The following were the major predictors of 30-day mortality: pre-operative diagnosis of septic shock [OR: 2.46, (95% CI: 1.94-3.13)], dialysis dependence [OR: 2.05, (95% CI: 1.45-2.90)], recent weight loss [OR: 1.80, (95% CI: 1.16-2.79)], age ≥80 years [OR: 1.67, (95% CI: 1.25-2.23)], and ventilator dependence [OR: 1.65, (95% CI: 1.23-2.23)]. In the absence of these predictors, survival rate was 84%. The major predictors of discharge to post-acute care (PAC) included age ≥80 years [OR: 3.70, (95% CI: 2.50-5.47)] and pre-operative septic shock [OR: 2.20, (95% CI: 1.42-3.41)]. Conclusion In the geriatric patient, a diagnosis of mesenteric ischemia does not equate to an automatic death sentence. The presence of certain pre-operative risk factors confers a high risk of mortality, whereas their absence is associated with a high chance of survival.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Objective The relationship between total transfusion volume and infection in the trauma patient remains unclear, especially at lower volumes of transfusion. We sought to quantify the cumulative, independent impact of transfusion within 24 hours of admission on the risk of infection in trauma patients. Methods Using the Trauma Quality Improvement Program 2013 to 2016 database, we included all patients who received blood transfusions in the first 4 hours. Patients who were transferred or had incomplete/wrongly coded information on transfusion volume were excluded. Patients were divided into 20 cohorts based on the total blood product volume transfused in the first 24 hours. A composite infection variable (INF) was created, including surgical site infection, ventilator-associated pneumonia, urinary tract infection, central line associated blood stream infection, and sepsis. Univariate and stepwise multivariable logistic regression analyses were performed to study the relationship between blood transfusion and INF, controlling for demographics (e.g., age, sex), comorbidities (e.g., cirrhosis, diabetes, steroid use), severity of injury (e.g., vital signs on arrival, mechanism, Injury Severity Score), and operative and angiographic interventions. Results Of 1,002,595 patients, 37,568 were included. The mean age was 42 ± 18.6 years, 74.6% were males, 68% had blunt trauma, and median Injury Severity Score was 25 [17-34]. Adjusting for all available confounders, odds of INF increased incrementally from 1.00 (reference, 0-2 units) to 1.23 (95% confidence interval, 1.11-1.37) for 4 units transfused to 4.89 (95% confidence interval, 2.72-8.80) for 40 units transfused. Each additional unit increased the odds of INF by 7.6%. Conclusion Transfusion of the bleeding trauma patient was associated with a dose-dependent increased risk of infectious complications. Trauma surgeons and anesthesiologists should resuscitate the trauma patient until prompt hemorrhage control while avoiding overtransfusion. Level of evidence Retrospective cohort study, Therapeutic IV.

Background: More than 145,500 abdominal abscesses occur annually in the U.S. Percutaneous catheter drainage (PCD) is the primary treatment for clinically significant intra-abdominal collections (IACs), but only approximately 90% of all IACs are treatable with PCD. This leaves a significant number of patients facing long courses of management, including multiple interventions. Minimally invasive debridement techniques are now employed regularly for the treatment of infected necrosis caused by acute pancreatitis. We describe the use of minimally invasive videoscopic debridement techniques employed as part of a "step-up" approach to resolve IACs of other etiologies that are unresponsive to PCD. Methods: Data of all patients undergoing this procedure at a tertiary referral academic center from 2015 to 2017 after failure of different PCD techniques were analyzed retrospectively. Results: Four men and two women, mean age 54.6 years (range 26-70 years), with refractory IACs (mean drainage time 91.3 days; mean number of drainage procedures 4.6) following a variety of surgical interventions and inflammatory conditions underwent either video-assisted retroperitoneal debridement or sinus tract endoscopic debridement with a rigid or flexible endoscope. Technical success was achieved in all cases, and clinical success was observed in five cases. No immediate procedural complications were detected. The mean hospital stay and post-procedure drainage times were 5.5 and 25.2 days, respectively. There were no recurrent IACs. Conclusion: Minimally invasive debridement techniques can safely resolve IACs refractory to standard PCD techniques. Employment of these techniques as part of a step-up approach may reduce the morbidity and duration of drainage for the thousands of patients treated annually who have refractory IACs, whatever their etiology.

