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Background This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. Methods Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. Results We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. Conclusion Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. Level of evidence Therapeutic, level III.

Background Anastomotic leaks are a dreaded complication after colorectal surgery. Although anastomotic leak is often used as a metric to compare patient outcomes, a standard definition does not exist. Materials and methods A web-based survey was developed and distributed to US surgeons. Respondents were queried on the definition of anastomotic leaks using a 5-point Likert scale to rate different scenarios related to colorectal surgery. Results Of potential 2209 respondents, 649 (29%) responded to the survey. The majority of respondents was men (76%) and practiced colon and rectal surgery as their primary specialty (89%). Contrast extravasation at the anastomosis, regardless of timing related to the surgery, is the clinical scenario with greatest consensus (>85%). 50% of surgeons do not believe that an abscess near the anastomosis in an asymptomatic patient defines a leak. Conclusions These results highlight the pressing need for standardization of the anastomotic leak definition given the implications on outcomes measurement, research trials, and health care reimbursement.

Background Almost a decade after international guidelines defining anastomotic leak (AL) were published, the definition of AL remains inconsistent. Methods A 3-round modified Delphi study was conducted among a national panel of 8 surgeon experts to assess consensus related to the definition of AL following colorectal resection. Consensus was defined when a scenario was rated as very important or absolutely essential by at least 85% of the experts in round 3. Results Seven of fifteen (47%) clinical and radiological scenarios of AL achieved consensus. 80% of clinical scenarios reached consensus. 30% of radiological scenarios reached consensus including CT demonstrating air bubbles around the anastomosis. No consensus was achieved in 70% of radiological scenarios. Conclusions Consensus on the definition of AL is difficult to reach, in relation to international guidelines; which implies that further refinement of the definition of AL is needed to compare patient outcomes.

BACKGROUND: The role of changes in gut microflora on upper gastrointestinal (UGI) perforations is not known. We conducted a retrospective case-control study to examine the relationship between antibiotic exposure—a proxy for microbiome modulation— and UGI perforations in a national sample. METHODS: We queried a 5% random sample of Medicare (2009–2013) to identify patients ≥ 65 years old hospitalized with UGI (stomach or small intestine) perforations using International Classification of Diseases diagnosis codes. Cases with UGI perforations were matched with 4 controls, each based on age and sex. Exposure to outpatient antibiotics (0–30, 31–60, 61–90 days) prior to case patients’ index hospitalization admission data was determined with Part D claims. Univariate and multivariable regression analyses were performed to evaluate the effect of antibiotic exposure on UGI perforation. RESULTS: Overall, 504 cases and 2016 matched controls were identified. Compared to controls, more cases had antibiotic exposure 0–30 days (19% vs. 3%, p < 0.001) and 31–60 days (5% vs. 2%, p < 0.001) prior to admission. In adjusted analyses, antibiotic exposure 0–30 days prior to admission was associated with 6.8 increased odds of an UGI perforation (95% CI 4.8, 9.8); 31–60 days was associated with 1.9 increased odds (95% CI 1.1, 3.3); and 61–90 days was associated with 3.7 increased odds (95% CI 2.0, 6.9). CONCLUSIONS: Recent outpatient antibiotic use, in particular in the preceding 30 days, is associated with UGI perforation among Medicare beneficiaries. Exposure to antibiotics, one of the most modifiable determinants of the microbiome, should be minimized in the outpatient setting.

BACKGROUND: In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly. METHODS: From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi squared tests, then regression models to measure odds of ACS relative to proportion of women. RESULTS: 779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with

Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States.We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias.This was a prospective observational study.The study occurred at the 2017 Tripartite Meeting.The primary outcome measured was the percentage of women in the formal program relative to conference attendees and forms of address.Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender.Overall, 31% of meeting attendees who are ASCRS members were women, with higher percentages of women as Candidates (44%) and Members (35%) compared with Fellows (24%). Women comprised 28% of moderators (n = 26) and 28% of speakers (n = 80). The highest percentage of women moderators and speakers was in education (48%) and the lowest was in techniques and technology (17%). In the 41 of 47 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs 54.0%, p = 0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs 66.7%, p = 0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs 59.2%, p = 0.003).Yearly program gender composition may fluctuate. Low numbers in certain areas limit interpretability. Other factors potentially influenced speaker introductions.Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty. See Video Abstract at http://links.lww.com/DCR/A802.

Background Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients. Methods We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project. Results Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations. Discussion Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease. Conclusions Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Background Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or “acute abdomen,” in older Americans. Methods Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. Results We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). Conclusions Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.

