bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing Field Triage Decisions and the International Classification Injury Severity Score (ICISS) at Predicting Outcomes of Trauma Patients
Authors: Allen Casey J. , Baldor Daniel J. , Schulman Carl I. , Pizano Louis R. , Livingstone Alan S. , Namias Nicholas
Published: June 2020

Florida considers the International Classification Injury Severity Score (ICISS) from hospital discharges within a geographic region in the apportionment of trauma centers (TCs). Patients with an ICISS <0.85 are considered to require triage to a TC, yet many are triaged to an emergency department (ED). We assess outcomes of those with an ICISS <0.85 by the actual triage decision of emergency medical services (EMS). From October 2011 to October 2013, 39,021 consecutive admissions with injury ICD-9 codes were analyzed. ICISS was calculated from the product of the survival risk ratios for a patient's three worst injuries. Outcomes were compared between patients with ICISS <0.85 either triaged to the ED or its separate, neighboring, free-standing TC at a large urban hospital. A total of 32,191 (83%) patients were triaged to the ED by EMS and 6,827 (17%) were triaged to the TC. Of these, 2544 had an ICISS <0.85, with 2145 (84%) being triaged to the TC and 399 (16%) to the ED. In these patients, those taken to the TC more often required admission, and those taken to the ED had better outcomes. When the confounders influencing triage to an ED or a TC are eliminated, those triaged by EMS to the ED rather than the TC had better overall outcomes. EMS providers better identified patients at risk for mortality than did the retrospective application of ICISS. ICISS <0.85 does not identify the absolute need for TC as EMS providers were able to appropriately triage a large portion of this population to the ED.
Percutaneous Tracheostomy under Bronchoscopic Visualization Does Not Affect Short-Term or Long-Term Complications
Authors: Easterday Thomas S. , Moore Joshuaw , Redden Meredith H. , Feliciano David V. , Henderson Vernon J. , Humphries Timothy , Kohler Katherine E. , Ramsay Philip T. , Spence Stanston D. , Walker Mark , Wyrzykowski Amy D.
Published: June 2020

Percutaneous tracheostomy is a safe and effective bedside procedure. Some advocate the use of bronchoscopy during the procedure to reduce the rate of complications. We evaluated our complication rate in trauma patients undergoing percutaneous tracheostomy with and without bronchoscopic guidance to ascertain if there was a difference in the rate of complications. A retrospective review of all tracheostomies performed in critically ill trauma patients was performed using the trauma registry from an urban, Level I Trauma Center. Bronchoscopy assistance was used based on surgeon preference. Standard statistical methodology was used to determine if there was a difference in complication rates for procedures performed with and without the bronchoscope. From January 2007, to April 2016, 649 patients underwent modified percuteaneous tracheostomy; 289 with the aid of a bronchoscope and 360 without. There were no statistically significant differences in any type of complication regardless of utilization of a bronchoscope. The addition of bronchoscopy provides several theoretical benefits when performing percutaneous tracheostomy. Our findings, however, do not demonstrate a statistically significant difference in complications between procedures performed with and without a bronchoscope. Use of the bronchoscope should, therefore, be left to the discretion of the performing physician.
In the Modern Era of CT, Do Blunt Trauma Patients with Markers for Blunt Bowel or Mesenteric Injury Still Require Exploratory Laparotomy?
Authors: Young Katelyn , Benson Melina , Higgins Andrew , Dove James , Hunsinger Marie , Shabahang Mohsen , Blansfield Joseph , Torres Denise , Widom Kenneth , Wild Jeffrey
Published: June 2020

After blunt trauma, certain CT markers, such as free intraperitoneal air, strongly suggest bowel perforation, whereas other markers, including free intraperitoneal fluid without solid organ injury, may be merely suspicious for acute injury. The present study aims to delineate the safety of non-operative management for markers of blunt bowel or mesenteric injury (BBMI) that are suspicious for significant bowel injury after blunt trauma. This was a retrospective review of adult blunt trauma patients with abdominopelvic CT scans on admission to a Level I trauma center between 2012 and 2014. Patients with CT evidence of acute BBMI without solid organ injury were included. The CT markers for BBMI included free intraperitoneal fluid, bowel hematoma, bowel wall thickening, mesenteric edema, hematoma and stranding. Two thousand blunt trauma cases were reviewed, and 94 patients (4.7%) met inclusion criteria. The average Injury Severity Score was 13.6 ± 10.1 and the median hospital stay was four days. The most common finding was free fluid (74 patients, 78.7%). The majority of patients (92, 97.9%) remained asymptomatic or clinically improved without abdominal surgery. After a change in abdominal examination, two patients (2.1%) underwent laparotomy with bowel perforation found in only one patient. Thus, 93 patients did not have a surgically significant injury, indicating that these markers demonstrate 1.1 per cent positive predictive value for bowel perforation. The presence of these markers after blunt trauma does not mandate laparotomy, though it should prompt thorough and continued vigilance toward the abdomen.
Disparities in the Care of Differentiated Thyroid Cancer in the United States: Exploring the National Cancer Database
Authors: Jaap Kathryn , Campbell Rebekah , Dove James , Fluck Marcus , Hunsinger Marie , Wild Jeffrey , Arora Tania , Shabahang Mohsen , Blansfield Joseph
Published: June 2020

