bluuebunny/crossref_metadata_2025 huggingface dataset:
Measuring Satisfaction: Factors that Drive Hospital Consumer Assessment of Healthcare Providers and Systems Survey Responses in a Trauma and Acute Care Surgery Population
Authors: Kahn Steven A. , Iannuzzi James C. , Stassen Nicole A. , Bankey Paul E. , Gestring Mark
Published: June 2020

Hospital quality metrics now reflect patient satisfaction and are measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Understanding these metrics and drivers will be integral in providing quality care as this process evolves. This study identifies factors associated with patient satisfaction as determined by HCAHPS survey responses in trauma and acute care surgery patients. HCAHPS survey responses from acute care surgery and trauma patients at a single institution between 3/11 and 10/12 were analyzed. Logistic regression determined which responses to individual HCAHPS questions predicted highest hospital score (a rating of 9–10/10). Demographic and clinical variables were also analyzed as predictors of satisfaction. Subgroup analysis for trauma patients was performed. In 70.3 per cent of 182 total survey responses, a 9–10/10 score was given. The strongest predictors of highest hospital ranking were respect from doctors (odds ratio [OR] = 24.5, confidence interval [CI]: 5.44–110.4), doctors listening (OR: 9.33, CI: 3.7–23.5), nurses’ listening (OR = 8.65, CI: 3.62–20.64), doctors’ explanations (OR = 8.21, CI: 3.5–19.2), and attempts to control pain (OR = 7.71, CI: 3.22–18.46). Clinical factors and outcomes (complications, intensive care unit/hospital length of stay, mechanism of injury, and having an operation) were nonsignificant variables. For trauma patients, Injury Severity Score was inversely related to score (OR = 0.93, CI: 0.87–0.98). Insurance, education, and disposition were also tied to satisfaction, whereas age, gender, and ethnicity were nonsignificant. In conclusion, patient perception of interactions with the healthcare team was most strongly associated with satisfaction. Complications did not negatively influence satisfaction. Insurance status might potentially identify patients at risk of dissatisfaction. Listening to patients, treating them with respect, and explaining the care plan are integral to a positive perception of hospital stay.
Local Anesthesia in Open Inguinal Hernia Repair Improves Postoperative Quality of Life Compared to General Anesthesia: A Prospective, International Study
Authors: Huntington Ciara R. , Wormer Blair A. , Cox Tiffany C. , Blair Laurel J. , Lincourt Amy E. , Augenstein Vedra A. , Heniford B. Todd
Published: June 2020

The choice of general (GA) versus local anesthesia (LA) in open inguinal hernia repair (OIHR) has a substantial financial impact and may influence clinical outcomes. Our study compares postoperative quality of life (QOL) in patients undergoing OIHR under LA versus GA. A cooperative prospective study from centers in 10 countries was performed through the International Hernia Mesh Registry from 2007 to 2012. QOL was compared at one, six, 12, and 24 months for LA versus GA with univariate and multivariate analysis controlling for known confounding variables. Of 1128 patients who underwent OIHR, 585(52%) used GA and 533(48%) used LA. Most were male (92%) with unilateral (94%), primary (91%) repairs with a mean age 57 ± 16 years. There was no difference ( P > 0.05) in age, gender, operative time, mesh size, length of stay, infection, recurrence, reoperation, or death. Multivariate analysis demonstrated significant QOL differences between groups: GA had higher odds of discomfort at one and six months [odds ratio (OR) 3.3, 2.0], movement limitation at one and six months (OR 3.5, 2.8), and mesh sensation at one and 12 months (OR 2.9, 1.8). Overall, patients undergoing OIHR under LA had improved postoperative QOL in the short and long term compared with GA.
A NSQIP Analysis of MELD and Perioperative Outcomes in General Surgery
Authors: Zielsdorf Shannon M. , Kubasiak John C. , Janssen Imke , Myers Jonathan A. , Luu Minh B.
Published: June 2020

It is well known that liver disease has an adverse effect on postoperative outcomes. However, what is still unknown is how to appropriately risk stratify this patient population based on the degree of liver failure. Because data are limited, specifically in general surgery practice, we analyzed the model of end-stage liver disease (MELD) in terms of predicting postoperative complications after one of three general surgery operations: inguinal hernia repair (IHR), umbilical hernia repair (UHR), and colon resection (CRXN). National Surgical Quality Improvement Program data on 17,812 total patients undergoing one of three general surgery operations from 2008 to 2012 were analyzed retrospectively. There were 7402 patients undergoing IHR; 5014 patients undergoing UHR; 5396 patients undergoing CRXN. MELD score was calculated using international normalized ratio, total bilirubin, and creatinine. The primary end point was any postoperative complication. The statistical method used was logistic regression. For IHR, UHR, and CRXN, the overall complication rates were 3.4, 6.4, and 45.9 per cent, respectively. The mean MELD scores were 8.6, 8.5, and 8.5, respectively. For every 1-point increase greater than the mean MELD score, there was a 7.8, 13.8, and 11.6 per cent increase in any postoperative complication. The overall 30-day mortality rate was 0.9 per cent. In conclusion, the MELD score continuum adequately predicts patients’ increased risk of postoperative complications after IHR, UHR, and CRXN. Therefore, MELD could be used for preoperative risk stratification and guide clinical decision making for general surgery in the cirrhotic patient.
Surgical Site Occurrences of Simultaneous Panniculectomy and Incisional Hernia Repair
Authors: Warren Jeremy A. , Epps Matthew , Debrux Cart , Fowler James L. , Ewing Joseph A. , Cobb William S. , Carbonell Alfredo M.
Published: June 2020