Background Recent studies demonstrate comparable outcomes of Mohs micrographic surgery (MMS) versus local excision (LE) for melanoma in situ. These studies are limited by their focus on the head and neck. Objective The primary objective was to compare 5-year overall and melanoma-specific mortality among patients with melanoma in situ of the trunk or extremities who undergo MMS versus LE. The secondary objective was to compare 5-year local recurrence among the same cohort of patients who undergo MMS versus LE. Materials and methods The Surveillance, Epidemiology, and End Results (SEER) database (2000-2015) was queried to identify patients who underwent MMS versus LE for melanoma in situ of the trunk, upper extremities, or lower extremities. Outcomes were 5-year recurrence, melanoma-specific mortality, and overall mortality. Multivariable regression analyses were performed. Results Thirty three thousand nine hundred eighty-three patients underwent surgical treatment (MMS 3%; LE 97%). In adjusted analyses, there was no difference in local recurrence (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.78), melanoma-specific mortality (HR 0.89, 95% CI 0.12-6.47), nor overall mortality (HR 1.10, 95% CI 0.82-1.48) between MMS versus LE. Conclusion There is no difference of 5-year local recurrence, melanoma-specific mortality, nor overall mortality associated with MMS versus LE for melanoma in situ of the trunk or extremities.

Acute care surgery (ACS) was proposed to address a general surgery workforce crisis; however, the ACS workforce composition is unknown. A national survey was conducted to determine the differences in the emergency general surgery (EGS) workforce between ACS and non-ACS hospitals.The American Hospital Association (AHA) Annual Survey of Hospitals database was queried to identify acute care general hospitals. A hybrid mail/electronic survey was sent to 2811 acute care hospitals that met the inclusion criteria of hospitals that care for adult patients (≥18 years old) with an emergency room (ER), ≥ 1 operating room (OR), and 24-h ER access. Hospitals were queried on whether they utilized an ACS model. The workforce composition among ACS and non-ACS hospitals was evaluated using XSurvey response was 60% (N = 1690). ACS hospitals had a higher proportion of emergency surgeons who were female (20% vs. 14%, p 0.0001), newly-trained (17% vs 10%, p 0.0001), critical care trained (78% vs. 31%, p 0.0001), and who had an additional degree (35% vs. 13%, p 0.0001). More ACS hospitals had 24/7 in-house OR nursing staff (72% vs. 15%, p 0.0001) and ancillary staff.ACS and non-ACS hospitals differ in their surgical workforce. It is clear that ACS hospitals have more human capital, which suggests that ACS hospitals may require more dedicated resources compared to non-ACS hospitals.

BACKGROUND: Small bowel obstruction (SBO) no longer mandates urgent surgical evaluation raising the question of the role of operating room (OR) access on SBO outcomes. METHODS: Data from our 2015 survey on emergency general surgery (EGS) practices, including queries on OR availability and surgical staffing, were anonymously linked to adult SBO patient data from 17 Statewide Inpatient Databases (SIDs). Univariate and multivariable associations between OR access and timing of operation, complications, length of stay (LOS), and in-hospital mortality were measured. RESULTS: Of 32,422 SBO patients, 83% were treated non-operatively. Operative patients were older (median 66 vs 65 years), had more comorbidities (53% vs 46% with ≥ 3), and experienced moresystemic complications (36% vs 23%), higher mortality (2.8% vs 1.4%), and longer LOS (median 10 vs 4 days). Patients had lower odds of operation if treated at hospitals lacking processes to tier urgent cases (aOR 0.90, 95% CI [0.83–0.99]) and defer elective cases (aOR 0.87 [0.80–0.94]). Patients had higher odds of operation if treated at hospitals with surgeons sometimes (aOR 1.14 [1.04–1.26]) or rarely/never (aOR 1.16 [1.06–1.26]) covering EGS at more than one location compared to always. Odds of systemic complication (OR 2.0 [1.6–2.4]), operative complication (OR 1.5 [1.2–1.8]), and mortality were increased for very late versus early operation (OR 2.6 [1.7–4.0]). CONCLUSIONS: Although few patients with SBO require emergency surgery, we identified EGS structures and processes that are important for providing timely and appropriate intervention for patients whose SBO remains unresolved and requires surgery.

Purpose We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care. Methods 2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models. Results 272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols. Conclusions Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.

Background Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals. Methods In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables. Results Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1). Conclusion Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence. Level of evidence Therapeutic, level III.