Differentiated thyroid cancer (DTC) treatment is multifaceted, and may be influenced by socio-economic factors. The goal of this study is to examine disparities in DTC treatment. DTC patients from 1998 to 2012 were identified using the National Cancer Database. DTC was identified in 262,041 patients. The mean age was 48.2. The majority of patients (52%) received care at Comprehensive Community Cancer Programs (CCCPs). Total thyroidectomy was less common at Community Cancer Programs (CCPs) [odds ratio (OR): 0.735; 95% confidence interval (CI): 0.707–0.764), and more common at academic centers (OR: 1.129; 95% CI: 1.102–1.157) compared with CCCP. A central neck dissection was performed most often at academic center (20.6%) versus CCP (10.0%). Black patients were less likely to undergo central neck dissection compared with white patients (OR: 0.468; 95% CI: 0.452–0.484). Patients more likely to receive radioactive iodine were white compared with black patients (hazard ratio: 0.833; 95% CI: 0.806–0.861), privately insured compared with uninsured patients (hazard ratio: 1.272; 95% CI: 1.210–1.341), and patients treated at CCCP. Disparities exist in DTC treatment. Individuals at risk for under-treatment are black patients, uninsured patients, and those treated at CCP. As the Affordable Care Act changes access to health care, future studies will be needed to readdress disparities.
Blood Transfusion and Survival for Resected Adrenocortical Carcinoma: A Study from the United States Adrenocortical Carcinoma Group
Authors: Poorman Caroline E. , Postlewait Lauren M. , Ethun Cecilia G. , Tran Thuy B. , Prescott Jason D. , Pawlik Timothy M. , Wang Tracy S. , Glenn Jason , Hatzaras Ioannis , Shenoy Rivfka , Phay John E. , Keplinger Kara , Fields Ryan C. , Jin Linda X. , Weber Sharon M. , Salem Ahmed , Sicklick Jason K. , Gad Shady , Yopp Adam C. , Mansour John C. , Duh Quan-Yang , Seiser Natalie , Solorzano Carmen C. , Kiernan Colleen M. , Votanopoulos Konstantinos I. , Levine Edward A. , Staley Charles A. , Poultsides George A. , Maithel Shishir K.
Published: June 2020

Perioperative blood transfusion is associated with decreased survival in pancreatic, gastric, and liver cancer. The effect of transfusion in adrenocortical carcinoma (ACC) has not been studied. Patients with available transfusion data undergoing curative-intent resection of ACC from 1993 to 2014 at 13 institutions comprising the United States Adrenocortical Carcinoma Group were included. Factors associated with blood transfusion were determined. Primary and secondary end points were recurrence-free survival (RFS) and overall survival (OS), respectively. Out of 265 patients, 149 were included for analysis. Out of these, 57 patients (38.3%) received perioperative transfusions. Compared to nontransfused patients, transfused patients more commonly had stage 4 disease (46% vs 24%, P = 0.01), larger tumors (15.8 vs 10.2 cm, P < 0.001), inferior vena cava involvement (24.6% vs 5.4%, P = 0.002), additional organ resection (78.9% vs 36.3%, P < 0.001), and major complications (29% vs 2%, P < 0.001). Transfusion was associated with decreased RFS (8.9 vs 24.7 months, P = 0.006) and OS (22.8 vs 91.0 months, P < 0.001). On univariate Cox regression, transfusion, stage IV, hormonal hypersecretion, and adjuvant therapy were associated with decreased RFS. On multivariable analysis, only transfusion [hazard ratio (HR) = 1.7, 95% confidence interval (CI) 51.0–2.9, P = 0.04], stage IV (HR = 3.2, 95% CI = 1.7–5.9, P < 0.001), and hormonal hypersecretion (HR = 2.6, 95% CI = 1.5–4.2, P < 0.001) were associated with worse RFS. When applying this model to OS, similar associations were seen (transfusion HR = 2.0, 95% CI = 1.1–3.8, P = 0.02; stage 4 HR = 6.2, 95% CI = 3.1–12.4, P < 0.001; hormonal hypersecretion HR = 3.5, 95% CI = 1.9–6.4, P < 0.001). There was no difference in outcomes between patients who received 1 to 2 units versus >2 units of packed red blood cells in median RFS (8.9 vs 8.4 months, P = 0.95) or OS (26.5 vs 18.6 months, P = 0.63). Peri-operative transfusion is associated with earlier recurrence and decreased survival after curative-intent resection of ACC. Strategies and protocols to minimize blood transfusion should be developed and followed.
A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?
Authors:   The Georgia Research Institute for Trauma Study Group, Ashley Dennis W. , Pracht Etienne E. , Medeiros Regina S. , Atkins Elizabeth V. , Nesmith Elizabeth G. , Johns Tracy J. , Dunne James R. , Nicholas Jeffrey M.
Published: June 2020