Horizontal panniculectomy (PAN) offers the advantage of wide exposure for hernia repair with elimination of excess skin and adiposity, at the expense of massive subcutaneous flap creation and its attendant risks. We report our experience with ventral hernia repair (VHR) with PAN compared with patients with hernia repair alone. A prospective database was reviewed retrospectively for all patients undergoing open VHR + PAN. A matched cohort of patients without PAN was used for comparison, resulting in 43 study and 43 control patients. Incidence of surgical site occurrences (SSO), surgical site infection (SSI), and recurrence were analyzed. A total of 43 patients underwent PAN + VHR with mesh. Mean body mass index was 34.3 kg/m2, with 35 per cent having undergone prior bariatric surgery. Repair techniques included retromuscular (74.4%), preperitoneal (11.6%), intraperitoneal (6.9%), onlay (4.6%), and suture (2.3%). Mesh used was polypropylene (76.7%), polyester (18.6%), bioabsorbable (2.3%), and polytetrafluoroethylene (ePTFE) (2.3%). Component separation was performed in 44.2 per cent of patients. There was a significant difference in total SSO between PAN + VHR and VHR alone (46.5% vs 27.9%; P < 0.001), though the difference for individual SSOs was not significant. There was no difference in SSI between groups (16.3% vs 20.9%; P = 0.776). Mean follow-up was 11.4 months, with recurrence rate of 11.6 per cent in the PAN group and 9.3 per cent in the control group ( P = 0.725). Panniculectomy at the time of VHR does not increase the incidence of SSI, though higher rates of skin necrosis and cellulitis were seen. There is no difference in recurrence. This approach is a valid option for patients with excessive abdominal panniculus requiring VHR.
Torso Computed Tomography Can be Bypassed after Thorough Trauma Bay Examination of Patients who Fall from Standing
Authors: Lavingia Kedar S. , Collins Jay N. , Soult Michael C. , Terzian W. Helman , Weireter Leonard J. , Britt L.D.
Published: June 2020

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.
Cost-effectiveness of Bariatric Surgery: Increasing the Economic Viability of the Most Effective Treatment for Type II Diabetes Mellitus
Authors: Warren Jeremy A. , Ewing Joseph A. , Hale Allyson L. , Blackhurst Dawn W. , Bour Eric S. , Scott John D.
Published: June 2020

There has been considerable debate on the cost-effectiveness of bariatric surgery within larger population groups. Despite the recognition that morbid obesity and its comorbidities are best treated surgically, insurance coverage is not universally available. One of the more costly comorbidities of obesity is Type II diabetes mellitus (T2DM). We propose a model that demonstrates the cost-effectiveness of increasing the number of bariatric surgical operations performed on patients with T2DM in the United States. We applied published population cost estimates (2012) for medical care of T2DM to a retrospective cohort of morbidly obese patients in South Carolina. We compared differences in 10-year medical costs between those having bariatric surgery and controls. Resolution of T2DM in the bariatric cohort was assumed to be 40 per cent. Considering only the direct medical costs of T2DM, the 10-year aggregate cost savings compared with a control group is $2.7 million/1000 patients; the total (direct and indirect) cost savings is $5.4 million/1000 patients. When considering resolution of T2DM alone, increasing the number of bariatric operations for a given population leads to a substantial cost savings over a 10-year period. This study adds to the growing body of evidence suggesting that bariatric surgery is a cost-effective means of caring for the obese patient.
Understanding Gram-negative Central Line-Associated Blood Stream Infection in a Surgical Trauma ICU
Authors: Duane Therese M. , Kikhia Rashid M. , Wolfe Luke G. , Ober Janis , Tessier Jeffrey M.
Published: June 2020

The purpose of this study was to review central line-associated blood stream infection (CLABSI) data from a surgical trauma intensive care unit to better understand patient risk factors, pathogens, and treatment interventions. We performed a retrospective review of all surgical ICU patients who met the Centers for Disease Control definition for Gram-negative CLABSI from 2006 through 2013. Demographics, pathogens, interventions, and outcomes were evaluated. A total of 40 patients were included with an average age of 49.9 ± 19 years and 72.5 per cent male. The average length of central venous line (CVL) was 11 ± 5.9 days with average time from line placement to positive culture 9.4 ± 6.8 days. Most common organisms were Enterobacter species (37.5%) with 17.8 per cent of all cultured organisms considered multidrug resistant. Piperacillin–tazobactam (67.5%) was the most commonly used antibiotic. Overall mortality rate was 22.5 per cent. A total of 11 patients who developed a recurrence did so at 10.7 ± 8 days and were similar to those without recurrence. Predominant pathogens associated with surgical trauma intensive care unit CLABSI in this study are different from those Gram-negative bacteria associated with published studies in the general hospital population. Further investigation into risk factors for infection and relapse is important to minimize such consequences. Understanding appropriate line placement and use as well as clarifying optimal duration of therapy is integral in improving outcomes.
Risk Factors for Postoperative Unplanned Intubation: Analysis of a National Database
Authors: Alvarez Martin P. , Samayoa-Mendez Andres X. , Naglak Mary C. , Yuschak James V. , Murayama Kenric M.
Published: June 2020