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.

We sought to examine whether preoperative endoscopic retrograde cholangio-pancreatography (ERCP) increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy.Patients admitted to an academic hospital from 2010 to 2016, who were older than 18 and had a laparoscopic or a laparoscopic converted to open cholecystectomy for complicated biliary tract disease were included. We compared those who had a preoperative ERCP to those who did not. Our primary endpoint was the rate of SSI.A total of 640 patients were included. Of them, 122 (19.1%) received preoperative ERCP and 518 (80.9%) did not. The former had different preoperative diagnoses compared to non-ERCP patients (choledocholithiasis [35.2%-7.0%], acute cholecystitis [31.2%-76.4%], gallstone pancreatitis [20.5%-16.2%], and cholangitis [13.1%-0.4%], p 0.001). The rate of SSI was higher in the preoperative ERCP group (11.5%-4.0%, p = 0.005). In a multivariable analysis conversion to open (OR = 2.57, 95% CI = 1.06-6.21, p = 0.037) and preoperative ERCP (OR = 3.12, 95% CI = 1.34-7.22, p = 0.008) were the only independent predictors of SSI.Preoperative ERCP is associated with a threefold increase in the risk of SSI after laparoscopic cholecystectomy.

Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality. We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality. Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21–14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23–12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30–10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25–14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19–17.68, p = 0.027) were independent predictors of mortality. SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.

Importance The familial aspect of acute appendicitis (AA) has been proposed, but its hereditary basis remains undetermined. Objective To identify genomic variants associated with AA. Design, setting, and participants This genome-wide association study, conducted from June 21, 2019, to February 4, 2020, used a multi-institutional biobank to retrospectively identify patients with AA across 8 single-nucleotide variation (SNV) genotyping batches. The study also examined differential gene expression in appendiceal tissue samples between patients with AA and controls using the GSE9579 data set in the National Institutes of Health's Gene Expression Omnibus repository. Statistical analysis was conducted from October 1, 2019, to February 4, 2020. Main outcomes and measures Single-nucleotide variations with a minor allele frequency of 5% or higher were tested for association with AA using a linear mixed model. The significance threshold was set at P = 5 × 10-8. Results A total of 29 706 patients (15 088 women [50.8%]; mean [SD] age at enrollment, 60.1 [17.0] years) were included, 1743 of whom had a history of AA. The genomic inflation factor for the cohort was 1.003. A previously unknown SNV at chromosome 18q was found to be associated with AA (rs9953918: odds ratio, 0.99; 95% CI, 0.98-1.00; P = 4.48 × 10-8). This SNV is located in an intron of the NEDD4L gene. The heritability of appendicitis was estimated at 30.1%. Gene expression data from appendiceal tissue donors identified NEDD4L to be among the most differentially expressed genes (14 of 22 216 genes; β [SE] = -2.71 [0.44]; log fold change = -1.69; adjusted P = .04). Conclusions and relevance This study identified SNVs within the NEDD4L gene as being associated with AA. Nedd4l is involved in the ubiquitination of intestinal ion channels and decreased Nedd4l activity may be implicated in the pathogenesis of AA. These findings can improve the understanding of the genetic predisposition to and pathogenesis of AA.