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.
The Utility of the Alvarado Score in the Diagnosis of Acute Appendicitis in the Elderly
Authors: Shchatsko Anastasiya , Brown Rebecca , Reid Trista , Adams Sasha , Alger Amy , Charles Anthony
Published: June 2020

Clinical scores determining the likelihood of acute appendicitis (AA), including the Alvarado score, were devised using a younger population, and their efficacy in predicting AA in elderly patients is not well documented. This study's purpose is to evaluate the utility of Alvarado scores in this population. A retrospective chart review of patients >65 years old presenting with pathologically diagnosed AA from 2000 to 2010 was performed. Ninety-six patients met inclusion criteria. The average age was 73.7 ± 1.5 years and our cohort was 41.7 per cent male. The average Alvarado score was 6.9 ± 0.33. The distribution of scores was 1 to 4 in 3.7 per cent, 5 to 6 in 37.8 per cent, and 7 to 10 in 58.5 per cent of cases. There was a statistically significant increase in patients scoring 5 or 6 in our cohort versus the original Alvarado cohort (P < 0.01). Right lower quadrant tenderness (97.6%), left shift of neutrophils (91.5%), and leukocytosis (84.1%) were the most common symptoms on presentation. In conclusion, our data suggest that altering our interpretation of the Alvarado score to classify elderly patients presenting with a score of ≥5 as high risk may lead to earlier diagnosis of AA. Physicians should have a higher clinical suspicion of AA in elderly patients presenting with right lower quadrant tenderness, left shift, or leukocytosis.
Pneumatosis Intestinalis in Patients Receiving Tube Feeds
Authors: Cavalea Alexander C. , Heidel Robert E. , Daley Brian J. , Lawson Christy M. , Benton Darrell A. , Mcloughlin James M.
Published: June 2020

Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.
Indicators of Survival and Favorable Functional Outcomes after Decompressive Craniectomy: A Multi-Institutional Retrospective Study
Authors: Khan Abid D. , Elseth Anna J. , Head Brian , Rostas Jack , Dunn Julie A. , Schroeppel Thomas J. , Gonzalez Richard P.
Published: June 2020

The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.
The Impact of Hemodynamic Transesophageal Echocardiography on the Use of Continuous Renal Replacement Therapy in Trauma
Authors: Griffin Madison , Howard Brett , Devictor Sam , Ferenczy Josh , Cobb Frances , Christie D. Benjamin
Published: June 2020

Post-traumatic fluid management is a widely debated topic. No best-practice consensus exists. Adverse outcomes such as acute kidney injury or volume overload are common. Continuous renal replacement therapy (CRRT) is an adjunct therapy for severe acute renal failure and volume overload, but is costly and not without risk. Hemodynamic transesophageal echocardiography (hTEE) is widely accepted as a reliable way to monitor volume status of intensive care unit (ICU) patients. Although data exist evaluating hTEE and CRRT independently, there is a lack of research mutually inclusive of the two. We hypothesized that the use of hTEE is associated with less need for CRRT. Retrospective review of a level I trauma center from 2009 to 2015 identified patients that required CRRT. In 2013, we implemented a protocol using hTEE in trauma patients with significant resuscitation needs. We compared CRRTuse before and after implementation of the protocol (pre- and post-hTEE). Multivariate analysis using two sample t tests and χ2 test of the odds ratio (O.R.) was completed on variables such as injury severity score (ISS), acute kidney injury network (AKIN), days of CRRT, ICU length of stay (LOS), and hospital LOS. A total of 5037 and 6699 trauma patients were evaluated in the pre- and post-hTEE groups, respectively. Mean ISS was 22 and 28 for pre- and post-hTEE, respectively (P value 0.19). Mean AKIN was 2.7 for both groups. Mean days on CRRT was eight before hTEE and seven after hTEE (P value 0.7); 23 patients required CRRT pre-hTEE, and 15 required CRRT post-hTEE (P value 0.01 O.R. 2.4). Given, the odds of CRRT pre-hTEE are more than twice that of CRRT post-hTEE; we conclude that the use of hTEE is associated with a reduction of CRRT.
Optimal Modified Frailty Index Cutoff in Older Gastrointestinal Cancer Patients
Authors: Garland Mary , Hsu Fang-Chi , Shen Perry , Clark Clancy J.
Published: June 2020