Postoperative unplanned intubation (PUI) is a significant complication and is associated with severe adverse events and mortality. By participating in the National Surgical Quality Improvement Program (NSQIP), we learned that PUI occurred more frequently than expected at our institution. The aim of this study was to identify risk factors that are predictors of PUI at our institution. We reviewed the NSQIP data from our institution and the NSQIP national database for surgery patients from 2010 through 2013. The rate of PUI at our institution was 1.54 per cent compared with the national rate of 1.03 per cent. Perioperative risk factors were analyzed by multivariate logistic regression. Analysis of the national NSQIP database identified 14 independent risk factors for PUI. Analysis of the NSQIP data at our institution demonstrated that emergent cases, preoperative ventilator status, smoking, chronic obstructive pulmonary disease, and older age were independent risk factors. In conclusion, patients at our institution with these five risk factors were at higher risk of requiring PUI. These risk factors could be used to help identify patients at high risk and possibly help prevent postoperative respiratory failure and unplanned intubation.
Over 250 Laparoendoscopic Single Site (LESS) Fundoplications: Lessons Learned
Authors: Sukharamwala Prashant , Teta Anthony , Ross Sharona , Co Franka , Alvarez-Calderon Giannina , Luberice Kenneth , Rosemurgy Alexander
Published: June 2020

Laparoendoscopic single site (LESS) surgery is a more recent advance in the progression of minimally invasive surgery. This study was undertaken to assess lessons learned after our first 250 LESS fundoplications for gastroesophageal reflux disease (GERD). All patients undergoing LESS fundoplications were prospectively followed from 2008 to 2014. Patients scored the frequency/severity of their symptoms before/after LESS fundoplication using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients also scored satisfaction with their incision using a Likert scale (1 = revolting to 10 = beautiful). A total of 300 patients undergoing LESS fundoplication for GERD were not different by age or gender. Surgeons undertook 190 Nissen fundoplications and 110 Toupet fundoplications; 28 of which were “redo” fundoplications. Preoperative symptoms were notable, especially heartburn (frequency = 8, severity = 7). Symptoms were ameliorated postoperatively (e.g., heartburn: frequency = 0, severity = 0, P < 0.01). Postoperatively, patients scored satisfaction of their incisions with a median score of 10. Eighty-three per cent of patients were at least satisfied with their overall experience; 92 per cent would undergo the operation again knowing what they know now. Patients report significant symptom relief, high satisfaction, and excellent cosmesis after LESS fundoplication. LESS fundoplication safely ameliorates symptoms of GERD with pronounced satisfaction, in part, because of the cosmetic outcome (i.e., lack of scaring), and its application is encouraged.
Should All Severely Injured Pediatric Patients be Treated at Pediatric Level I Trauma Centers? A National Trauma Data Bank Study
Authors: Miyata Shin , Haltmeier Tobias , Inaba Kenji , Matsushima Kazuhide , Goodhue Catherine , Bliss David W.
Published: June 2020

The American College of Surgeons Committee on Trauma stratification system for trauma centers presumes that increasing levels of resources will improve patient outcomes. Although some supportive data exist in adult trauma, there is a paucity of evidence demonstrating improved survival in pediatric trauma when patients are treated primarily at Level I versus Level II pediatric trauma centers. We hypothesized that there is no difference in the mortality of comparably injured pediatric patients treated at these two types of facilities. The study population consists of all severely injured pediatric patients (18 years old or younger, injury severity score > 15) registered in the National Trauma Data Bank, treated in designated pediatric trauma centers. A total of 13,803 patients were included in the analysis and were separated into two groups: Pediatric Level I trauma center (n = 9690) and Pediatric Level II trauma center (n = 4113). Although analysis of the clinical characteristics of the unmatched groups showed significant differences including mortality rate (11.7% vs 15.4%, P < 0.001), case matching technique, comparing 2956 pairs, successfully eliminated demographic differences and, when adjusted for injury severity, showed no difference in mortality between center types (10.0% vs 10.1%, P = 0.966, odds ratio of mortality = 0.996 and 95% confidence interval = 0.841–1.180). Subgroup analyses including Glasgow Coma Scale < 9, need for immediate procedures, and ICD-9 (International Classification of Diseases) code groupings indicative of serious injury also failed to demonstrate statistically significant differences in mortality between trauma center types.
CT Chest with IV Contrast Compared with CT Angiography after Blunt Trauma
Authors: Zaw Andrea A. , Stewart Donovan , Murry Jason S. , Hoang David M. , Sun Beatrice , Ashrafian Sogol , Hotz Heidi , Chung Rex , Margulies Daniel R. , Ley Eric J.
Published: June 2020