Background: Post-operative infectious complications after repair of intestinal-cutaneous fistulas (ICF) represent a substantial burden and these outcomes vary widely in the literature. We aimed to evaluate the use of the modified frailty index-5 (mFI-5) to account for physiologic reserve to predict infectious complications in patients with ICF undergoing operative repair. Methods: We used the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) 2006-2017 dataset to include patients who underwent ICF repair. The main outcome measure was 30-day infectious complications (surgical site infection [SSI], sepsis, pneumonia, and urinary tract infection [UTI]). The risk of 30-day post-operative infectious complications was assessed based on mFI-5 score. We performed multivariable logistic regression analyses to evaluate the association between infectious complications and mFI-5. Results: We identified 4,197 patients who underwent an ICF repair. The median age (interquartile range [IQR]) was 57 (46, 67) years, and the majority of patients were female (2,260; 53.9%); white (3,348; 79.8%); and 1,586 (38.3%) were obese. After adjustment for relevant confounders such as baseline patient characteristics, and operative details, mFI-5 was independently associated with infectious complications (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.25-3.21), particularly SSI (OR, 2.16; 95% CI, 1.28-3.63) and pneumonia (OR, 5.31; 95% CI, 2.29-12.35), but not UTI or sepsis. Conclusions: We showed that the mFI-5 is a strong predictor of infectious complications after ICF repair. It can be utilized to account for physiologic reserve, therefore reducing the variability of outcomes reported for ICF repair.

Background Optimal use of interventional procedures and diagnostic tests for patients with suspected choledocholithiasis depends on accurate pretest risk estimation. We sought to define sensitivity/specificity of transaminases in identifying choledocholithiasis and to incorporate them into a biochemical marker composite score that could accurately predict choledocholithiasis. Methods All adult patients who underwent laparoscopic cholecystectomy by our Emergency Surgery Service between 2010 and 2018 were reviewed. Admission total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) was captured. Choledocholithiasis was confirmed via intraoperative cholangiogram, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography. Area under receiver operating characteristic curve (AUC) or C-statistic for AST, ALT, ALP, and TB as a measure of detecting choledocholithiasis was calculated. For score development, our database was randomly dichotomized to derivation and validation cohort and a score was derived. The score was validated by calculating its C-statistic. Results 1089 patients were included; 210 (20.3%) had confirmed choledocholithiasis. The AUC was .78 for TB, .77 for ALP and AST, and .76 for ALT. 545 and 544 patients were included in the derivation and the validation cohort, respectively. The elements of the derived score were TB, AST, and ALP. The score ranged from 0 to 4. The AUC was .82 in the derivation and .77 in the validation cohort. The probability of choledocholithiasis increased from 8% to 89% at scores 0 to 4, respectively. Conclusions Aspartate aminotransferase predicted choledocholithiasis adequately and should be featured in choledocholithiasis screening algorithms. We developed a biochemical composite score, shown to be accurate in preoperative choledocholithiasis risk assessment in an emergency surgery setting.

Enteral nutrition is associated with improved outcomes in acute pancreatitis (AP), but previous studies have not focused on critically-ill patients. Our purpose was to determine the association between nutritional support and infectious complications in ICU-admitted patients with AP.A retrospective analysis of patients with AP admitted in ICUs of 127 US hospitals from the eICU Collaborative were included. Patients were classified by type (initial and any use) of nutritional support they received: none (NN); oral (ON); enteral (EN); and parenteral nutrition (PN).925 patients were identified. Length of stay was longer in the initial PN group (PN 21.3 ± 15.4 d, EN 19.1 ± 20.1 d, ON 8 ± 7.1 d, NN 6.6 ± 6.3 d, p0.001) and mortality was more common in the initial EN group (EN 16.7%, PN 8.9%, ON 2.7%, NN 10.9%, p0.001). Multivariate analysis found any EN use to be associated with infections (OR 2.12, 95% CI: 1.13-3.98, p = 0.019) and pneumonias (OR 2.04, 95% CI: 1.04-4.03, p = 0.039).EN was associated with an increased risk for pneumonias and overall infections in critically-ill patients with AP. More studies are needed to assess optimal nutritional approaches in critically-ill AP patients and patients who do not tolerate EN.