The newly characterized modified frailty index (mFI) is a robust predictor of postoperative outcomes for surgical patients. The present study investigates the optimal cutoff for mFI specifically in older gastrointestinal (GI) cancer patients undergoing surgery. All patients more than 60 years old who underwent surgery for a GI malignancy (esophagus, stomach, colon, rectum, pancreas, liver, and bile duct) were identified in the 2005 to 2012 National Surgical Quality Improvement Program, Participant Use Data File (NSQIP PUF). Patients undergoing emergency procedures, of American Society of Anesthesiologists (ASA) five status, or diagnosed with preoperative sepsis were excluded. Logistic regression modeling and 10-fold cross validation were used to identify an optimal mFI cutoff. A total of 41,455 patients (mean age 72, 47.4% female) met the eligibility criteria. Among them, 19.0 per cent (n = 7891) developed a major postoperative complication and 2.8 per cent (n = 1150) died within 30 days. A random sampling by a cancer site was performed to create 90 per cent training and 10 per cent test sample datasets. Using 10-fold cross validation, logistical regression models evaluated the association between mFI and endpoints of 30-day mortality and major morbidity at various cutoffs. Optimal cutoffs for 30-day mortality and major morbidity were mFI ≥ 0.1 and ≥0.2, respectively. After adjusting for age, sex, ASA, albumin ≥3g/dl, and body mass index ≥ 30 kg/m2, mFI ≥ 0.1 was associated with increased mortality (odds ratio (OR) 1.49, 1.30–1.71 95% confidence interval (CI), P < 0.001) and mFI ≥ 0.2 was associated with increased morbidity (OR 1.52, 1.39–1.65 95% CI, P < 0.001). For older GI cancer patients, a very low mFI was a predictor of poor postoperative outcomes with an optimal cutoff of two or more mFI characteristics.
Operative Outcomes after Open Abdominal Wall Reconstruction with Retromuscular Mesh Fixation Using Fibrin Glue versus Transfascial Sutures
Authors: Weltz Adam S. , Sibia Udai S. , Zahiri H. Reza , Schoeneborn Alexa , Park Adrian , Belyansky Igor
Published: June 2020

Ideal fixation techniques have not been fully elucidated at the time of complex open abdominal wall reconstruction (AWR). We compared operative outcomes and quality of life with retromuscular mesh fixation using fibrin glue (FG) versus transfascial sutures (TS). Retrospective review identified complex hernia patients who underwent open AWR with mesh from November 2012 through April 2016. Multivariate analysis examined postoperative outcomes between groups. Quality of life was assessed using the Carolinas Comfort Scale. Seventy-five patients (18 FG vs 57 TS) with mean age (54.3 vs 53.9 years, P = 0.914), body mass index (35.8 vs 34.7 kg/m2, P = 0.623) and American Society of Anesthesiologist score (2.6 vs 2.5, P = 0.617) were reviewed. No differences in wound (P = 0.072) and nonwound (P = 0.639) related complications were noted between groups. Risk of reoperations (P = 0.275) and 30-day readmissions (P = 0.137) were also comparable. The TS group was twelve times more likely to report pain at six-month follow-up compared with FG (12.29 OR, 95 per cent confidence interval 1.26–120.35, P = 0.031). No hernia recurrences were noted in either group at a mean follow-up of 390 ± 330 days. The use of FG to secure mesh in the retromuscular space during complex open AWR may be a safe alternative to penetrating transfascial fixation with potential to reduce chronic pain.
Inclusion of the Acute Care Surgeon in the Difficult Airway Protocol: A Nine-Year Experience
Authors: Lee Seong K. , Rosenthal Andrewa , Davare Dafney L. , Kiffin Chauniqua , Sanchez Rafael , Hurtado Michael , Carrillo Eddy H.
Published: June 2020

An emergency surgical airway is a lifesaving intervention required in the event of airway loss or respiratory failure when conventional endotracheal intubation cannot be performed. The Acute Care Surgery/Trauma Service is a critical component in the angioedema/difficult airway protocol at our institution. We conducted a retrospective review (2007–2016) to analyze the role our service has in managing patients requiring an emergency surgical airway. Cases were analyzed for preexisting conditions, hospital location of procedure, techniques, complications, and mortality. Our protocol involves early coordination between anesthesia and the Acute Care Surgery/ Trauma Service for patients with a potentially difficult airway. If anesthesia is unable to intubate the patient, a surgical airway is performed. Patients are preemptively taken to the operating room (OR) if stable for transport. There were 43 surgical airways performed during the study period. All patients had a failed attempt with oral endotracheal intubation. The most common factors associated with these patients were history of tracheostomy, angioedema, or difficult anatomy. Nineteen (44%) of the surgical airways were performed in the OR. Three deaths (7%) occurred from cardiac or respiratory arrest despite the emergency procedure. No immediate deaths occurred in the patients taken to the OR. Early coordination in patients with a difficult airway is another hospital resource that the acute care surgeon can provide to improve patient outcomes.
Delta Shock Index in the Emergency Department Predicts Mortality and Need for Blood Transfusion in Trauma Patients
Authors: Schellenberg Morgan , Strumwasser Aaron , Grabo Daniel , Clark Damon , Matsushima Kazuhide , Inaba Kenji , Demetriades Demetrios
Published: June 2020