BACKGROUND Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach. METHODS We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics). RESULTS Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values

National data evaluating outcomes for occlusive abdominal aortic reconstructions are well described. The relative effect of operative indication as well as the presence of concomitant abdominal aortic aneurysm (AAA) on in-hospital mortality is not well defined.The Nationwide Inpatient Sample was queried to identify patients who underwent open aortic surgery (2003-2010). Indication for surgery was classified by International Classification of Diseases, Ninth Revision diagnostic codes to identify isolated occlusive indications as well as combined occlusive disease and AAA. Primary outcome was in-hospital mortality. Secondary outcomes were complications and discharge disposition.Overall, 56,374 underwent aortic reconstruction, 48,591 for occlusive disease (86.2%) and 7783 for combined occlusive disease with AAA (13.8%). Intermittent claudication was the most common indication for intervention (60.9%), whereas 39.7% underwent intervention for critical limb ischemia (22.2% rest pain, 17.6% gangrene). Patients with intermittent claudication had more concomitant AAAs (17.3%) than did patients with critical limb ischemia (8.4%). The baseline characteristics for those with occlusive disease and combined occlusive with AAA disease were similar in terms of obesity (4.8% vs 4.2%; P = .27) and congestive heart failure (6.6% vs 6.3%; P = .65) but differed by age (62.2 years vs 68.4 years; P .0001) and hypertension (65.4% vs 69.1%; P = .005). Patients with combined occlusive and AAA disease had higher mortality than those with occlusive disease alone (3.9% vs 2.7%; P = .01). On multivariable regression, factors associated with in-hospital mortality included gangrene with AAA compared with gangrene alone (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.7; P .0002), age65 years age (OR, 3.1; 95% CI, 2.4-4.1; P .0001), renal failure (OR, 2.7; 95% CI, 1.9-3.8; P .0001), and concurrent lower extremity revascularization (OR, 1.3; 95% CI, 1.1-1.7; P .02).Intermittent claudication or critical limb ischemia with concomitant AAA carries a higher mortality than intermittent claudication or critical limb ischemia alone, especially in older patients with gangrene requiring revascularization and renal insufficiency. Preoperative risk stratification strategies should focus on the indication for surgery as well as the presence of concomitant AAA.

Background An association between lack of insurance and inferior outcomes has been well described for a number of surgical emergencies, yet little is known about the relationship of payor status and outcomes of patients undergoing emergent surgical repair for upper gastrointestinal (UGI) perforations. We evaluated the association of payor status and in-hospital mortality for patients undergoing emergency surgery for UGI perforations in the United States. Methods Nationwide Inpatient Sample (NIS) was queried to identify patients between 18 and 64 years of age who underwent emergent (open or laparoscopic) repair for UGI perforations secondary to peptic ulcer disease (2010–2014). Primary outcome was in-hospital mortality. Secondary outcomes were major and minor postoperative complications. The main predictor outcome was insurance status (Private, Medicaid, Uninsured). Univariate and multivariable regression analyses were performed. Data were weighted to provide national estimates. Results 21,005 patients underwent surgical repair for UGI perforations. Patients with private insurance represented the largest payor group (47%). After adjustment of other factors, payor status was not a statistically significant predictor of in-hospital mortality (Medicaid vs. Private: [OR] 1.1; 95% [CI] 0.67–1.81; Uninsured vs. Private: OR 0.9, 95% CI 0.52–1.61). However, payor status remained a statistically significant predictor of major postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.8; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.5) and minor postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.9; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.6). Conclusions Emergency surgery for UGI perforations is associated with high mortality and morbidity across all payor classes; however, Medicaid is a predictor for both major and minor postoperative complications. Preventing perforation through preventative measures will be key to reducing the burden of peptic ulcer disease across all populations.

Background Acute care surgery (ACS) was proposed to improve emergency general surgery (EGS) care; however, the extent of ACS model adoption in the United States is unknown. A national survey was conducted to ascertain factors associated with variations in EGS models of care, with particular focus on ACS use. Methods A hybrid mail/electronic survey was sent in 2015 to 2,811 acute care hospitals with an emergency room and an operating room. If a respondent indicated that the approach to EGS was a dedicated clinical team whose scope encompasses EGS (± trauma, ± elective general surgery, ± burns), the hospital was considered an ACS hospital. Results Survey response was 60.1% (n = 1,690); 272 (16.1%) of these hospitals reported having used an ACS model of care for EGS patients. Teaching status and general hospital practices (for example, interventional radiology available within one hour) were associated with ACS use. In bivariate analyses, ACS use was associated with many EGS–specific practices (40.1% of ACS hospitals freed their surgeons of daytime clinical responsibilities after operating overnight vs. 4.7% of general surgeon on call (GSOC) hospitals; p Conclusion There are wide variations in EGS practices in the United States, with use of an ACS model of care being relatively low despite reported benefits of ACS models of care on EGS access, quality, and costs. Hospital factors associated with using ACS models are overall size and higher level of existing resources. These findings could be applied to the development of centers of excellence for EGS care.