Background Peri-operative blood transfusion (BT) may lead to transfusion-induced immunomodulation. We aimed to investigate the association between peri-operative BT and infectious complications in patients undergoing intestinal-cutaneous fistulas (ICF) repair. Methods We queried the ACS-NSQIP 2006–2017 database to include patients who underwent ICF repair. The main outcome was 30-day infectious complications. Univariate and multivariable logistic regression analyses were performed to assess the predictors of post-operative infections. Results Of 4,197 patients included, 846 (20.2%) received peri-operative BT. Transfused patients were generally older, sicker and had higher ASA (III–V). After adjusting for relevant covariates, patients who received intra and/or post-operative (and not pre-operative) BT had higher odds of infectious complications compared (OR = 1.22, 95% CI 1.01–1.48). Specifically, they had higher odds of organ-space surgical site infection (OR = 1.61, 95% CI 1.21–2.13), but not other infectious complications. Conclusions Intra and/or post-operative (and not pre-operative) BT is an independent predictor of infectious complications in ICF repair.

Background: Patients on prehospital anticoagulation with warfarin or direct oral anticoagulants (DOACs) represent a vulnerable subset of the trauma population. While protocolized warfarin reversal is widely available and easily implemented, prehospital anticoagulation with DOAC is cost prohibitive with only a few reversal options. This study aims to compare hospital outcomes of non-head injured trauma patients taking pre-injury DOAC versus warfarin.Methods: A retrospective cohort study at a level 1 trauma center was performed. All adult trauma patients with pre-injury anticoagulation admitted between January 2015 and December 2018, were stratified into DOAC-using and warfarin-using groups. Patients were excluded if they had traumatic brain injury (TBI). Univariate and multivariable analyses were performed. Outcomes measures included inhospital mortality, blood transfusion requirements, ICU length of stay (LOS), hospital LOS and discharge disposition.Results: 374 non-TBI trauma patients on anticoagulation were identified, of which 134 were on DOACs and 240 on warfarin. Patients on DOACs had a higher ISS (9 [IQR, 9-10] vs. 9 [IQR, 5-9]; p

Background The outcomes of operative repair of intestinal-cutaneous fistulas vary widely throughout the literature. We aimed to investigate whether the modified frailty index-5 is a reliable tool to account for physiologic reserve and whether it serves as a predictor of Clavien-Dindo grade IV complications in those with intestinal-cutaneous fistulas undergoing operative repair. Methods We queried the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2017 database to include patients who underwent intestinal-cutaneous fistulas repair. The outcome of interest was 30-day Clavien-Dindo grade IV complications. The incidence of 30-day post-operative Clavien-Dindo grade IV complications were evaluated based on calculated modified frailty index-5 score. Multivariable logistic regression analyses were performed to assess the association of Clavien-Dindo grade IV complications and modified frailty index-5. Results A total of 3,995 patients were identified who underwent an intestinal-cutaneous fistulas repair. The median age (interquartile range) was 57 years (46, 67), and most patients were female (2,143 [53.7%]), White (3,206 [80.3%]), and 1,512 (38.2%) were obese. After adjusting for relevant covariates such as demographics, comorbidities, and operative details, modified frailty index-5 was independently associated with Clavien-Dindo grade IV complications (odds ratio = 2.81, 95% confidence interval 1.64–4.82; P Conclusion Modified frailty index-5 is an independent predictor of Clavien-Dindo grade IV complications following intestinal-cutaneous fistulas repair. It can be used to account for physiologic reserve, thus reducing the variability of outcomes reported for intestinal-cutaneous fistulas repair.

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Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs.The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (6 years, 6-13 years, 13-20 years,20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs.A large tertiary care teaching hospital.Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident.A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with6, 6-13, 13-20, and20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with20 years of experience compared to those with6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs.The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.