Shock Index (SI = heart rate/systolic blood pressure) predicts outcomes among trauma patients. Studies have also shown that the change in SI between the field and Emergency Department (ED) arrival (Delta SI) predicts mortality in trauma. Given the lack of reliable prehospital data, Delta SI may more accurately prognosticate if used within the ED. All trauma patients arriving to our Level I trauma center in 2014 were reviewed. Patients were matched for age, gender, mechanism of injury, and injury severity score. SI and ED Delta SI were calculated. ED Delta SI >0.1 and ≤0.1 defined the study groups. Pregnant patients, pediatric patients, and patients with incomplete data were excluded. Outcomes included intensive care unit (ICU) length of stay, blood products, and mortality. A total of 2591 patients were identified (n = 1294 patients analyzed). After matching, patients with ED Delta SI >0.1 had greater mortality (6.6 vs 2.6%, P = 0.010), need for blood transfusion (1764 vs 565 cc, P < 0.001), and ICU length of stay (5.6 vs 3.8 days, P = 0.014) compared with patients with ED Delta SI ≤0.1. In conclusion, ED Delta SI >0.1 is associated with increased mortality, need for blood transfusion, and ICU length of stay. Delta SI may be superior to traditional SI for trauma outcome prognostication.
Survival Analysis with Extended Lymphadenectomy for Gastric Cancer: Removing Stage Migration from the Equation
Authors: Vuong Brooke , Graff-baker Amanda N. , Dehal Ahmed , Stern Stacey , Fujita Manabu , Goldfarb Melanie , Bilchik Anton J.
Published: June 2020

The survival benefit of an extended versus standard lymphadenectomy for gastric cancer (GC) is often attributed to upstaging when more lymph nodes (LNs) are removed, i.e., stage migration. An extended lymphadenectomy is defined as 30 or more LNs examined, a surrogate for a D2 dissection. The aim of this study is to examine whether the survival benefit of extended lymphadenectomy persists when stage migration is not possible. The National Cancer Data Base was queried to identify patients with pathologic N3 (pN3, ≥7 positive LNs) gastric adenocarcinoma. Overall survival (OS) was compared by extent of lymphadenectomy (7–14, 15–29, and ≥30 LN) and stratified by Tstage. Of 2101 pN3 patients, 419 (19.9%) had 7 to 14 LNs examined, 1164 (55.4%) had 15 to 29 LNs examined, and 518 (24.7%) had ≥30 LNs examined. Unadjusted three-year OS in the entire cohort was 24.6, 27.3, 30.5 per cent for 7 to 14 LNs, 15 to 29 LNs, and ≥30 LNs, respectively (P = 0.003). On adjusted survival analysis by stage for patients with pT1-T2N3 disease, removing ≥30 LNs significantly improved OS compared with removing 7 to 14 LNs (hazard ratio [HR] 2.45, 95% confidence interval = 1.25–4.82, P = 0.009). Extended lymphadenectomy may confer a survival benefit in select patients with pT1N3 and pT2N3 GC, highlighting the importance of the number of LNs examined rather than stage migration on survival. For the majority of the N3 population, pT3-pT4, the extent of lymphadenectomy did not significantly improve the OS.
Comparative Analysis of Laparoscopic and Open Approaches in Emergency Abdominal Surgery
Authors: Siletz Anaar , Grotts Jonathan , Lewis Catherine , Tillou Areti , Cryer Henry Magill , Cheaito Ali
Published: June 2020

The objective of this study was to evaluate usage and outcomes of emergency laparoscopic versus open surgery at a single tertiary academic center. Over a three-year period 165 patients were identified retrospectively using National Surgical Quality Improvement Program results. Appendectomies and cholecystectomies were excluded. Open and laparoscopic approaches were compared regarding preoperative and operative characteristics, the development of postoperative complications, 30-day mortality, and length of hospital stay. Indications for operation were similar between groups. Patients who underwent open surgery had more severe comorbidities and higher ASA class. Laparoscopy was associated with reduced complication rates, operative time, length of stay, and discharges to skilled nursing facilities on univariate analysis. In a multivariate model, surgical approach was not associated with the development of complications. Older age, dependent status, and dyspnea were predictors of conversion from attempted laparoscopic to open approaches.
Predictors of Steal in Hemodialysis Access
Authors: Korn Abraham , Alipour Hamid , Zane Joshua , Gray Kelsey , Ryan Timothy , Kaji Amy , De Virgilio Christian , Bowens Nina
Published: June 2020