Importance Owing to lack of adequate emergency care infrastructure and decline in general surgery workforce, the United States faces a crisis in access to emergency general surgery (EGS) care. Acute care surgery (ACS), an organized system of trauma, general surgery, and critical care, is a proposed solution; however, ACS diffusion remains poorly understood. Objective To investigate geographic diffusion of ACS models of care and characterize the communities in which ACS implementation is lagging. Design, Setting, and Participants A national survey on EGS practices was developed, tested, and administered at all 2811 US acute care hospitals providing EGS to adults between August 2015 and October 2015. Surgeons responsible for EGS coverage at these hospitals were approached. If these surgeons failed to respond to the initial survey implementation, secondary surgeons or chief medical officers at hospitals with only 1 general surgeon were approached. Interventions Survey responses on ACS implementation were linked with geocoded hospital data and national census data to determine geographic diffusion of and access to ACS. Main Outcomes and Measures We measured the distribution of hospitals with ACS models of care vs those without over time (diffusion) and by US counties characterized by sociodemographic characteristics of county residents (access). Results Survey response rate was 60% (n = 1690); 272 responding hospitals had implemented ACS by 2015, steadily increasing from 34 in 2001 to 125 in 2010. Acute care surgery implementation has not been uniform. Rural regions have limited ACS access, with hospitals in counties with greater than the 75th percentile population having 5.4 times higher odds (95% CI, 1.66-7.35) of implementing ACS than hospitals in counties with less than 25th percentile population. Communities with greater percentages of adults without a college degree also have limited ACS access (OR, 3.43; 95% CI, 1.81-6.48). However, incorporating EGS into ACS models may be a potential equalizer for poor, black, and Hispanic communities. Conclusions and Relevance Understanding and addressing gaps in ACS implementation across communities will be crucial to ensuring health equity for US residents experiencing general surgery emergencies.

BACKGROUND: As the U.S. population ages and the number of emergent surgical repairs for perforated peptic ulcer disease (PUD) rise, contemporary national data evaluating operative outcomes for open surgical repair for perforated PUD among the elderly are lacking. MATERIALS AND METHODS: The National Surgical Quality Improvement Program (2007-2014) was queried for patients ≥65 y who underwent open surgical repair for perforated PUD. The primary outcome was 30-d mortality. Secondary outcomes included 30-d postoperative complications. Univariate and multivariable regression analyses were performed. RESULTS: Overall, 2131 patients underwent open surgical repair for perforated PUD. Among those who died, more used steroids preoperatively (15% versus 9%, P = 0.001) and fewer were independent preoperatively (55% versus 83%, P < 0.0001) compared to those who were alive 30-d postoperatively. Common postoperative complications were septic shock (15%) and pneumonia (12%). The overall 30-d mortality rate was 17.7%, with more deaths in subsequent decades of life (65-75 y 13% versus 75-84 y 18% versus >85 y 24%, P < 0.0001). After adjustment for other factors, mortality was significantly associated with older age (85+ versus 65-74 y) (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.8, 1.7), dependent functional status preoperatively ([OR], 0.2; 95% CI, 0.2, 0.3), and American Society of Anesthesiologist classification ≥4 (OR, 3.2; 95% CI, 2.4, 4.3). CONCLUSIONS: At U.S. hospitals, open surgical repair, the accepted treatment of perforated PUD, among the elderly is associated with significant 30-d morbidity and mortality rates that are unacceptably high in our contemporary era. Furthermore, mortality rates are associated with older age. Therefore, as the elderly population continues to increase in the United States, preoperative, perioperative, and postoperative measures must be taken to reduce this high morbidity and mortality rates.