BACKGROUND The optimal method of fascial closure, interrupted fascial closure (IFC) versus continuous fascial closure (CFC) has never been studied exclusively in the setting of emergency surgery. We hypothesized that IFC decreases postoperative incisional hernia development following emergent laparotomies. METHODS Between August 2008 and September 2015, patients undergoing emergent laparotomies were consented and randomly assigned to either IFC or CFC. Patients were followed up postoperatively for at least 3 months and assessed for incisional hernia, dehiscence, or wound infection. We excluded those with trauma, elective surgery, mesh in place, primary ventral hernia, previous abdominal surgery within 30 days, or those not expected to survive for more than 48 hours. Our primary endpoint was the incidence of postoperative incisional hernias. RESULTS One hundred thirty-six patients were randomly assigned to IFC (n = 67) or CFC (n = 69). Baseline characteristics were similar between the groups. No difference was noted in the length of the abdominal incision, or the peak inspiratory pressure after the closure. The median time needed for closure was significantly longer in the IFC group (22 minutes vs. 13 minutes, p < 0.001). Thirty-seven (55.2%) IFC and 41 (59.4%) CFC patients completed their follow-up visits. There was no statistically significant difference in baseline and intraoperative characteristics between those who completed follow-ups and those who did not. The median time from the day of surgery to the day of the last follow-up was similar between IFC and CFC (233 days vs. 216 days, p = 0.67), as were the rates of incisional hernia (13.5% versus 22.0%, p = 0.25), dehiscence (2.7% vs. 2.4%, p = 1.0), and surgical site infection (16.2% vs. 12.2%, p = 0.75). CONCLUSION There was no statistically detectable difference in postoperative hernia development between those undergoing IFC versus CFC after emergent laparotomies. However, this may be due to the relatively low sample size. LEVEL OF EVIDENCE Therapeutic/Care Management Study, level III.

Background The true incidence of intraoperative adverse events (iAEs) remains unknown. Methods All patients undergoing abdominal surgery at an academic institution between January and July 2016 were included in a prospective fashion. At the end of surgery, using a secure REDCap database, the surgeon was given the Institute of Medicine definition of intraoperative adverse events and asked whether an intraoperative adverse event had occurred. Blinded reviewers systematically examined all operative reports for intraoperative adverse events and their severity. The response rate and the intraoperative adverse event rate reported by surgeons were calculated. The latter was compared with the rate of intraoperative adverse events detected by operative report review. The severity of intraoperative adverse events was assessed based on a previously validated intraoperative adverse event classification system. Results A total of 1,989 operations were included. The surgeons’ response rate was 71.9%, reporting intraoperative adverse events in 107 operations (7.5%). Of those intraoperative adverse events, 26 (24.3%) were not described in the operative report. Operative report review revealed intraoperative adverse events in 417 operations (21.0%). Most injuries were of lower severity (85.8% were either class I or II). The surgeons’ response rate was similar in operations with and without intraoperative adverse events (69.8% versus 72.5%, P=.28), but they underreported low severity intraoperative adverse events—only 13.2% of class I compared with 35.3%, 36.8%, and 55.6% of injury classes II, III, and IV respectively (P Conclusion Surgeons are willing to report intraoperative adverse events, but systematically and significantly underreport them, especially if they are of lower severity. This is potentially related to the absence of a clear intraoperative adverse event definition or their personal interpretation of their clinical significance.

Purpose To explore whether psoas cross sectional area (CSA) and density (Hounsfield Units, HU) are associated with nutritional adequacy and clinical outcomes in surgical intensive care unit patients. Materials and methods Subjects with at least one CT scan within 72 h of ICU admission were included. Demographic, nutritional, radiographic, and outcomes data were collected. Psoas muscle CSA and HU were assessed at the L4–L5 intervertebral disk level. Change (Δ) in CSA and HU overall and per day were calculated. Results 140 patients were included. There was no significant correlation between baseline CSA and HU and clinical outcomes. Patients with at least two CT scans (n = 65), had a median decrease in CSA of − 15% [IQR: − 20%, − 8%] and decrease in HU of − 2% [IQR: − 30%, + 24%]. Patients with the greatest daily %HU decline received significantly fewer calories/kg and proteins/kg and accumulated greater protein deficits at day 7 and overall. Patients with daily %HU increase had the shortest ICU and hospital LOS and more ventilator-free days in univariate and multivariable analyses. Conclusions In this exploratory study, early nutritional deficits were correlated with muscle quality deterioration. Inpatient gain in psoas density, compared to maintenance or loss, is associated with shorter hospital stay.