Pathological steal is an uncommon but devastating complication after the creation of arteriovenous access for hemodialysis. In this study, we sought to assess predictors of clinically significant steal syndrome and to further evaluate the outcome of differing surgical treatment approaches. A retrospective analysis was performed of 282 consecutive patients undergoing hemodialysis access at a single center from November 2014 to April 2016. Adequate follow-up to assess for the development of steal was obtained in 237 patients. One hundred and fifty-seven (66%) patients were male, 152 (64%) Hispanic, and 164 (69%) had diabetes. Forty-three (18%) had prior access procedures. Autologous fistula was created in 218 patients (92%). Pathologic steal occurred in 15 patients (6.7%). On univariate analysis, significant predictors of steal included female sex [P = 0.03, odds ratio (OR) = 3.3, CI [1.1–9]), no systemic heparin at operation (P = 0.02, OR = 5.0, CI [1.4–10]), use of angiotensin-converting enzyme inhibitor (P = 0.003, OR = 5.6, CI [1.7–18.6]), and increased vein size (3.1 vs 4.1 mm P = 0.01). Twelve patients had steal managed with an intervention, but only one patient received distal revascularization. Furthermore, we identify key predictors of clinically significant steal syndrome while demonstrating that distal revascularization and/or fistula ligation are rarely indicated treatment modalities.
Prognostic Factors Associated with Outcomes in Small Bowel Neuroendocrine Tumors
Authors: Manguso Nicholas , Johnson Jeffrey , Harit Attiya , Nissen Nicholas , Mirocha James , Hendifar Andrew , Amersi Farin
Published: June 2020

Small bowel neuroendocrine tumors (SBNET) account for most gastrointestinal neuroendocrine tumors. Patients often present with late-stage disease; however, there is little information regarding factors that contribute to recurrence. Database review identified 301 patients diagnosed with SBNET between 1990 and 2013. Univariate analysis included patients who underwent complete resection. Survival was estimated by the Kaplan–Meier method. A total of 147 patients met study criteria. Average age was 60 years (range 21–91); 49 per cent were male. Thirty-seven (25.3%) patients had laparoscopic resection, and 29 (19.9%) patients had only small bowel disease, whereas 108 (72.6%) had nodal metastasis. Five-year overall and disease-free survival were 97.5 and 73.5 per cent. Forty-seven (32%) patients had recurrence. The recurrence group was more likely to have an open operation (59.6 vs 32%, P < 0.01), mesenteric invasion, or lymphatic metastasis (87.2 vs 67%, P < 0.01) compared with the no-recurrence group. Cox regression analysis showed that variables associated with recurrence included nodal disease (HR 9.06, P = 0.03), lymphovascular invasion (LVI) (3.95, P < 0.01), perineural invasion (PNI) (3.48, P < 0.01), and mesenteric involvement (3.77, P = 0.03). Patients with SBNET presenting with nodal metastasis, mesenteric involvement, LVI, or PNI have a higher risk of recurrence. Closer surveillance should be considered after operative resection.
The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma
Authors: Malekpour Mahdi , Bridgham Kelly , Jaap Kathryn , Erwin Ryan , Widom Kenneth , Rapp Megan , Leonard Diane , Baro Susan , Dove James , Hunsinger Marie , Blansfield Joseph , Shabahang Mohsen , Torres Denise , Wild Jeffrey
Published: June 2020

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01–2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05–1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04–1.40).
Do Transferred Patients Increase the Risk of Venous Thromboembolism in Trauma Centers?
Authors: Yorkgitis Brian K. , Olufajo Olubode A. , Metcalfe David , Reznor Gally , Havens Joaquim M. , Cooper Zara , Salim Ali
Published: June 2020

Trauma patients often require initial stabilization followed by transfer for ongoing trauma care. Thus, the administration of VTE prophylaxis is often delayed until admission to the receiving hospital. It is unclear if transfer status is a risk factor for VTE. The National Trauma Database v6.2 was used to identify patients admitted to Level I and II trauma centers. Exclusions included patients on anticoagulation, <18 years, known VTE before trauma, or pregnant. Patients transferred were compared with nontransferred patients. Analysis included 736,374 patients with 189,166 (25.69%) transferred patients within 24 hours of injury. Using weighted measures, VTE was identified in 11,619 (1.50%) patients. The VTE rate was significantly higher in the transferred group compared with the nontransferred group (1.73% vs 1.42%, P = 0.002) including deep venous thrombosis (1.39% vs 1.14%, P = 0.004) and pulmonary embolism (0.45% vs 0.39%, P = 0.003). Multivariable analyses adjusting for patient-level risk factors demonstrated that transfer was associated with a higher likelihood of VTE (aOR 1.18; 95% CI: 1.09–1.28, P ≤ 0.001), pulmonary embolism (aOR 1.21; 95% CI: 1.11–1.33, P ≤ 0.001), and deep venous thrombosis (aOR 1.17; 95% CI: 1.07–1.28, P = 0.0004). Transfer status of trauma patients is a risk factor for VTE. Accepting a transferred patient results in an increased VTE risk and may not be reflective of the quality of care at the receiving facility.
A Preliminary Analysis of Compassion Fatigue in a Surgeon Population: Are Female Surgeons at Heightened Risk?
Authors: Wu Daniel , Gross Brian , Rittenhouse Katelyn , Harnish Carissa , Mooney Claire , Rogers Frederick B.
Published: June 2020