Background Fenestrated endovascular aneurysm repair (FEVAR) allows endovascular treatment of thoracoabdominal and juxtarenal aneurysms previously outside the indications of use for standard devices. However, because of considerable device costs and increased procedure time, FEVAR is thought to result in financial losses for medical centers and physicians. We hypothesized that surgeon leadership in the coding, billing, and contractual negotiations for FEVAR procedures will increase medical center contribution margin (CM) and physician reimbursement. Methods At the UMass Memorial Center for Complex Aortic Disease, a vascular surgeon with experience in medical finances is supported to manage the billing and coding of FEVAR procedures for medical center and physician reimbursement. A comprehensive financial analysis was performed for all FEVAR procedures (2011-2015), independent of insurance status, patient presentation, or type of device used. Medical center CM (actual reimbursement minus direct costs) was determined for each index FEVAR procedure and for all related subsequent procedures, inpatient or outpatient, 3 months before and 1 year subsequent to the index FEVAR procedure. Medical center CM for outpatient clinic visits, radiology examinations, vascular laboratory studies, and cardiology and pulmonary evaluations related to FEVAR were also determined. Surgeon reimbursement for index FEVAR procedure, related adjunct procedures, and assistant surgeon reimbursement were also calculated. All financial analyses were performed and adjudicated by the UMass Department of Finance. Results The index hospitalization for 63 FEVAR procedures incurred $2,776,726 of direct costs and generated $3,027,887 in reimbursement, resulting in a positive CM of $251,160. Subsequent related hospital procedures (n = 26) generated a CM of $144,473. Outpatient clinic visits, radiologic examinations, and vascular laboratory studies generated an additional CM of $96,888. Direct cost analysis revealed that grafts accounted for the largest proportion of costs (55%), followed by supplies (12%), bed (12%), and operating room (10%). Total medical center CM for all FEVAR services was $492,521. Average surgeon reimbursements per FEVAR from 2011 to 2015 increased from $1601 to $2480 while the surgeon payment denial rate declined from 50% to 0%. Surgeon-led negotiations with the Centers for Medicare & Medicaid Services during 2015 resulted in a 27% increase in physician reimbursement for the remainder of 2015 ($2480 vs $3068/case) and a 91% increase in reimbursement from 2011 ($1601 vs $3068). Assistant surgeon reimbursement also increased ($266 vs $764). Concomitant FEVAR-related procedures generated an additional $27,347 in surgeon reimbursement. Conclusions Physician leadership in the coding, billing, and contractual negotiations for FEVAR results in a positive medical center CM and increased physician reimbursement.

Open surgical reconstruction for supra-aortic trunk occlusive disease persists despite advances in endovascular therapy. Although extrathoracic reconstructions developed as a safer alternative to transthoracic reconstructions, contemporary national data evaluating relative rates of operative outcomes are lacking.With use of the National Surgical Quality Improvement Program (2005-2011), patients who underwent transthoracic or extrathoracic reconstruction were evaluated. Patients with nonocclusive indications were excluded. The primary outcome was a composite end point of stroke/myocardial infarction (MI)/death. Secondary outcomes were 30-day postoperative complications. Univariate and multivariable regression analyses were performed.Overall, 83 patients (10.7%) underwent transthoracic reconstructions and 692 patients (89.3%) underwent extrathoracic reconstructions. Vascular surgeons performed most transthoracic (96%) and extrathoracic (97%) reconstructions. The most common extrathoracic reconstructions were carotid-subclavian bypass (68%), carotid-carotid bypass (14%), and subclavian transposition (7%). Less commonly, axillary-axillary bypass (6%), subclavian-axillary bypass (2%), subclavian-subclavian bypass (1%), and carotid transposition (1%) were performed. At the time of operation, 10% (transthoracic reconstructions) and 8% (extrathoracic reconstructions) of patients had a concurrent carotid endarterectomy (P.60). Analysis of more than 20 characteristics showed that the groups did not differ significantly. The two groups had similar rates of postoperative stroke (1.2% in the transthoracic reconstruction group vs 2.2% in the extrathoracic reconstruction group; P.99), MI (0% vs 1.3%; P = .61), death (2.4% vs 1.3%; P = .33), and stroke/MI/death (3.6% vs 3.8%; P.99). Transthoracic reconstruction patients had longer hospital stays (6.3 days vs 4.0 days; P.0002), received more transfusions (8.4% vs 2.5%; P.0096), and had higher rates of postoperative sepsis (3.6% vs 0.3%; P.01) and venous thromboembolic complications (3.6% vs 0.4%; P.02). After adjustment for other factors, including surgical approach, stroke/MI/death was significantly associated with postoperative pneumonia (odds ratio [OR], 26.0; 95% confidence interval [CI], 6.29-108.28; P.0001), postoperative ventilator dependence (OR, 12.45; 95% CI, 2.74-56.48; P = .001), and postoperative return to the operating room (OR, 4.75; 95% CI, 1.67-13.54; P = .004).At U.S. hospitals, extrathoracic reconstruction is the more common reconstruction for supra-aortic trunk occlusive disease. Both approaches carry acceptably low rates of death, MI, and stroke. Transthoracic reconstruction results in more resource utilization because of its postoperative complications and greater complexity.