BACKGROUND Serum albumin and prealbumin levels, may be more strongly associated with inflammation than with nutrient delivery. Their predictive value has not been extensively described in surgical intensive care unit (ICU) patients. METHODS We analyzed a registry of adult surgical ICU patients receiving enteral nutrition. Subjects with at least 1 serum albumin, prealbumin, or C-reactive protein (CRP) level were included. Demographic, nutrition, and clinical outcome data were collected. RESULTS A total 252 subjects were included. A subset had serial measurements: albumin (n = 194), prealbumin (n = 13), CRP (n = 9), white blood cell (WBC) (n = 131), and neutrophil-lymphocyte ratio (NLR) (n = 86). Serum albumin level was inversely correlated with all 3 inflammatory biomarkers (CRP, ρ = -0.24, P

Patients with gallstone pancreatitis (GP) or choledocholithiasis (CDL) may have common bile duct (CBD) stones that persist until cholangiography. The aim of this study is to evaluate pre-cholangiogram factors that predict persistent CBD stones. Multiple logistic regression analyses were performed to identify demographic, laboratory, and radiologic predictors of persistent CBD stones and non-therapeutic cholangiography among adults with GP or CDL. In 152 patients from 2010 to 2015, preoperative diagnosis, presence of a CBD stone on US, and age ≥ 60 years were associated with persistent CBD stones. Two risk factors alone had a PPV of 88% and the absence of all risk factors had a NPV of 94%. Age

The exact role of IV contrast-enhanced computed tomography (CT) in the diagnosis of necrotizing soft tissue infections (NSTIs) has not yet been established. We aimed to explore the role of CT in patients with clinical suspicion of NSTI and assess its sensitivity and specificity for NSTI. The medical records of patients admitted between 2009 and 2016, who received IV contrast-enhanced CT to rule out NSTI, were reviewed. CT was considered positive in case of: (a) gas in soft tissues, (b) multiple fluid collections, (c) absence or heterogeneity of tissue enhancement by the IV contrast, and (d) significant inflammatory changes under the fascia. NSTI was confirmed only by the presence of necrotic tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify necrosis, or if the patient was successfully treated non-operatively. Of the 184 patients, 17 had a positive CT and hence underwent surgical exploration with NSTI being confirmed in 13 of them (76%). Of the 167 patients that had a negative CT, 38 (23%) underwent surgical exploration due to the high clinical suspicion for NSTI and were all found to have non-necrotizing infections; the remaining 129 (77%) were managed non-operatively with successful resolution of symptoms. The sensitivity of CT in identifying NSTI was 100%, the specificity 98%, the positive predictive value 76%, and the negative predictive value 100%. A negative IV contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI.

Fulminant Clostridium difficile colitis (fCDC) occurs in 2%-8% of patients with CDC and carries a high death rate. Prompt operation may reduce death. Our aim was to determine whether a standardized hospital-wide protocol for surgical referral in CDC would result in earlier surgical consultation, earlier identification of patients who could benefit from surgical therapy, and reduced deaths from fCDC.A multidisciplinary team developed consensus criteria for surgical consultation. Compliance was evaluated by prospective review of all inpatient CDC cases. Outcomes of the prospective cohort (POST) were compared to an historic control group (PRE).From November 1, 2010 to October 31, 2012, we identified 1,106 inpatients with CDC; 339 patients matched the consultation criteria, of whom 213 received a surgical consultation, resulting in an overall compliance rate of 62.8%. All those with fCDC received a surgical consultation, with a median time to surgical referral of three hours. Of 46 patients with fCDC, 11 (23.9%) died, compared with 34.8% in the historical control group (p = 0.15). The death rate was 14.7% in the POST group, when excluding patients with limitations of care and those transferred to our institution in a fulminant state. There was a shorter interval between admission and surgical intervention for those who required operation in the POST group-three (1-11) days versus 1.5 (0-3) days, respectively, in the PRE and POST groups (p = 0.018), and a shorter adjusted median hospital length of stay (adjusted difference 9.0, 95% CI 2.2-12.3, p = 0.007) Conclusions: A hospital-wide protocol with established criteria for surgical consultation resulted in faster intervention and a shorter adjusted median hospital length of stay. The overall death rate for fCDC patients without limitations of life-sustaining treatment who presented to our emergency department or in whom fCDC developed while they were admitted to our hospital was 14.7%.