Compassion fatigue (CF), a state of physical/emotional distress caused by repeatedly caring for those experiencing traumatic episodes, is a prevalent issue for today's healthcare provider. We sought to characterize levels of CF within a surgeon population, particularly comparing trauma surgery with other surgical specialties. A survey containing the Professional Quality of Life Scale (ProQOL), a validated tool assessing compassion satisfaction (CS), CF, and burnout (BO) was distributed via electronic newsletter to members of the American College of Surgeons. Demographic data and Professional Quality of Life Scale scores for CS, BO, and CF were collected and compared within specialty and gender subgroups. A total of 178 surgeons completed surveys. Respondents were predominantly male, general surgeons, >55 years old. Trauma surgeons composed the second largest subgroup. Levels of CS were significantly lower in the trauma surgeon subgroup compared to other surgical specialties (trauma: 37.1 ± 5.28, other: 39.5 ± 6.30; P = 0.044). Female surgeons from all specialties exhibited significantly higher levels of BO (female: 26.7 ± 6.10, male: 24.6 ± 6.79; P = 0.035) and CF (female: 24.2 ± 6.29, male: 21.9 ± 6.11; P = 0.021) compared with male surgeons. Subanalyses comparing female trauma surgeons to female surgeons in other specialties found female trauma surgeons exhibited significantly lower levels of CS (trauma: 34.8 ± 4.63, other: 38.8 ± 5.99; P = 0.038) and higher levels of BO (trauma: 29.1 ± 3.14, other: 25.3 ± 6.41; P = 0.049). Trauma surgeons, particularly female trauma surgeons, may be at a heightened risk for developing a poorer overall professional quality of life compared with surgeons of other specialties. In addition, female surgeons may be at greater risk for developing CF compared with male counterparts.
Laparoscopic Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis from Gastric Cancer: Its Beneficial Effects on Reduction and Exact Evaluation of the Peritoneal Cancer Index
Authors: Takeshita Kazuyoshi , Liu Yang , Ishibashi Haruaki , Yonemura Yutaka
Published: June 2020

We assessed whether the laparoscopic hyperthermic intraperitoneal chemotherapy (L-HIPEC) + neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) could reduce the peritoneal cancer index (PCI; which is defined by Sugerbaker) and improve the possibility to obtain a complete cytoreductive surgery (CRS with peritonectomy; basically according to the Suger-baker's procedure). After L-HIPEC + NIPS, the PCI score was decreased in 89.5 per cent of patients, and the average score was significantly reduced. The average PCI reduction of improved PCI cases was 10.2 ± 8.4. The hypothetical cut-off was at a PCI score of six with significant higher possibility of CRS completeness. Twelve patients had high-PCI (PCI > 6), and six of them (50.0%) were converted to low-PCI (PCI ≤ 6) and got a complete CRS. There was a significant relationship between post-PCI (PCI after L-HIPEC + NIPS) and CRS completeness; however, pre-PCI (PCI before L-HIPEC + NIPS) value was not a relevant factor. The high-PCI and increased PCI even after L-HIPEC + NIPS (deteriorated-PCI) were suggested as important risk factors for surgical completeness. Neither pre- nor postcytological results had a significant relationship between CRS completeness. However, the deteriorated cytological class was considered as a risk factor for CRS completeness. The second-look laparoscopy would be recommended for the better selection of the patients who can receive benefits by this extensive surgery.
External Validation of Velazquez-Gomez Severity Score Index and ATLAS Scores and the Identification of Risk Factors Associated with Mortality in Clostridium difficile Infections
Authors: Figh Matthew L. , Zoog Evon S. L. , Moore Richard A. , Dart Benjamin W. , Heath Gregory , Butler Reed M. , Gao Cuilan , Kong Joseph C. , Stanley J. Daniel
Published: June 2020

Treatment guidelines for Clostridium difficile infection (CDI) are limited by a lack of widely accepted clinical prediction tools (CPTs). Two published CPTs, the Velazquez-Gomez Severity Score Index (VGSSI) and ATLAS scores, were evaluated, and variables showing the greatest correlation with mortality in patients with CDI were identified to further develop an objective, mortality-based CPT. A retrospective review of the charts of 271 hospitalized patients with CDI was performed. VGSSI and ATLAS scores were assigned. Means and correlations of these scores with mortality were evaluated. Multivariate logistic regression analysis was performed on 32 known potential mortality predictor variables. Mortality was overall strongly associated with VGSSI and ATLAS scores with poor correlation within the intermediate ranges. Mean scores for nonsurvivors indicated poor calibration. The variables most associated with mortality were Age, vasopressors, steroids, creatinine level, and albumin. Although both CPTs revealed the ability to discriminate patients at greater risk for mortality, precision and overall calibration were lacking. Five variables were identified which had the greatest correlation with mortality. Utilization of these variables to enhance or modify the existing CPTs is suggested as the next step in the development of a useful and accurate mortality-based CPT for the treatment of CDI.
Radiofrequency Thermal Ablation Heat Energy Transfer in an Ex-Vivo Model
Authors: Thakur Shivani , Lavito Sandi , Grobner Elizabeth , Grobner Mark
Published: June 2020