Blunt aortic injury (BAI) after chest trauma is a potentially lethal condition that requires rapid diagnosis for appropriate treatment. We compared CT with IV contrast (CTI) with CT with angiography (CTA) during the initial phase of care at an urban Level I trauma center from January 1, 2010 to December 31, 2013. Overall, 281 patients met inclusion criteria with 167 (59%) CTI and 114 (41%) CTA. There were no differences between cohorts in age, gender, initial heart rate, systolic blood pressure, and Glasgow Coma Scale. Mortality rates were similar for CTI and CTA (4% vs 8%, P = 0.20). CTI identified any chest injury in 54 per cent of patients compared with 46 per cent with CTA ( P = 0.05). The rate of BAI was similar with CTI and CTA (2% vs 2%, P = 0.80), and neither modality was falsely negative. We conclude that CTI and CTA are similar at evaluating trauma patients for BAI, although CTI may be preferable during the initial assessment phase because the contrast injection may be combined with abdominal scanning and image time is reduced when whole-body CT is required.
Outcomes of Colostomy Reversal in a Public Safety Net Hospital: The End or Beginning of a New Problem?
Authors: Adam Nadir , Rahbar Shahrzad , Skinner Ruby
Published: June 2020

Colostomy reversals can be technically challenging and linked to significant morbidity. There is sparse evidence that evaluates outcomes after colostomy reversals performed by acute care surgeons. We performed a review of 61 colostomy reversals from January 2011 to January 2014. Colostomies for acute diverticulitis were predominate, n = 32 (52%). Traumatic colorectal injuries were n = 15, 25 per cent. Colorectal cancer was n = 8, 13 per cent. Sigmoid volvulus accounted for n = 2 cases. Abdominal sepsis from adhesions was n = 3. A rectal foreign body was for n = 1 case. The time to reversal was 360 ± 506 days. Completion of reversals was successful in 90 per cent of cases and protecting stoma use was in n = 12, (22%). Surgical site infections occurred in n = 20, patients (32%). Surgical site infections were prevalent in obese patients, (55%). Anastomotic leaks (ALs) occurred at 12 per cent, and were prevalent in obese, [obese (22%) vs nonobese (8%), P = 0.1]. The majority of AL n = 6, (85%) were in acute diverticulitis and trauma. There were no ALs in cases with protective diversion. No deaths occurred. The elective nature of colostomy reversals does not imply low morbidity. Obesity and major inflammatory processes were associated with major surgical complications. These data suggest that protective stomas should be applied liberally, particularly in high-risk cases.
Pancreatectomy in Patients with Impaired Renal Function: How Risky is It?
Authors: Feyko Jared , Hazard Hannah , Cardinal Jon , Thomay Alan , Cho Sung
Published: June 2020

Chronic renal impairment causes profound physiologic and metabolic changes. Its impact on surgical outcome after pancreatectomy is not well established. We sought to quantify complication rates of pancreatectomy in patients with chronic renal impairment. Database from the American College of Surgeons National Surgical Quality Improvement Project (2005–2011) was queried to identify patients with chronic renal impairment who underwent pancreatectomy. The study population consisted of 16,708 patients of whom 16,649 patients were not on dialysis and 59 patients were on dialysis. Overall mortality for those on dialysis was 5.1 per cent, whereas it was 2.3 per cent for those not on dialysis ( P = 0.114). Patients on dialysis were more likely to have failure to wean ventilation ( P < 0.001), reintubation ( P = 0.004), myocardial infarction ( P = 0.007), and sepsis ( P = 0.046). Patients not on dialysis were then divided into three groups: serum creatinine levels <1.2 mg/dL, between 1.2 mg/dL and 2.0 mg/dL, and >2.0 mg/dL. We found the mortality rates for these three groups were 2.0 per cent, 4.6 per cent, and 7.5 per cent, respectively ( P < 0.001). In conclusion, need for dialysis is associated with increased postoperative complications. Increased serum creatinine levels were associated with increased mortality rates. These findings should facilitate informative risk/benefit calculation for patients with renal impairment who are considering pancreatectomy.
Analysis of Profit and Loss by Injury Severity over 20 Years at a University Level I Trauma Center
Authors: Dietch Zachary , Young Jeffrey S. , Young Steven D.
Published: June 2020

We examined financial data from a University Level I Trauma Center from 1994 to 2014. We sought to investigate the hypothesis that lower injury severity correlates with increased profitability. We examined data from July 1994 to December 2014. This included hospital charges, Medicare cost data, final reimbursement, and payor source. Patients were separated into Injury Severity Score (ISS) groupings: 0 to 9, 10 to 14, 15 to 24, >24, and >14. Mean and standard deviation of mean are reported. We had complete data on 27,582 patients. Overall profit per case when subtracting costs from reimbursements was $1,932/case (total profit in unadjusted dollars = $53,475,828 or $2,673,791/year). When examined by ISS, profitability was significantly different between ISS 0 to 14 and 15 to 24, and > 24. When charge data were examined, the average loss per case was -$31,313 for the 27,582 patient data set. When using cost, and not charge data, overall trauma care had a positive margin. Severely injured patients (ISS > 14) were the most profitable, with a significantly higher profit per case than all other groupings. Only through examination of cost data can realistic determinations of trauma center profitability be made. If only charge data had been examined in this study, the overall loss from the 20-year period would have been $863,675,166 and not a profit of $53,475,828.
Alternatives to Indwelling Catheters Cause Unintended Complications
Authors: Nguyen Jessica , Harvey Ellen M. , Lollar Daniel I. , Bradburn Eric H. , Hamill Mark E. , Collier Bryan R. , Love Katie M.
Published: June 2020