Laparoscopic cholecystectomy (LC) has a wide range of technical difficulty. Preoperative risk stratification is essential for adequate planning and patient counseling. We hypothesized that gallbladder wall thickness (GWT) is more objective marker than symptom duration in predicting complexity, as determined by operative time (OT), intraoperative events (IE), and postoperative complications.All adult patients who underwent LC during 2010-2018 were included. GWT, measured on imaging and on the histopathologic exam, was divided into three groups:3 mm (normal), 3-7 mm and7 mm. Univariate and multivariable analyses were performed to determine the association between GWT and 1) operative time, 2) the incidence of IE and 3) postoperative outcomes.A total of 1089 patients, subjects to LC, were included in the study. GWT was positively correlated with median OT (p 0.001), the incidence of IE (p 0.001) and median length of hospital stay (p 0.001). GWT independently predicted IE (OR = 2.1 95% CI: 1.3-3.4) and outperformed symptom duration, which was not significantly associated with any of the outcomes (p = 0.7).GWT independently predicted IE and may serve as an objective marker of LC complexity.

Patients with mild traumatic brain injury (mTBI) are frequently transferred to level 1 trauma centers (L1TC) if they have minor findings on a computerized tomographic scan of the head due to the absence of continuous neurosurgical coverage in community hospitals (CH). We hypothesized that such patients can be safely managed at community hospitals with a qualified Trauma team.This is a multicentered Retrospective Cohort Study. Patients with mild Traumatic Brain Injury (defined as Glasgow Coma Scale [GCS] 13-15 at presentation) and with minor findings on head Computerized Tomography (CT) presenting at a L1TC or 4 Community Hospitals between March 1st, 2012 and February 28th, 2014 were included. All these community hospitals are Level III Trauma center with a well-organized trauma team. Minor CT findings were defined as 1) epidural hematoma2 mm; 2) subarachnoid hemorrhage2 mm; 3) subdural hematoma4 mm; 4) intraparenchymal hemorrhage5 mm; 5) minor pneumocephalus; or 6) linear or minimally depressed skull fracture. Our primary end point was the need for TBI specific interventions in 3 groups of patients: 1) direct admission to the L1TC (L1TC group), 2) those admitted at one of the 4 CH (CH group), and 3) those transferred from CH to L1TC (TRANSFER group). TBI-specific interventions were defined as intracranial pressure monitor (ICP) placement, hyperosmolar therapy, or neurosurgical operation. Our secondary aim was to demonstrate that these patients can be safely managed in Community Hospitals with qualified Trauma teams. We also sought to identify the clinical outcomes in these three groups of patients - in terms of mortality and complications.A total of 191 patients were included - 39 CH, 64 L1TC and 88 TRANSFER. There was no difference among the groups in terms of TBI-specific interventions: one TRANSFER, four L1TC, and no CH patients required hyperosmolar therapy (p = 0.277). None of the patients required placement of an intracranial pressure monitoring device (ICP) or a neurosurgical operation and complications and mortality rates were similar among the groups.Patients with mild TBI and minor findings on head CT can be safely managed at CH with qualified Trauma Teams.Therapeutic/Care Management Study, Level IVhbv.