Little work has been done to consider the temperature changes and energy transfer that occur in the tissue outside the vein with ultrasound-guided vein ablation therapy. In this experiment, a ex-vivo model of the human calf was used to analyze heat transfer and energy degradation in tissue surrounding the vein during endovascular radiofrequency ablation (RFA). A clinical vein ablation protocol was used to determine the tissue temperature distribution in 10 per cent agar gel. Heat energy from the radiofrequency catheter was measured for 140 seconds at fixed points by four thermometer probes placed equidistant radially at 0.0025, 0.005, and 0.01 m away from the RFA catheter. The temperature rose 1.5°C at 0.0025 m, 0.6°C at 0.005 m, and 0.0°C at 0.01 m from the RFA catheter. There was a clinically insignificant heat transfer at the distances evaluated, 1.4 ± 0.2 J/s at 0.0025 m, 0.7 ± 0.3 J/s at 0.0050 m, and 0.3 ± 0.0 J/s at 0.01 m. Heat degradation occurred rapidly: 4.5 ± 0.5 J (at 0.0025 m), 4.0 ± 1.6 J (at 0.0050 m), and 3.9 ± 3.6 J (at 0.01 m). Tumescent anesthesia injected one centimeter around the vein would act as a heat sink to absorb the energy transferred outside the vein to minimize tissue and nerve damage and will help phlebologists strategize options for minimizing damage.
Robotic Rectopexy for Rectal Prolapse in Pediatric Patients
Authors: Hiller David J. , Bohl Jaime L. , Zeller Kristen A.
Published: June 2020

Rectal prolapse is the protrusion of the rectum out of the anus. Surgical correction can be accomplished via open and minimally invasive abdominal approaches, as well as from the perineum. Robotic rectopexy is an option for minimally invasive treatment of rectal prolapse. There are no studies that have established the efficacy of robotic rectopexy for rectal prolapse in the pediatric population. The aim of this study was to review the experience of robotic rectopexy at a single institution. This is a retrospective review of our pediatric robotic rectopexy experience from 2012 to 2015. Information was obtained from chart review of both operative notes and clinic visits. Four pediatric patients underwent a robotic rectopexy for rectal prolapse from 2012 to 2015. Three patients were male and one was female. The mean age was 15.5 years (range 13–17). Two patients had rectal prolapse with chronic constipation. One patient had rectal prolapse from Ehlers Danlos syndrome, and the last had rectal prolapse after imperforate anus repair as an infant. Three patients received a bowel preparation. Three patients were completed robotically, and one patient required conversion to an open procedure. The average postoperative length of stay was 3.25 days (range 2–4). There were no episodes of recurrent prolapse. Two patients had improvement in constipation, one had no improvement, and one had no documented change. Average postoperative follow-up was 11.5 months (range 3–29). This study was a review of one institution's experience with pediatric robotic rectopexy. With short-term follow-up, there was no recurrence of prolapse. Robotic rectopexy provided a safe, reliable, and short-term resolution of rectal prolapse in pediatric patients.
Limit Crystalloid Resuscitation after Traumatic Brain Injury
Authors: Ko Ara , Harada Megan Y. , Barmparas Galinos , Smith Eric J. T. , Birch Kurtis , Barnard Zachary R. , Yim Dorothy A. , Ley Eric J.
Published: June 2020

Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received <2 L of crystalloids were categorized as low volume (LOW), whereas those who received ≥2 L were considered high volume (HIGH). Mortality and outcomes were compared. Multivariable regression analysis was used to determine the odds of mortality while controlling for confounders. Over 10 years, 875 patients met inclusion criteria. Overall mortality was 12.5 per cent. Seven hundred and forty-two (85%) were in the LOW cohort and 133 (15%) in the HIGH cohort. Gender and age were similar between the groups. The HIGH cohort had lower admission systolic blood pressure (128 vs 138 mm Hg, P = 0.001), lower Glasgow coma scale score (10 vs 12, P < 0.001), higher head abbreviated injury scale (3.8 vs 3.3, P < 0.001), and higher injury severity score (25 vs 18, P < 0.001). The LOW group had a lower unadjusted mortality (10 vs 26%, P < 0.001). Multivariable analysis adjusting for confounders demonstrated that those resuscitated with ≥2 L of crystalloids had increased odds of mortality (adjusted odds ratio 2.25, P = 0.005). Higher volume crystalloid resuscitation after TBI is associated with increased mortality, thus limited resuscitation for TBI patients may be indicated.
Article Commentary: Controversies Regarding the Diagnosis and Management of Ductal Carcinoma in Situ
Authors: Levinsohn Erik , Altman Marcus , Chagpar Anees B.
Published: June 2020

Ductal carcinoma in situ (DCIS) is a premalignant condition, whose incidence is increasing in the current era of widespread screening mammography. While eminently treatable, there are innumerable controversies that surround this disease in terms of its diagnosis and treatment. We discuss these issues and review the data to date regarding this condition which affects roughly 20 per cent of all patients presenting with breast cancer.