To reduce the risk of catheter-associated urinary tract infection (CAUTI), limiting use of indwelling catheters is encouraged with alternative collection methods and early removal. Adverse effects associated with such practices have not been described. We also determined if CAUTI preventative measures increase the risk of catheter-related complications. We hypothesized that there are complications associated with early removal of indwelling catheters. We described complications associated with indwelling catheterization and intermittent catheterization, and compared complication rates before and after policy updates changed catheterization practices. We performed retrospective cohort analysis of trauma patients admitted between August 1, 2009, and December 31, 2013 who required indwelling catheter. Associations between catheter days and adverse outcomes such as infection, bladder overdistention injury, recatheterization, urinary retention, and patients discharged with indwelling catheter were evaluated. The incidence of CAUTI and the total number of catheter days pre and post policy change were similar. The incidence rate of urinary retention and associated complications has increased since the policy changed. Practices intended to reduce the CAUTI rate are associated with unintended complications, such as urinary retention. Patient safety and quality improvement programs should monitor all complications associated with urinary catheterization practices, not just those that represent financial penalties.
Discharge with Pancreatic Fistula after Pancreaticoduodenectomy Independently Predicts Hospital Readmission
Authors: Mosquera Catalina , Vohra Nasreen A. , Fitzgerald Timothy L. , Zervos Emmanuel E.
Published: June 2020

Readmission rates after pancreaticoduodenectomy (PD) are among the highest of any surgical procedure. The purpose of this study was to identify those factors present at discharge that may predict readmission after PD. All patients undergoing PD between 2010 and 2015 at a very high (>35 PD/year) volume center were entered into a prospective database. Twenty factors present at discharge from index admission identified on univariate analysis were subjected to multivariate analysis to identify those independently predictive of 30-day hospital readmission. A total of 220 patients underwent PD during the study period, 88 per cent of which had cancer. Mean age was 64.4 ± 11.7 years with slight male preponderance (54.5%) and significant African American representation (33.2%). Surgical complications occurred in 67.3 per cent of patients the most common of which included infectious/leak (30%), gastrointestinal (29%), cardiorespiratory (13%), other (13%), minor complications (7%), multi system failure (5%), and new onset diabetes (3%). The 30-day readmission rate was 27.3 per cent and was due to infection (89%), failure to thrive (32%), nausea/vomiting (15%), or other (15%). On multivariate analysis, presence of pancreatic leak/fistula at discharge was the only significant predictor of readmission, present in 62.5 per cent of all readmitted patients ( P = 0.001). Comorbidities, length of stay, insurance status, obesity, smoking, and discharge to a care venue other than home did not predict readmission. Patients manifesting pancreatic fistula after PD are at high risk for hospital readmission. Enhanced scrutiny regarding suitability for discharge should be exercised in these patients and measures taken to minimize readmission whenever possible.
Excessive Postoperative Fluid Administration in Infants with Gastroschisis
Authors: Bonasso Patrick C. , Lucke-Wold Brandon , Hobbs Gerald R. , Vaughan Richard A. , Shorter Nicholas A. , Nakayama Don K.
Published: June 2020

Careful fluid management is a cornerstone of neonatology because the cardiovascular, respiratory, and gastrointestinal systems in the newborn are sensitive to overhydration. Fluid management in gastroschisis is complicated by insensible fluid loss and postoperative third-space fluid shifts. Study of perioperative fluid management in gastroschisis is limited and has not undergone careful scrutiny. We reviewed perioperative fluid administration and urine output in all infants with gastroschisis over a 5-year period. Data included whether the patient underwent primary closure or staged repair, weight, and events during hospitalization (length of hospitalization and duration of gastric decompression, parenteral nutrition, and ventilator support). Paired t test gave statistical comparisons with significance at P < 0.05. From 2010 to 2014, 24 patients underwent abdominal closure, 17 had primary and 7 had staged closures. Fluid administration exceeded 100 mL/kg/d after primary closure, and was significantly higher (>150 mL/kg/d; P < 0.05) after staged closure on postoperative days 0 to 5. Postoperative urinary output exceeded 75 mL/kg/d for all patients, with higher volumes reaching 100 mL/kg/d after staged closure on postoperative days 4 to 6 ( P < 0.05). Two patients died of sepsis. All survivors were discharged with intestinal continuity and gaining weight on oral feeding. Patients with gastroschisis received large volumes of fluid after operation despite similarly high urine output and positive daily fluid balances. The amounts of fluid administered after both primary and staged closure may be excessive and potentially deleterious.
Diabetic Foot Ulcers: The Importance of Patient Comorbidity Recognition and Total Contact Casting in Successful Wound Care
Authors: Jagadish Mayuri , Mcnally Michael M. , Heidel R. Eric , Teffeteller Susan , Arnold Joshua D. , Freeman Michael , Stevens Scott L. , Grandas Oscar H. , Goldman Mitchell H.
Published: June 2020

Diabetic foot ulcers (DFUs) are a major burden on the health-care system. The purpose of this study is to investigate factors affecting the healing rate of DFU in a university wound care center. Records of DFU patients treated between July 2013 and February 2015 were reviewed. Demographics, comorbidities, wound characteristics, and treatment modalities including offloading, hyperbaric oxygen treatment, total contact casting, and bioengineered skin were investigated. All patients underwent weekly debridement regardless of treatment modality. A total of 114 patients ages 18 to 98 comprised the study population. Total contact casting was the only treatment associated with increased healing ( P = 0.02). Smoking ( P = 0.004) and deep vein thrombosis history ( P = 0.001) significantly decreased the likelihood of wound healing. Patients with past vascular event trended toward longer healing times ( P = 0.07). Total contact casting in combination with weekly wound debridement showed benefit in DFU wound healing, whereas patients with a history of deep vein thrombosis and smoking were less likely to heal.
Closure of a Traumatic Esophagomediastinal Fistula in a Child by Endoscopic Fulguration and Fibrin Injection
Authors: Maizlin Ilan Igor , Chen Jerry S. , Smith Nicholas James , Rogers David A.
Published: June 2020

Posttraumatic esophagomediastinal fistula is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Its management, especially in previously operated field, is controversial and several endoscopic methods are being proposed as alternatives. Ours is the first report of endoscopic fulguration and fibrin injection in successful closure of such fistula. A 9-year-old female sustained complete tracheoesophageal transection from a gunshot wound to the neck and underwent immediate primary repair. She presented nine months later with fevers and swelling over anterior neck. CT revealed air tracking posteriorly to the dorsal neck and interiorly to the mediastinum. Considering difficulty of open surgical approach, endoscopic intervention was attempted. Posterior wall fistula was identified via microlaryngoscopy above the esophageal anastomosis. The fistula tract was de-epithelialized via a Bugbee fulgurating electrode and then sealed with fibrin glue. Consequent imaging studies demonstrated complete occlusion of the fistula. Posterior posttraumatic esophagomediastinal fistula presents a challenging scenario from a surgical standpoint, as it combines difficulty of safe approach, high rate of injury to surrounding structures, and significant postoperative recurrence rate. Endoscopic Bugbee fulguration and fibrin glue injection are a safe and effective alternative to the traditional approach.
Arterial Injuries Associated with Blunt Fractures in the Lower Extremity
Authors: Coleman Jamie J. , Tavoosi Saharnaz , Zarzaur Ben L. , Brewer Brian L. , Rozycki Grace S. , Feliciano David V.
Published: June 2020

Problems related to the combination of an arterial injury and a blunt fracture in the lower extremity are well known—delayed diagnosis, damaged soft tissue, and high amputation rate. The actual incidence of this injury pattern is, however, unknown. The purposes of this study were to determine the current incidence of named arterial injuries in patients with blunt fractures in the lower extremities and assess potential associated risk factors. This was a 7-year (2007–2013) retrospective review of patients ≥18 years with blunt lower extremity fractures at a Level I trauma center. Fracture location and concomitant arterial injury were determined and patients stratified by age, gender, and injury velocity. Low injury velocity was defined as falls or assaults, whereas an injury secondary to a motorized vehicle was defined as high velocity. A total of 4413 patients (mean age 52.2 years, 54.3% male, mean Injury Severity Score 13.1) were identified. Forty-six patients (1.04%) had arterial injuries (20.4% common femoral, 8.2% superficial femoral, 44.9% popliteal, and 26.5% shank). After stratifying by age and injury velocity, younger age was associated with a significantly higher rate of vascular injury. For high-velocity injuries, there was no difference based on age. In conclusion, the prevalence of arterial injury after blunt lower extremity fractures is 1.04 per cent in our study. A significant paradoxical relationship exists between age and associated arterial injuries in patients with low-velocity injuries. If these data are confirmed in future studies, a low index of suspicion in patients >55 years after falls is appropriate.
Neuropsychological Changes in Primary Hyperparathyroidism after Parathyroidectomy
Authors: Liu Jessica Y. , Saunders Neil D. , Chen Aaron , Weber Collin J. , Sharma Jyotirmay
Published: June 2020

Neuropsychiatric symptoms (NPSs) of sporadic primary hyperparathyroidism (PHPT) are often subtle and effects of parathyroidectomy (PTX) on symptoms remains poorly characterized. Our aim was to evaluate effects of PTX on NPS in patients with PHPT. A prospective questionnaire was distributed to all patients undergoing PTX and to a thyroidectomy (TX) control group. The questionnaire included the validated scales Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) to assess for depression and anxiety respectively, as well as questions modified from Pasieka's Parathyroid Assessment of Symptoms (M-PAS). Point values were assigned to questionnaire answers to create a score, with a maximum of 63. Fifty-eight patients underwent PTX (58.6%) and 41 TX (41.4%). Mean preoperative scores were greater in PTX versus TX patients in total score, PHQ-9, GAD-7, and M-PAS (all P < 0.05). Post-PTX scores were lower than pre-PTX in total score, PHQ-9, GAD-7, and M-PAS (all P < 0.05), but not in pre- and post-TX. Post-PTX 69.0 and 82.8 per cent of patients showed no symptoms of depression and anxiety, respectively, compared with 37.9 and 56.9 per cent pre-PTX. A total of 16.2 and 10.3 per cent of patients had moderately severe to severe depression and anxiety, which fell to 0 per cent post-PTX. NPSs are more common in patients with PHPT when compared with TX. Patients undergoing PTX have improvements in NPS. NPS scoring should occur in all patients with PHPT and severity of NPS should be considered a relative indication for PTX.
Management of Completion and Total Thyroidectomy Patients Based on 1-Hour Postoperative Parathyroid Hormone
Authors: Park Joshua , Frank Ethan , Simental Alfred , Yang Sara , Vuong Christopher , Lee Steve , Filho Pedro Andrade
Published: June 2020

After thyroid surgery, protocols based on postoperative parathyroid hormone (PTH) levels may prevent symptoms of hypocalcemia, while avoiding unnecessary prophylactic calcium and/or vitamin D supplementation. We examined the value of an initial management protocol based solely on a single PTH level measured one hour after completion or total thyroidectomy to prevent symptomatic hypocalcemia by conducting a retrospective review of 697 consecutive patients treated from July 2003 to April 2015. The proportion of patients who developed symptomatic hypocalcemia was similar between those treated before (n = 155) and after (n = 542) implementation of this 1-hour PTH protocol (16.8% vs 15.9%; P = 0.786). Those in the 1-hour PTH groups had lower overnight observation rates (97.4% vs 53.7%; P < 0.001) and length of stay (1.98 ± 2.61 vs 0.89 ± 1.87 days; P < 0.001), and required less calcium (3.9% vs 0.8%; P = 0.015) and vitamin D (2.6% vs 0%; P = 0.002) supplementation one year after surgery. Less than 1 per cent of patients discharged on the day of surgery in accordance with the 1-hour PTH guidelines returned to the emergency room for symptomatic hypocalcemia; none experienced significant morbidity. This protocol facilitates early discharge of low-risk patients and results in a similar or improved postoperative course compared with traditional overnight observation.
Robotic Colorectal Surgery: Our Initial Experience
Authors: Dehal Ahmed , Patel Sunal , Park Hanna , Nguyen Patrick , Yuhan Robert , Ruan Joseph
Published: June 2020

Robotic colorectal surgery was first performed at our institution in January 2014. The objective of this study is to present our initial experience with robotic colorectal surgery. This is a retrospective review of the prospectively collected data of all patients who underwent robotic colorectal surgery from January 2014 to April 2015. Baseline, perioperative, and postoperative data were obtained for analysis. A total of 101 patients with a mean age of 56 and a body mass index of 31 underwent robotic colorectal surgery between January 2014 and April 2015. The indication for surgery was malignancy in approximately 40 per cent, diverticulitis in 40 per cent, and benign diseases in 20 per cent of the patients. The most common operation was sigmoidectomy (40%) followed by low anterior resection (36%), abdominoperineal resection (7%), right hemicolectomy (6%), rectopexy (6%), total colectomy (4%), and left hemicolectomy (1%). The mean operative and docking time was 226 (range, 104–496) minutes and 3 (range, 1–18) minutes, respectively. The median number of lymph nodes harvested was 19 (range, 0–34). The median length of stay was 3 (range, 1–18) days. Anastomotic leak occurred in one patient and surgical site infection in two patients. Robotic colorectal surgery is safe and technically feasible.
Impact of Massive Transfusion and Aging Blood in Acute Trauma
Authors: Anand Tanya , Ramnanan Rajesh , Skinner Ruby , Martin Maureen
Published: June 2020

Blood transfusions cause altered immunity and the duration of storage is contributory. In the era of massive transfusion protocols (MTPs) this impact is unclear, particularly as it relates to balanced transfusions. Trauma patients requiring our MTP after admission to our Level II trauma center were studied. The average age of blood transfused was calculated; old blood was a storage time of ≥14 days versus new blood <14 days. Blood to plasma ratios of 1:1 were compared with ratios >1:1. Infections, organ dysfunction multiorgan injury (MOD, and death were compared based on ratios and blood storage times. Of 2200 trauma admissions, 89 patients required MTP. Penetrating injuries were the majority, n = 53; and Injury Severity Score was 33 ± 14. Overall mortality was 31 per cent and sepsis was 28 per cent. Outcomes (storage time): Patients receiving old versus new blood had comparable age and Injury Severity Score. Sepsis rates, multiorgan injury and mortality were similar. Outcomes (packed red blood cells:fresh frozen plasma): Balanced transfusions (ratios of 1:1) demonstrated significant survival benefit and less infections compared with ratios >1:1. These data underscore the complexity of transfusion-related morbidity. In the modern era of MTP and balanced transfusions, the age of stored blood may not impact outcomes as demonstrated historically.
Excision and Primary Closure May be the Better Option in the Surgical Management of Pilonidal Disease in the Pediatric Population
Authors: Zagory Jessica A. , Golden Jamie , Holoyda Kathleen , Demeter Natalie , Nguyen Nam X.
Published: June 2020

The optimal management of pilonidal disease in the pediatric population is still debated. We conducted a retrospective review of patients 21 years old and younger who underwent surgical management for pilonidal disease between 2009 and 2013 at a single pediatric institution. Sixty patients (41.7% male) were included in the analysis, with a mean age of 15.0 years (range, 13–20). Twelve (20%) had a prior drainage procedure for pilonidal abscess before the definitive operative treatment. After excision to the presacral fascia, 36 (60%) had primary closure, 17 (28.3%) were left to heal by secondary intention, and 7 (11.7%) had flap closure. Overall recurrence rate was 41.7 per cent with 33.3 per cent in the primary, 58.8 per cent in the secondary, and 42.9 per cent in the flap group, respectively. Ten (16.7%) patients developed postoperative complications, which were similar among surgical groups, gender, and body mass index. The average length of stay was 0.67 (median 0, range, 0–5) days. Primary closure had the shortest length of stay (analysis of variance P = 0.04), and flap closure had no reoperations (analysis of variance P < 0.01). Pilonidal disease remains surgically challenging. Our data suggest that excision and primary closure is a better option in the pediatric population.
Use of Antibiotic-Impregnated Absorbable Beads and Tissue Coverage of Complex Wounds
Authors: White Terris L. , Culliford Alfred T. , Zomaya Martin , Freed Gary , Demas Christopher P.
Published: June 2020

The treatment of complex wounds is commonplace for plastic surgeons. Standard management is debridement of infected and devitalized tissue and systemic antibiotic therapy. In cases where vital structures are exposed within the wound, coverage is obtained with the use of vascularized tissue using both muscle and fasciocutaneous flaps. The use of nondissolving polymethylmethacrylate and absorbable antibiotic-impregnated beads has been shown to deliver high concentrations of antibiotics with low systemic levels of the same antibiotic. We present a multicenter retrospective review of all cases that used absorbable antibiotic-impregnated beads for complex wound management from 2003 to 2013. A total of 104 cases were investigated, flap coverage was used in 97 cases (93.3%). Overall, 15 patients (14.4%) required reoperation with the highest groups involving orthopedic wounds and sternal wounds. The advantages of using absorbable antibiotic-impregnated beads in complex infected wounds have been demonstrated with minimal disadvantages. The utilization of these beads is expanding to a variety of complex infectious wounds requiring high concentrations of local antibiotics.
Mixed Hepatocellular Carcinoma, Neuroendocrine Carcinoma of the Liver
Authors: Baker Erin , Jacobs Carl , Martinie John , Iannitti David A. , Vrochides Dionisios , Swan Ryan Z.
Published: June 2020

We present the case of a 76-year-old male found to have a large tumor involving the left lateral lobe of the liver, presumed to be hepatocellular carcinoma (HCC). After resection, pathologic features demonstrated both high-grade HCC and high-grade neuroendocrine carcinoma (NEC). Areas of NEC stained strongly for synaptophysin, which was not present in HCC component. The HCC component stained strongly for Hep-Par 1, which was not present in the NEC component. The patient underwent genetic analysis for biomarkers common to both tumor cell types. Both tumor components contained gene mutations in CTNNB1 gene (S33F located in exon 3). They also shared mutations in PD-1, PGP, and SMO. Mixed HCC/NEC tumors have been rarely reported in the literature with generally poor outcomes. This patient has been referred for adjuvant platinum-based chemotherapy; genetic biomarker analysis may provide some insight to guide targeted chemotherapy.
The Use of Transanal Hemorrhoidal Dearterialization for Treatment of Hemorrhoid Disease at a Single Institution
Authors: Haskins Ivy N. , Holzmacher Jeremy , Obias Vincent , Agarwal Samir
Published: June 2020

Transanal hemorrhoidal dearterialization (THD) is a relatively new, minimally invasive approach for the treatment of hemorrhoid disease. Despite increasing use of this procedure, there remains scarce United States-based data on the perioperative variables affected by this surgical technique. This article details the experience with THD at a single institution. This is a single-institution study that includes consecutive patients that underwent THD at George Washington University from November 2011 to April 2014. After Institutional Review Board approval, retrospective chart review was performed. Patient demographic information, preoperative management of hemorrhoid disease, and quality of life indicators after THD were collected for all patients. A total of 96 patients underwent THD during the period of investigation. A majority of the patients were male and all patients had grade II or III hemorrhoids. Most patients who underwent THD presented with rectal bleeding. Four patients required postoperative admission to the hospital for pain control, eight patients experienced constipation postoperatively, and one patient had recurrence of their hemorrhoid disease at 30-day follow-up. No patients required admission to the hospital for postoperative hemorrhage and none experienced urinary retention or incontinence of flatus or stool. THD is a feasible alternative to Ferguson hemorrhoidectomy for the surgical treatment of grade II and III hemorrhoidal disease. Future prospective studies are needed to help improve patient selection for each respective surgical approach.